Health Plan Basics

APTC’s or Subsidies are available from the Federal Government if you fall within certain income guidelines (explained below). The amount you qualify for can be used to lower your monthly premium payments you make to the insurance company. For specific questions on your situation, please contact us for more information. You can also see how much you qualify for by obtaining a quote from our website.

How federal poverty levels are used to determine eligibility for reduced-cost health coverage

  • Income between 100% and 400% FPL: If your income is in this range, in all states you qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan.
  • Income below 138% FPL: If your income is below 138% FPL and your state has expanded Medicaid coverage, you qualify for Medicaid based only on your income. Utah has not expanded Medicaid, this is considered a “Gap” which means you won’t qualify for a subsidy.
  • Income below 100% FPL: If your income falls below 100% FPL and your state hasn’t expanded Medicaid coverage, you won’t qualify for either income-based Medicaid or savings on a Marketplace health insurance plan. You may still qualify for Medicaid under your state’s current rules.
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*Chart is for 48 contiguous states and the District of Columbia; for Hawaii and Alaska, please visit the website of the HHS Assistant Secretary for Planning and Evaluation (ASPE):

“Income” above refers to “modified adjusted gross income” (MAGI). For most people, it’s the same or very similar to “adjusted gross income” (AGI). MAGI isn’t a number on your tax return. It is an estimated amount based on the calendar year you are looking for coverage. For example, if you are applying for a plan for 2017, you will use your estimated 2017 annual income.

MAGI is adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest.

  • For many people, MAGI is identical or very close to adjusted gross income.
  • MAGI doesn’t include Supplemental Security Income (SSI).
  • MAGI does not appear as a line on your tax return.
There are 4 categories of health insurance plans: Platinum, Gold, Silver and Bronze. These plans show how you and your plan share costs (see below). These plan categories have nothing to do with quality of care, it’s simply a way to classify the plans and how much they cover.


There are primarily two types of health insurance purchase options, Individual/Family and Group/Employer Sponsored health Plans.

Group/Employer Plans: If your employer offers health insurance to its employees, it can be a good way to purchase health insurance. Typically your employer pays a portion of the premium and you have your portion of the premiums deducted from your paycheck, ideally pre-tax. If a group plan is not an option for you, there are many options available for the Individual/Family health plans.

Individual/Family Health Plans: When it comes to purchasing a health plan for yourself/family, there are a few avenues in which you can purchase them.

  • Agent: Insurance agents (like us) have been the traditional source for purchasing health insurance. Insurance agents are independent and can therefor recommend the best carrier and plan that meets your needs. Using an insurance agent does not increase the cost of your plan and can be a valuable resource for you in answering questions and navigating the complexities of health care.
  • Direct: In years past, you had the option to purchase health insurance directly from the carriers. There is a misconception that it is less expensive to go directly to the carrier, as explained above, that is not the case. In most cases, the carrier will refer you to an agent to work with.
  • Online: There are many options on the web to purchase health insurance for yourself/family. Some of the more “well known” online agencies are out of state and do not have local representation. It’s useful and important to know when using an online agency, that you are able to speak with someone locally (like us).
  • HealthCare Marketplace: This is the place that you will have to use if you qualify for an Advanced Premium Tax Credit. It is still recommended to use an agent as they are able to help navigate the many options it will give you.
  • Medicaid/CHIP: Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly, and people with disabilities.
As a result of the Affordable Care Act (ACA aka Obamacare) the times to enroll for Individual/Family Health plans are very specific. There are two periods in which you can enroll in a health plan: Open Enrollment and Special Enrollment Periods.

Open Enrollment: Each year there is a time designated for Open Enrollment. It’s during this time you can enroll on a new plan or make changes to your current plan. For example for plan year 2017 the dates are the following:

  • November 1, 2016: Open Enrollment started — first day to enroll, re- enroll, or change a 2017 insurance plan.
  • December 15, 2016: Last day to enroll in or change plans for coverage to start January 1, 2017.
  • January 1, 2017: 2017 coverage started for those who enrolled or changed plans by December 15.
  • January 31, 2017: Last day to enroll in or change a 2017 health plan. Your effective date could be as late as March 1 st , 2017. After this date, you can enroll or change plans only if you qualify for a Special Enrollment Period (see below).


Special Enrollment Period: A time outside the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.

If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to apply.

There are a few key benefits that are important to be aware of when comparing health insurance plans. Below are brief explanations of those benefits, for detailed questions on your plan Contact Us.

Office Visits

Preventive Services: There is no charge for an office visit when you see your in- network primary care physician for services considered preventive care under the Affordable Care Act (ACA). You might get a bill if your doctor orders additional tests or performs other services – but covered preventive visits are free.

When you visit the doctor’s office you will pay either one of three ways:

  1. Copays/Copayments: Copay is a flat fee that you pay on the spot each timeyou go to your doctor. There are usually two types of copays, one  amount for Primary Care doctors and a higher amount for Specialists.
  2. Deductible: A deductible is the amount you pay each year for eligible medical services before your insurance pays for expenses. For example, if you have a $3,000 yearly deductible, you’re responsible for the first $3,000 of your total eligible medical expenses. If your plan does not have Copays for office visits, you will then be required to pay for the out of pocket until you’ve met your deductible. Depending on your plan, you may have a deductible “Per Person/Individual” and a “Family” deductible.
  3. Coinsurance: Coinsurance is the portion of medical cost that you pay after the deductible has been reached and is usually a percentage, for example 20%. You will pay the coinsurance amount until you have reached the Out of Pocket or Coinsurance Maximum. Once the Maximum has been reached, your plan pays 100% of the eligible medical expenses.

Prescription Medications

Prescription benefits can be somewhat confusing in health plans today. Below we have provided some basic information on these benefits. Feel free  to Contact Us with any questions.

  1. Tiers: Most carriers group their medications in different benefits levels or tiers. The tier that your medication is on determines your portion of the cost. A typical prescription benefit has 4 tiers: Tier 1 are usually generic medications. Tier 2 usually includes preferred brand drugs. Tier 3 usually includes non-preferred brand drugs. Tier 4 usually includes specialty drugs.
  2. Deductible: Not all plans have a deductible for medications. Some plans have a separate deductible for prescriptions while others have a combined medical and prescription deductible. It’s important that you understand how your plan works.
  3. Copays/Copayments: Generally your plan will have either copays (flat dollar amount) or coinsurance (a percentage) for the prescriptions and is dependent on the tier the prescription is on.

Network Options

Most carriers utilize a Provider Network with their health plans. A provider network is a list of doctors, facilities, and other healthcare services that have an agreement with your insurance company to provide services at a reduced cost.

  1. In-Network: If a provider is considered “in-network,” they are on the list of “approved” or “participating” providers for the insurance company and specific plans. If you use an “in-network” or participating provider, you will have lower deductible and out-of- pocket costs than if you use an “out-of- network” or “nonparticipating” provider.
  2. Out-of- Network: if you have Out-of- Network benefits on your plan, it means you can see providers that are not considered “approved” or “participating”. With that being said, you’ll want to be aware that you typically have a separate and usually higher deductible and out-of- pocket maximum than in-network providers. On some plans, you will not have any Out-of- Network options which mean the insurance company will not have any coverage for services provided Out-of- Network.

Health Savings Accounts

The term Health Savings Accounts (HSA’s) is used synonymously with Qualified High Deductible Health Plans (QHDHP). It’s important to note the distinction between the two. Below is a summary, Contact Us with specific questions.

  1. Qualified High Deductible Health Plan (QHDHP): A high-deductible health plan is a qualified health plan with deductibles that are at least $1,250 for an individual or $2,500 for a family. Under the federal tax code, most individuals with a qualified high-deductible health plan are allowed to make tax-free contributions to a Health Savings Account that can then be used to pay out- of-pocket medical expenses.
  2. Health Savings Account (HSA): A health savings account (HSA) gives anyone enrolled in a QHDHP a way to put money aside for medical expenses, tax- free. Think of it like a regular savings account you’d have in a bank, except that the money is earmarked for medical expenses. Money placed in an HSA can help pay for medical expenses, including those that count toward meeting your deductible. Unlike flexible spending accounts (FSA), unused money in your HSA is not forfeited at the end of the year, and it continues to grow tax-free.