ACA
What happens when I reach my maximum out of pocket expense?
Once you've reached your out-of-pocket maximum, your health plan will pay for covered health care services and prescription drugs for the rest of the year.
What is the minimum and highest income to qualify for Obamacare? 1 - an individual.
The income limits for Obamacare in 2025 are between $15,060 (minimum) and $60,240 (maximum) for an individual. For a couple, the income limits to qualify for Obamacare are between $20,440 and $81,760. For a family of three, the minimum is $25,820 and the maximum is $103,280.
What's Medicare Supplement Insurance (Medigap)?
Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private health insurance company to help pay your share of out-of-pocket costs in Original Medicare.
Que debo hacer si un cliente me Pregunta por los Benficios de su plan?
Permitame reviso el Correo Electronico que SU AGENTE -(Sra Mary/Lina) le envio con la informacion y CON MUCHO GUSTO LO REPASAMOS JUNTOS.
Enumere 3 minimas acciones para tranquilizar a un Cliente molesto.
Escuchar con Empatia
Decir lo Entiendo
No discutir su punto
OFRECER SOLUCION (Call back con Agente- Pedirle a nuestra Manager de Oficina que le llame)
Informarlo inmediatamente x el Slack.
What is the fundamental principle of the ACA?
Under the ACA, those who were previously uninsured due to pre-existing conditions or financial circumstances, and those who were insured in plans with high premiums or limited benefits, may now be eligible for more affordable health plans with essential benefits
What is the highest income to qualify for Medicaid?
The highest income to qualify for Medicaid varies by state, household size, and the specific Medicaid program. Generally, in states that have expanded Medicaid, the income limit is set at 138% of the Federal Poverty Level (FPL) for adults under 65.
What is the difference between Florida KidCare and Medicaid?
Florida KidCare is the state's high-quality, low-cost health and dental insurance for children from birth until the 19th birthday. Florida KidCare is made up of four programs: Medicaid for Children, MediKids, Florida Healthy Kids and Children's Medical Services (CMS) Health Plan
Allowed with PTC:
What can an agent do with PTC?
Agents may contact potential and existing clients with permission as follows:
Does Medicare pay for long-term care?
Long-term supports and services can be provided at home, in the community, in assisted living, or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don't pay for long-term care
Cuando estoy organizando una Poliza de un FUTURO Medicare, Que fecha debe tener el "Effective date "?
Siempre!! debe tener el dia 1 del Mes en que cumple sus 65 a#os. Excepcion - cuando la persona cumple el dia 1 del mes - Seria el dia 1 del mes anterior a sus 65 anos.
Para personas con discapacidad- El medicare, inicia 2 anos despues de estar recibiendo cheque de SS.
Para Personas con Dialisis- Medicare inicia 4 meses despues de empezar la Dialisis.
The following factors do not affect your health insurance premium: name 3
If I am a victim of domestic abuse, should I file taxes with my spouse?
No, you don’t have to file jointly — and you can still qualify for a premium tax credit and other savings.
If you’re living apart from your spouse and are a victim of domestic abuse, domestic violence, or spousal abandonment and want to enroll in your own health plan separate from you abuser or abandoner, you can say you’re “unmarried” on your Marketplace application without fear of penalty for mis-stating your marital status.
What if I'm a dependent on someone else's Tax return and want to get Marketplace Insurance myself?
You won’t qualify for a premium tax credit and other savings based on your income. You can buy a Marketplace plan but would have to pay full price.
Prohibited Methods for Contacting Medicare Beneficiaries.
Cliente- Quisiera cambiar mi Plan de Medicare!
que debo hacer de inmediato?
Entiendo, Primero le voy a enviar una autorizacion para su firma - SOA
que su Agente - la Sra Mary(Lina) - necesita con 48 Horas de anticipacion. Y Agendamos el tiempo para que ella explore con usted sus Posibilidades de Cambio. Cual es la razon por la que desea Cambiar Sr/Sra-?
Un cliente nos manda via email -Texto - Whats up - Apizeal o llamada informacion de Inconformidad. Como TMember Que pasos debemos seguir?
1- Slack -Pin - @LC-LM-MB Traer su atencion a la situacion.
2- TMember pendiente que se haya revisado /dedito
nope?
3- Llamar directamente a LC-MB
4- Verificar que Nota de Solucion este en Apizeal
5 - Agendar Follow up 2/3 dias despues.
Why can you be denied Medicaid?
The formal Medicaid denial letter will clearly state why you have been denied. Usually, it's because you are over the income or asset limit for eligibility, or it might be because your medical needs are not severe enough
¿Qué es un crédito fiscal para las primas del seguro médico?
Es la oportunidad de ahorrar en su prima mensual con un Crédito Fiscal del Seguro Médico, El PTC ayuda a reducir el costo del seguro médico a través del Mercado de Seguros Médicos para las personas y familias elegibles que califican. PTC =The premium tax credit
Fechas importantes en el Mercado de Seguros?
1 de noviembre: Comienza el Período de Inscripción Abierta.
15 de diciembre: Inscríbase antes de esta fecha para la cobertura que comienza el 1 de enero.
1 de enero: Comienza la cobertura médica para los planes elegidos antes del 15 de diciembre.
When Does PTC (Medicare) Expire?
For compliant outreach, Permission to Contact (PTC) forms, including Business Reply Cards (BRCs), are valid for 12 months from the date of the beneficiary’s signature or initial request for information. Once the 12-month period expires, agents must obtain new permission to continue contact with the individual.
What is a PTC in Medicare?
What is Permission to Contact (PTC)? Permission to Contact (PTC) is the consent agents need before reaching out to Medicare beneficiaries for marketing. It ensures beneficiaries are contacted only when they allow it, building trust and transparency.
What is the four common types of health insurance?
1- HMO: Health Maintenance Organization
Lower costs , A dedicated primary care physician who can coordinate all your care needs.- A referral may be necessary to see a specialist.- There is no out-of-network coverage for non-emergency visits.
2-PPO: Preferred Provider Organization.
offer you more choices of healthcare providers. Their networks tend to be larger, so you can choose from more doctors and hospitals. While you can see out-of-network providers with a PPO plan, you may pay higher out-of-pocket costs than you would if you used in-network providers. With a PPO plan, you don't need a primary care physician, and you can see any specialist without a referral.
3-EPO: Exclusive Provider Organization (EPO)
EPO plans, are similar to HMO plans in that they have a specific network of providers that members must use, except in emergencies. You can use out-of-network providers for most services, but you may have to pay higher out-of-pocket costs. However, as with PPO plans, most EPO plans do not require you to have a PCP, and you don't need a referral from a PCP to see a specialist
4-POS: Point of Service
are like a combination of HMO and PPO plans. As with an HMO plan, you may be required to have an in-network primary care physician. This PCP must refer you to any specialists you need, but as with a PPO plan, you can see out-of-network specialists at a higher out-of-pocket cost.
What is a permanent life insurance policy?
A permanent life insurance policy is a contract with a life insurance company to provide protection throughout your entire life, as opposed to term insurance that just provides coverage for a specified number of years
What if I'm married and file taxes separately? Can I still have health coverage?
Cual es la manera de calcular el valor real de un menor de edad, dentro de la poliza en el Mercado de Seguros?
Colocar en el tabulador la edad de 19 anos para que no lo saque del credito Fiscal. Y Utilizar la palabra Valor APROXIMADO- puede variar en unos $10 a $20 x menor.
A) Como esta estructurada la cobertura Medica en Medicare?
B) Medicare- esta respaldado por fondos ____
C) Como puede el Beneficiario Cubrir su responsabilidad?
A) Medicare es una cobertura 80/20. 80% paga Medicare y 20% el Beneficiario
B) Federales
C) 1-Madicare Advantage - 20% lo cambia por un MOOP - Maximo de Bolsillo. 2-Poliza Adicional suplemental o Medigap Mas PDP (Plan medicamentos) 3- Con ayudas del Estado - Medicaid
Porque en las cartillas de Planes de Medicare vemos diferentes valores a pagar por un mismo servicio?
Los planes medicos desean controlar los valores a pagar por los servicios medicos del Beneficiario de Medicare. Incentivan a costos mas bajos o inclusive $0 en PCP- Specilista o centros diagnosticos. Los Valores mas costosos, es para atencion en el HOSPITAL.
What's Medicare not covered?
What affects health insurance premiums? Name 5 factors.
These five factors can affect the cost of a plan's monthly premium:
Marketplace cover these 10 essential health benefits:
1- Ambulatory patient services
2- Emergency services
3- Hospitalization
4- Pregnancy, maternity, and newborn care (both before and after birth)
5-Mental health and substance use disorder services
6- Prescription drugs
7- Rehabilitative and habilitative services and devices
8- Laboratory services
9- Preventive and wellness services and chronic disease management
10- Pediatric services, including oral and vision care
Cual es la mejor informacion que podemos dar a un cliente acerca de la conciliacion del credito fiscal?
Recibimos del Mercado de Seguros la forma 1095 A a cominzos del proximo ano. El Formulario 1095-A incluye la información que necesita para completar el Formulario 8962 si desea solicitar el PTC o es necesario conciliar el APTC que ya recibió .
A) Que significa "Tier" en un formulario de Medicamentos.
B) Cuales son las mas usuales?
C) Cual es la mas costosa?
A)Tier: linea - estructura del tipo de medicamentos que cubre el plan y sus costos.
B) Tier 1: Preferred Generic $0
Tier 2: Generic $0
Tier 3: Preferred Brand $30 - $35
Tier 4: Non-Preferred Drug % 33 o 35%
Tier 5: Specialty Tier % 33
Tier 6: Select Care Drugs $ 0
C) Tier 5: Specialty Tier Usualmente / or Non Preferred Drug
A) Que es el "TrOOP" en Medicare?
B) Cuanto el el Maximo que va a pagar un beneficiario de Medicare anual es Medicamentos?
A) El TrOOP, o Costos Reales de Bolsillo, se refiere al monto total que un beneficiario de Medicare paga por medicamentos recetados antes de alcanzar la fase de cobertura catastrófica de la Parte D de Medicare. Incluye copagos, coaseguros y deducibles de los medicamentos cubiertos.
B) $2,000 - Medicamentos cubiertos en el Fomulario de medicinas del plan escogido.
What is long term care insurance?
Long-term care insurance helps cover the costs of long-term care services, such as those needed for activities of daily living (ADLs) like bathing, dressing, and eating, typically in settings like your home or a nursing facility. Unlike health insurance, it's designed to address ongoing needs for assistance with personal care and other support.
Un cliente Paga Actualmente de Premium $220. Y necesita hacer un ajuste de Income, y su nuevo Premium seria $558. Cuanto seria su Ajuste en sus taxes al momento de Conciliar?
$ 558 - $220 = $338 Valor dado de Mas en credito fiscal. Por el a#o Pagara $228 x 12 = $4,056.
Si hace el cambio de vida - Ajustara los meses que no pago el valor correcto.