Health & Employee Benefits

 

 

 

 

 

 


Health & Employee Benefits FAQ


Can I get individual health coverage now?

To get a quote for individual or family health insurance during Open Enrollment, just go to this website: https://www.healthsherpa.com/?_agent_id=christopher-pelnik

There are two time periods that you can enroll in individual/family health coverage: the “Open Enrollment Period” and “Special Enrollment Periods.”

Open Enrollment is the only time of year you can get a major medical plan that counts as “minimum essential coverage” in the individual and family market without qualifying for a Special Enrollment Period. This is true for for policies both inside and outside the federal Health Insurance Marketplace. The Open Enrollment Period runs from November 1, 2016 through January 31, 2017.

If you missed the Open Enrollment Period, then you can sign up for health coverage if you qualify for a “Special Enrollment Period.” A Special Enrollment Period is a time outside of open enrollment in which you can get coverage due to qualifying life events. There are several events that can qualify you for a Special Enrollment Period, such as losing your job, a change in family status, or moving to another location. To sign up with a Special Enrollment Period, you should visit www.Healthcare.Gov directly.

If you missed the Open Enrollment Period, and you don’t qualify for a Special Enrollment Period, then you can apply for short-term health insurance. However, short-term policies don’t provide all of the benefits and consumer protections that more comprehensive policies provide. For example, there will be medical underwriting and your pre-existing conditions can be excluded from coverage. There may also be a maximum pay out limit for your benefits. Because of these limitations, a short-term policy won’t satisfy the Affordable Care Act’s mandate to have qualifying health coverage, and you will have to pay a penalty.

 

Do I have to pay a penalty for not having health insurance coverage?

Yes. If you can afford health insurance but choose not to buy it, you must either have a health coverage exemption or pay a fee. The fee is sometimes referred to as the “penalty,” “fine,” “individual responsibility payment,” or “individual mandate.”

If you don’t have coverage, you’ll pay the higher of these two amounts:

2.5% of your yearly household income (only the amount of income above the tax filing threshold, about $10,150 for an individual, is used to calculate the penalty). The maximum penalty is the national average premium for a bronze plan.

$695 per person for the year ($347.50 per child under 18). The maximum penalty per family using this method is $2,085 per year.

 

What do these metallic levels (Bronze, Silver, Gold, Platinum) next to the health insurance plan names mean?

The Affordable Care Act specified that beginning in 2014, health insurance newly sold to individuals and small businesses must be at one of five categories or “metal levels” of coverage. Plans in each category pay different amounts of the total costs of an average person’s care. This takes into account the plans’ monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums.

Metallic Level

Your Health Plan Pays (On Average):

You Pay (On Average):

Bronze

60%

40%

Silver

70%

30%

Gold

80%

20%

Platinum

90%

10%

 

The actual percentage you’ll pay in total or per service will depend on the services you use during the year.

There are also “Catastrophic” coverage plans, which pay less than 60% of the total average cost of care on average, but those are only available to people that are under 30 years old or have a hardship exemption.

 

How do I know what metallic level plan I should purchase?

It depends on your health care needs. For example, if you expect to frequently go to the doctor, you may want to purchase a Gold plan or Platinum plan. These plans generally have higher monthly premiums, but they will pay more of your health costs when you need care.

Conversely, if you don’t expect to use regular medical services and you don’t take regular prescriptions, then you may want to purchase a Silver or Bronze plan. These plans cost less per month in premiums, but they will pay a lesser share of the costs when you need care.

 

I have heard that the government provides financial assistance to individuals and families who may have a hard time affording the cost of health insurance. Is that true?

Yes! Subsidies are financial assistance from the Federal government to help you pay for health coverage or care. The amount of assistance you get is determined by your income and family size. There are two types of health insurance subsidies available through the Marketplace: the premium tax credit and the cost-sharing subsidy.

The premium tax credit helps lower your monthly expenses.  This subsidy is available to people with family incomes between 100% and 400% of the poverty level who buy coverage through the Health Insurance Marketplace. The amount of your tax credit is based on the price of a Silver plan in your area, but you can use your premium tax credit to purchase any Marketplace plan, including Bronze, Gold, and Platinum plans (these different types of plans are described below). You can choose to have your tax credit paid directly to the insurance company so that you pay less each month, or, you can decide to wait to get the tax credit in a lump sum when you do your taxes next year.

Cost-sharing subsidies (also called “cost-sharing reductions”) help you with your costs when you use health care, like going to the doctor of having a hospital stay. These subsidies are only available to people purchasing their own insurance who make between 100% and 250% of the poverty level (and some Native Americans). If you qualify for a cost-sharing subsidy, you would need to sign up for a Silver plan to take advantage of it. Unlike the premium tax credit (which can be used for other “metal levels”), cost-sharing subsidies only work with Silver plans. With a cost-sharing subsidy, you still pay the same low monthly rate of Silver plan, but you also pay less when you go to the doctor or have a hospital stay than you otherwise would.

 

How can I see what government assistance I can receive to help pay for my health coverage?

Use our free Health Insurance Marketplace Subsidy Calculator!

 

Who do I call for questions about my health insurance benefits or claims?

For Blue Cross Blue Shield of NC, call: 1-800-446-8053.

For Aetna, call: 1-877-204-9186.

For UnitedHealthcare, call: 1-800-842-8000.

For Cigna, call: 1-800-244-6224.

 

Where can I see my current health benefits and/or claims online?

For Blue Cross Blue Shield of NC, go to: https://www.bcbsnc.com/members/public/index.htm

For Aetna, go to: https://member.aetna.com/MbrLanding/

For UnitedHealthcare, go to: https://www.myuhc.com/member

For Cigna, go to: https://my.cigna.com/

If you need to create an account at one of those sites, you just need your health insurance card.

 

How do I see what medical providers are in my plan’s network?

For Blue Cross Blue Shield of NC, go to: https://www.bcbsnc.com/content/providersearch/index.htm

For Aetna, go to: https://www.aetna.com/individuals-families/find-a-doctor.html

For UnitedHealthcare, go to: http://www.uhc.com/find-a-physician

For Cigna, go to: https://hcpdirectory.cigna.com/web/public/providers

 

I’m a business owner. Can I get health coverage for my company now?

Yes! Please use the quote request form, or just call us at 919-459-8000.

 

Do I have to pay a penalty if I don’t offer health coverage to my employees?

If you are a “large” employer – yes. The Affordable Care Act’s employer shared responsibility provisions (also known as “pay or play”) require large employers—those with at least 51 full-time employees, including full-time equivalent employees (FTEs)—to offer affordable health insurance that provides a minimum level of coverage to full-time employees (and their dependents) OR pay a penalty tax. 

 

Our Locations

Triangle Office

100 Ridgeview Drive, Suite 100
Cary, NC 27511
Main office: 919-459-8000

Triad Office

3828 Burlington Road
Greensboro, NC 27405
Main office: 336-621-5057

Our Providers

Testimonials

High caliber, phenomenal customer service!! Expeditious responses from agents and extraordinarily knowledgeable! Accolades to all you folks that work at Pelnik Insurance!! I am very pleased to be a customer!!
Anne S
They provide the best pricing around, but the most important reason to do business with Pelnik Insurance is the professional, kind staff. Claims situations can be difficult, but they made it painless. First Class Agency!!
Jeanette B
I have never had to submit a claim before, but recently had a significant hail damage claim. I was worried about how long it would take to fix and a little lost as to what I needed to do. Pelnik Insurance helped me handle it quickly and very professionally too. Overall, great service from their staff and they were able to save me a significant amount of money on my insurance policies. Thank you!
Alex K
After a less than satisfactory experience with a couple of large, faceless insurance companies, I was referred to Pelnik Insurance. After my first meeting with Chris Pelnik, it was an easy decision to begin consolidating all of my business insurance to his agency. Throughout the 3+ years I have been with Pelnik, I have received outstanding customer service. Because we are frequently asked to provide insurance documentation to our customers, I make a lot of requests of the company. I have even had to file some claims. Every employee I have dealt with has provided immediate personal service. I also appreciate the annual review of my policies which is done in a face-to-face meeting prior to the renewal date of my policies. I highly recommend Pelnik Insurance.
Bruce F
Exceptional customer service and extremely competitive pricing are just some of the few reasons Pelnik Insurance has my business.
Robert T