How long do I have before I need to apply?

Please try to enroll as soon as possible as carriers are extremely backed up due to all policies being issued and renewing on the same date. Please note that if your deadline occurs on a weekend you should submit your application to us by noon on the Friday before or if it occurs on a weekday please submit before noon on day prior to the final day to ensure that the application is processed and you receive your requested issue date.

What information do I need to enroll?

For all family members that will be included in coverage, you will need the dates of birth, social security numbers, and premium payment. All carriers require that the initial premium payment is submitted upon applying. A carrier will not accept an application that does not have payment.

As a Member, am I able to enroll my dependents if I waive coverage due to having other coverage?

Yes, the Member Benefits Private Exchange is available to Members and their dependents. Spouses and children may enroll even though the Member waives the coverage.

Do I have to meet my deductible before I pay a copay?

Most services where a co-pay is noted the service is covered before you meet your deductible and the deductible is waived. There may be a few exceptions where you will have to meet a deductible prior to your copays. For example, for certain Rx tiers, you may have a separate Rx deductible prior to paying a copay. In these cases, you pay up to the Rx deductible before the copays apply. You will want to review the SBC for full coverage details.

When does my deductible apply?

For any service not covered by a co-pay you pay up to your deductible at the “negotiated” (lower) rate – then you pay your coinsurance % (0, 10, 20 or 30 percent usually) until you reach a total cost (including deductible) which is called your out of pocket maximum – after that you are covered 100% for covered services for the balance of the year.

What does the term “Out of Pocket Maximum” refer to?

OOPM is the most that you pay for covered services before the carrier covers at 100%. The OOPM includes the deductible, copays, coinsurance and Rx.

Does the law require me to be insured by a qualified health plan all year to avoid a tax penalty (individual mandate)?

No. If you have coverage for part of the year, the fee is 1/12 of the annual amount for each month you (or your tax dependents) don’t have coverage. If you’re uncovered only 1 or 2 months, you don’t have to pay the fee at all.

PPO

Can receive care from any doctor you choose, no referral for specialty care (except UHC FL), may use out-of-network doctors – but may have to pay addition fees. PPO plans typically have higher monthly premium.

POS

Very similar to a PPO. The biggest difference is the contract between the insurance carrier and healthcare providers.

HMO

Must pre-select an approved Primary Care Physician, referrals are needed and for most plans, there are no out of network benefits except for qualifying emergencies. HMO plans typically have lower monthly premiums.

EPO

Hybrid network that has limitations that vary based on the carrier. In some instances, you would need to get referrals and may not have coverage for out-of-network. These plans typically have a lower monthly premium.