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I’ve been told I must have health insurance. What happens if I don’t enroll in a plan?

The Affordable Healthcare Act (the ACA, or Obamacare) was created to give everyone better access to high-quality healthcare services. The new law mandates that all U.S. citizen must maintain minimum essential coverage throughout the year or pay a fee for each month you go without it. However, there are exemptions you may qualify for. There is a section in your Federal tax returns for reporting how many months of the year you were enrolled for coverage.

What’s the difference between HMO, PPO and POS plans?

The types of coverage you can get break down into three major plans: HMO, PPO, and POS.

An HMO is typically the most affordable option. Under this plan, you choose a primary care provider for all of your health care services, and must obtain a referral for specialists unless you have an emergency. While there are a few exceptions to this rule, your primary physician will coordinate all of your services, saving you paperwork and costs.

Under a PPO plan, you have greater flexibility to choose your health care services because you are not required to select a primary physician, but you will almost always pay more for your coverage. If you see a lot of specialists, this may be the best option for you.

The least familiar plan is an POS–it stands for Point of Service. It combines the cost-savings of an HMO plan with the flexibility of a PPO. These types of plans can vary– in some instances with a POS you may be required to obtain referrals for specialists while others may not. And while a POS plan allows for out-of-network healthcare services, you will pay the bulk of the cost incurred for those services.

I’ve already been offering health insurance for my employees. Do I need to change my plan due to the ACA?

No, not necessarily. Under the ACA, you are allowed to keep the plans you’ve been offering, as well as any benefits you included. The main difference now is that if you have fewer than 50 full-time employees, you might want to consider offering a healthcare plan through the Small Business Health Options (SHOP) Marketplace, where you may qualify for a small-business tax credit. You can enroll in a SHOP plan anytime of year.

What is a Health Savings Account (HSA) and why would I consider it?

A Health Savings Account (HSA) is a tax-advantaged plan where you can put money aside that can be used penalty-free for medical purposes. Typically, these plans have significantly lower premiums and the money being set aside is tax-free, whether it’s taken from your paycheck before taxes or reported on your tax return. Unlike an FSA account, the money you save rolls over from year to year and can be drawn on for any purpose at age 65 without a penalty. Other advantages of these plans include being able to roll your account over if you switch employers, your employer can make tax-free contributions to your account (hello free money!) and you can use this account to save for your retirement.

The ability to save money sounds great, but there’s a significant flip side you must consider. An HSA requires a high-deductible plan, meaning you could potentially pay quite a bit out-of-pocket to meet your deductible before your insurance company starts to kick in. Many types of medical expenses, such as prescriptions, count towards your deductible, while others such as dental care or eye glasses, do not. For all of these services however, you may use the money you’re putting aside into your HSA may be used to pay for these expenses.

Thanks to the ACA, many medical services are now provided to me for free. Does this apply to my dental care or vision plans as well?

For the most part, the benefits and rights offered under the ACA do not apply to dental or vision care. The one main exception applies to children – dental and vision care must now be offered for children, but you are under no obligation to take it.

Will my disability policy include dental and vision coverage?

No. Short-term and long-term disability policies are designed to replace a portion of your lost income in the instance of expected (i.e. maternity leave) or unexpected (i.e. injury from a car crash) leave.

How much life insurance should I get?

The answer to this really depends on your situation. You should look closely at your current situation, as well as your future obligations. Are you married? Your spouse is unlikely to return to work immediately, so will not only need help with funeral and medical expenses but a resource to tap for bills while they grieve. Do you have children? Consider the impact your loss will have on their future education bills. We can help you assess the right amount of coverage dependent on your specific needs.

Am I eligible for Medicare?

In order to be eligible for Medicare, you must be a U.S. citizen or legal resident for at least five years, and one of the following: 65 years or older; have a disability and are receiving Social Security disability payments; or have end-stage renal disease and require dialysis or a transplant.

How does the ACA affect my Medicare plans?

Medicare isn’t part of the healthcare exchange marketplace, so you don’t have to replace your Medicare plan with a Marketplace one. That said, thanks to the ACA, your plan now has some added benefits, including more preventative services, savings on certain brand-name drugs, and protection that Medicare will be around until at least 2029, due to a reduction of waste and fraudulent Medicare practices.

How do I find out if my prescription drugs are covered by Medicare Part D?

Each Medicare Prescription drug plans has its own “formularies,” a list of covered drugs that are placed into different tiers and have different costs. For a complete list of which drugs are covered under which plans, please visit

What’s the difference between in-network and out-of-network providers?

In-network providers are contracted to work with your insurance carriers and have negotiated lower-rates, meaning you pay less for healthcare services depending on your plan. Out-of-network providers have not accepted the discounted rates and therefore can be more expensive. It’s important to note however, the difference between being in-network and accepting your health insurance. A healthcare provider may accept your insurance without being in-network, which will result in higher payments for you. It’s up to you to ask when deciding where to go for services.

What’s the difference between a deductible, co-payment and co-insurance?

Used together in a single plan, these terms can be confusing. In short, your deductible is the amount you must pay out of pocket before your insurance carrier begins to pay your medical bills; a co-payment is a pre-determined amount you agree to pay to a provider when services are given, and co-insurance is the percentage you owe after your health insurance carrier has paid its portion–typically, this percentage is within 20-30% of the total bill.

If I apply for healthcare and am approved, am I obligated to purchase that plan?

No. While you must include payment information during the application process, you may cancel anytime during enrollment. Most insurance companies will not charge you until you have been approved, although a few carriers may require a non-refundable application fee. We will always notify you of this before beginning the application process.

What does Lyons & Associates charge for helping me find the right coverage?

There is no additional cost to you for our help! Insurance carriers build in brokerage rates to all plans and pay us a flat rate to help you enroll in coverage. It’s important to know you’re paying this fee whether you use our services or enroll directly through the carrier’s website.

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