[Podcast] Steps to getting covered under the Affordable Care Act

Sanford Health Plan can help individuals and families find affordable plans

Written by Mick Garry

Mick Garry (host): We are here today with Hollie Scott, a manager at Sanford Health Plan, and we're going to talk about individual and family health plans offered via the Affordable Care Act. To begin with, Hollie, can you provide some context on the Affordable Care Act? What is its purpose and who does it typically benefit?

Hollie Scott (guest): A very good question. We get this question quite often because as we get into the Affordable Care Act year after year, we're noticing it becoming more unaffordable for a lot of families. So originally the Affordable Care Act was designed to help those who fall within 100% to 400% of the federal poverty level. Those who fall within 100% to 400% of the poverty level qualify for what's called advanced premium tax credit, or a subsidy. What that does, that helps these families or individuals pay their premium every month. It also helps pay for some of the cost share with your deductibles or copayments depending on what level you're at.

Mick Garry: There is an open enrollment period for the Affordable Care Act and a non-open enrollment throughout the calendar year. Can you explain the difference between the two of them and why we should be aware of that?

Hollie Scott: So this is very important. So when the Affordable Care Act came out, this is one thing that changed the landscape of individual and family health plans. Before the Affordable Care Act, you could go and buy health insurance. As long as you answered some health questions you qualified and boom, you got your health insurance. With the Affordable Care Act, what that did was open that up for everybody. But in order to protect some risk within health insurance companies, now they have an open enrollment period that starts typically November 1st and goes through December 15th for a January 1st effective date. As we learn more and we go through pandemics like COVID, they have learned that we have to extend that for some people because we don't always have a decision by December 15th. So now they do offer that extension December 15th through January 15th, but those would take effect on February 1st. It's important to remember those dates because if you don't sign up during that time, you have to have a special enrollment period to qualify to buy a plan. A special enrollment period is really any life event that would cause you to lose health insurance or no longer qualify for your health insurance.

Mick Garry: What kind of Affordable Care Act plans does Sanford Health Plan offer?

Hollie Scott: So Sanford Health Plan offers all of the essential health benefits that are required by the Affordable Care Act. So when the Affordable Care Act came out, they set minimal essential coverage, essential health benefit coverages, and then required us to have copays on certain services and offer certain services, preventative services, at no cost. So Sanford and all of our Affordable Care Act plans – all of our individual and family plans – are considered Affordable Care Act plans. We offer all of those in all of our plans. Each metal level that is written into the Affordable Care Act – so gold, silver, bronze, and catastrophic – Sanford has plans in all of those categories.

Mick Garry: What is the best way to sift through the available plans? If I think one of these plans would work for me or for my family, what should be my next step?

Hollie Scott: So we get that question a lot at Sanford Health Plan. My team at Sanford Health Plan, we answer those questions. What we do is we try to answer some basic questions for you as an individual. But we really partner with our local agents to really get into the weeds because every situation is going to be different, especially when we're talking about the Affordable Care Act and families who qualify for subsidies. It's important that you get the maximum for what you're paying for, right? So if you fall between that 100% and 400%, you really are going to want to look at every option that's available to you, and our independent agents do that. So to answer the question more directly, talk to a local agent. If you don't have a local agent, you can sure call Sanford Health Plan and we can get you connected with one.

Mick Garry: We might be covering stuff here that you already answered, but can you walk me through the process of enrolling in a plan?

Hollie Scott: Yes. So when we're talking Affordable Care Act, there are multiple ways to enroll. You can enroll directly with Sanford Health Plan. If you enroll directly with Sanford Health Plan, you get just the plan that's offered, the premium that's filed with the government and approved. But if you are one of those that fall between that a 100% and 400% of the poverty level, you really want to explore that option – do you qualify for that subsidy? And so again, start with a local agent to see if you qualify for that subsidy. That's where you're going to start. You have that avenue through sanfordhealthplan.com on our website. You can go direct with us or we do have a platform where you can click to look at your options through the government on your own as well. But again, our local agents can do all of that for you and they're going to be the best route to help you and guide you through that application process.

Mick Garry: Obviously, cost is a big issue for many of us. How do I get a quote on health care plans I would qualify for? Is there something I can take care of online? And if I'm not internet friendly, what would be some of my other options for gathering information I need to enroll in the best plan for me?

Hollie Scott: You can go directly to sanfordhealthplan.com and get a quote again directly with us. Or we use a white label to jump into connect to the government from our website at marketplace.sanfordhealthplan.com. So you don't have to go through all that fun government site. Am I on the government site? Am I on a scammer site? So you can go directly into our website and do that if you want to self-service. Again, a local agent is really your best bet to help to make sure you're getting the best option for your budget. Or if you don't want to work with a local agent because you're afraid it's going to cost you more money – which it doesn't – you can sure call us direct at Sanford Health Plan at (888) 535-4831, too, and we can walk through and talk you through some of those options.

Mick Garry: What kind of information will I be asked to provide when I'm preparing to enroll in a plan?

Hollie Scott: If you are enrolling directly with Sanford Health Plan, not expecting to qualify for any subsidy, we're just going to ask you basic information: demographics, name, address, and then anybody else that's going to be covered. And then, obviously, what plan you want to enroll in. We're going to ask for payment information, obviously, to pay for your premium. Outside of that, that's all we really ask. There are no health questions anymore. We do ask if there are some programs we offer that you want more information on, but outside of that, it's just basic demographic information. Now, if you go and enroll and you're interested and feel you might qualify for a subsidy, they get a little bit more in the weeds. They ask income information. If you've moved where you live, they just get a little bit more weedy because it's, again, the government and they just want to make sure that they're giving you the proper assistance that you need.

Mick Garry: If I'm just turning 26 and will be looking for my own health care plan for the first time, how do I go about shopping for a plan that that would work best for me?

Hollie Scott: I feel like 26 is the new 18 – when that's when we officially become an adult, right? It’s because we're getting kicked off of mom and dad's plan. What do we do? Where do we go? So it's the same thing. At sanfordhealthplan.com, you can service yourself directly and look through a plan, or you can connect with an agent or call in and we can talk you through this turning 26, losing your mom and dad’s plan. That is a special enrollment period. We know that not everybody was born during November through December. So that is a special enrollment period for you. Start with a local agent or call us direct to help you walk through that.

Mick Garry: If I have a preexisting health condition, can that affect what kind of plan that I qualify for?

Hollie Scott: One of the great things about the Affordable Care Act is that took all of that preexisting away. So if you previously were diagnosed with cancer and have recovered and thought, “Oh, I'm healthy now,” before the Affordable Care Act, you might have had to pay 40% more in premium. Now everybody pays the same rate no matter how healthy or unhealthy they've been in the past, or currently are. So it does not affect your eligibility.

Mick Garry: Great. Well thanks so much, Hollie, for spending a little time with us today and getting us up to speed on the Affordable Care Act and how it applies to the Sanford Health Plan.

Hollie Scott: Thanks. We're happy to help. You can visit our website at sanfordhealthplan.com or give us a call at (888) 535-4831 and we're happy to help you walk through all your options.