Colorado Individual Health Insurance

Colorado Individual Health Insurance Coverage Outside of Open Enrollment:
Unless you have a qualifying event your only choices right now are for:

1.Short Term Medical Insurance
2. Coverage under an employer sponsored group health insurance plan if you need coverage before then next open enrollment in November. If you missed the deadline for open enrollment or are between jobs you do have a choice to get
Short Term Medical Insurance
. If you just got hired and have your 60 day waiting period this is a great option. Please go to
Short Term Insurance

 Note, this is CATASTROPHIC only, with no pre-existing conditions covered.

Do you qualify for Coverage outside of “Open Enrollment? Examples of qualifying life events For the purpose of triggering a Special Enrollment Period, these are some of the qualifying life events allowed by law:

  • Loss of existing health coverage because of a:
    • Job change
    • Job loss
  • Changes in your family due to:
    • Marriage or divorce
    • Birth or adoption of a child
    • Death of a family member
  • Permanently moving to a new location, that has a different coverage area
  • Loss of eligibility for:
    • Medicaid
    • CHIP (Child Health Insurance Plan)
  • Expiration of your COBRA benefits
  • Graduating college or losing coverage from your parent’s health plan
  • Gaining or losing a dependent
  • Change in disability status
  • Certain changes in your income
  • Changes in your household size

Not paying a bill will not count as an involuntary loss of coverage, so do notlet health insurance policies lapse. You
can enroll outside the marketplace if you meet the above criteria outside of open enrollment.

Did you enroll in an Individual Health Insurance and forget to add Individual Dental Insurance? You can enroll in Dental at anytime throughout the year: Dental Insurance with Cigna: Cigna Individual/Family Dental Insurance
Need Dental but don’t need to get a lot of dental work done? Discount Dental Plan Get a quote with access to 30+ discount dental plans, an affordable alternative to dental insurance. Save 10% to 60% on most dental procedures, including checkups, cleanings, braces, and cosmetic dentistry on select plans. Example, Crown that is normally $1200 will cost you $600-$800 depending on the plan you choose! You can look up your Dentist on line to see if the participate.

Discount Dental Plan
Hint: We use the Aetna Discount Dental Plan!
But look at the plans and dentist to see which is the best fit for you! Should you choose a Dental Insurance Plan or a Dental Discount Plan? That depends on your needs. If you have a lot of
dental work that needs to be done in the next year or two get the dental insurance plan. If you have current dental coverage on your previous plan you have “CREDITABLE” coverage with Cigna Dental Insurance so you have IMMEDIATE use of the major services benefit if you need crowns, periodontal, etc when you switch from another insurance or COBRA. Most insured plans have a 12 month wait on “major insurance”. If you just need cleanings and an occasional filling or just one crown in a year you may be better off with a discount dental plan.

Do I Qualify For A Subsidy???? Subsidy Eligible Instructions: For Health Colorado Individual Instructions.pdf
BY STEP Instructions for ConnectForHealth CO Please download our updated instruction list for open enrollment or have a qualifying event after open enrollment
on ConnectForHealth CO For Health Colorado IndividualInstructions.pdf
Please make sure I receive the ID and plan you chose and that I show up as your broker so that we can get billing set up for you Note: MOST of you will NOT qualify for a subsidy. Avoid the headache and purchase outside Connect For Health Colorado.


BUSINESS with 2-5 Employees: SMALL GROUPS

Important Information
Please note, if you are a business owner WITH EMPLOYEES and have been deducting individual policies it’s is not allowable after 7/1/15. You must have a GROUP plan in place to keep the IRS happy or be subject to fines/penalties.

Some of you will qualify for a 50% business tax credit. Please call me for a quote. Individuals and Families Health Coverage Information: ON Exchange / Marketplace and OFF Exchange/Marketplace Call to ask me about the fines and penalties you may be
subject to if you are carrying individual insurance on employees.

Frequently Asked Questions About Colorado Individual Health Insurance:

Who must use the Connect For Health Colorado exchange? No one is required to use the exchange. However, small businesses and individuals can only receive federal tax subsidies if they sign up for insurance through the exchange

If I Do Not Qualify (based on income) for the Marketplace/Exchange, Should I still apply on the Exchange? NO, NO, NO!
There are many options that we can help you with for coverage that meets the ACA guidelines outside of the Colorado Healthcare Exchange. You will have a variety of insurance companies and plan designs to choose from, you just will not be eligible for a subsidy from the exchange.
Please do NOT apply on Connect For Health CO if you do NOT need a subsidy as you’ll sit on hold in cue for hours, get hung up, and mostly be dealing with temporary staffers that are not able to handle questions about coverage, providers and medications.

Why Do I Need A Broker on Exchange? 
Most Licensed Brokers (some go by the title “agent”, especially if they are “captive” to one company) have years of industry experience and understand health insurance policies because they have been selling them for many years. Brokers have knowledge of the plan designs, the networks, how coverage works in and out of network, which plans and companies have limitations on certain benefits and which ones have richer benefits. They can also visit with you about how a plan might cover certain health conditions and be able to advise that one company and or network might help you better than another because of the years of working with these insurance companies. To work with the Colorado Healthcare Exchange in addition to handling life and health plans outside of the exchange, a broker must go
through online and classroom training to be a “certified broker”, listed on the Colorado Healthcare Exchange website and certified to work with you. Brokers also know the history of the companies when it comes to rate increases on blocks of business or even if the company has pulled out of certain markets. A broker can find you coverage if you are not eligible for the exchange. A broker is paid by the insurance company either way so it costs you the client nothing to assign a broker and work with that broker. 

The Colorado Healthcare exchange is advising most folks coming to the exchange to pick a broker as they do not have the staff to field all the calls.

How can we select you as our broker on the Connect For Health Colorado? A client may select a broker by clicking on the “Get Assistance” menu button on the upper right hand corner of their account screen. They may then select me as the broker of their choice by last name or license number. Brokers may also set-up an account for a client and send an invitation to the client to authorize them as their broker.

You can select Stacey Gilbert by going to ZIP CODE: 80126 and find me in the list or type in STACEY GILBERT in search

How Do Health Insurance Plans Differ Inside and Outside of The Colorado Healthcare Exchange? Insurance companies have filed plans both inside and outside of the Colorado Health Care Exchange. The plans for individuals inside the exchange are mostly HMO except for one insurance company and in most cases have a smaller network of MD’s and hospitals. Is My Doctor/Hospital On the Network? Some of the insurance plans on the Colorado Healthcare Exchange have limited networks for both doctors, specialists
and hospitals. Please make sure when you look at networks online that you are choosing 2015 and “exchange” to make sure the MD or hospital is in the network if it’s an “exchange” insurance plan

This is an IMPORTANT QUESTION-Please Read!
I Travel Around The US For Work…What are my best options for coverage?
AND/OR, I have a health condition and want the best care (cancer, heart, neurological, etc.), I run marathons or I am involved in sports nationwide: Make sure you choose a PPO or an EPO with Guest privileges in other states to have the best options to CHOOSE your care. Although an HMO is supposed to cover you in an emergency when you are out of town, some HMO’s will require you to return to the area to receive care once you are stabilized. In addition, you lose choice when you choose
some HMO’s. Let’s take an example, 6 months into a plan, you come down with an odd type of cancer and the oncologist in Denver tells you your best shot at treatment is a treatment and/or a new drug only available at MD Anderson Cancer Center in Houston or your heart specialist in Denver says you need a valve replacement and the best care for your situation is at Cleveland Clinic. With an HMO you have to submit to a Medical Director (the dreaded “death squad”) and he/she and a board sit every week to decide if they are going to provide treatment outside of the realm of the HMO contract. I worked for an HMO and used to visit with our in house MD. This is not the government making these choices (regardless of what has been in the media)….it’s your choice to give that power to them when you choose the HMO. It’s only in very unique circumstances that you get approved. I am sharing this because YOU want to have the option to get on a plane and from the time you land know that all your cost are covered either in network (because it’s a national network like Cigna with Centers of Excellence coverage) or under an out of network benefit to the annual cap on your policy (even if it means $15000-$25,000 out of your pocket vs. a medical director stamping “denied” and 100% out of your pocket. These are life and death decisions most people just don’t think about when they are selecting a policy and you will not be able to“switch” mid year as it’s adverse selection for an insurance company.

If you are a family with a child living outside of Colorado, again a PPO with a National network, or an HMO/EPO with guest privileges for the other state will be your best option.

How much is the tax subsidy for health insurance coverage for Individuals?
Tax subsidies will be set based on a person’s income level, his or her location and age. Subsidies will be greater for older Coloradans. A single person making from 133 percent to 400 percent of the federal poverty level will be eligible for a tax subsidy. A person making less than 133 percent of the federal poverty level will be covered by Medicaid.

The 133 percent-of federal-poverty-level amount is about $13,000 for a single person.

An example from the U.S. Treasury Department
: A family of four with an income of $50,000 would be expected to pay no more than $3,570 toward health insurance, under new rules. If a health insurance plan on the exchange turns out to cost $9,000, then the family’s subsidy would be $5,430 ($9,000 – $3,570).

How do you receive the tax subsidies? The tax subsidy on health-insurance premiums bought through the exchange can be received every month starting Jan. 1, 2016. Subsidies also can be received through tax returns filed at the end of the year. Please scroll down to the bottom of this page to see an example subsidy chart for individuals and families. This is subtracted off your premium.

Please Note: Qualifying for the subsidy requires you to APPLY FOR MEDICAID through PEAK and get DENIED by PEAK. The process is 45 minutes to an hour online to fill out the required data and then 2 weeks to 45 days until you can APPLY for medical coverage with the allowable subsidy amount

Can I purchase through Connect For Health Colorado if I have coverage through my Employer? You can shop through the Marketplace but unless your coverage is considered unaffordable, you will NOT be eligible for
the financial assistance through the Connect for Health Colorado Marketplace

Premiums are considered un-affordable if they are more than 9.5% of your wages.

To figure out if our company’s insurance is more than 9.5% of our income, is that the quote for just my husband or with everyone added onto the policy? It is affordable for just him but once he adds me it is more than 9.5%. No, It would be just the employee only. Tax credit calculations are based on your Modified Adjusted Gross Income. That is your Adjusted Gross plus foreign income, tax exempt interest and non-taxable social security benefits

How to Qualify For the Subsidy and Not Get Kicked Into Medicaid Medicaid is expanding its coverage for adults without kids and parents who have kids on Medicaid. You could be eligible for new coverage beginning in January if you earn less than $1,250 a month. You can apply starting in October. To qualify for the subsidy, you MUST apply for
PEAK/Medicaid FIRST. Once you apply you will either
get an approval immediately, a denial immediately from the PEAK Medicaid site or you can get a pending status with a tracking number where Medicaid will send them a letter will let them know if they are approved or denied. This is a few weeks to 45 days. For individuals $15,000 and under, some will only be offered Medicaid. Medicaid will be asking about household family members, employment. It’s rare to get approval or denial immediately. You need to fill out the Medicaid application ASAP so there is time to get qualified. $18,000-$20,000 input of income is probably the lowest you can put on the app to not get kicked into Medicaid. For couples or single parents, earned income of over $30,000 should qualify for a subsidy and not get kicked into Medicaid. For families with 2 adults and one child over $37,000 and for families with 2 children (4 household) over $44,000 income will get you a subsidy and not kick you into Medicaid. For 5 household $52,000, 6 in the household $60,000Information will confirmed by the IRS. This just based on EARNED income for 2014 (estimated), use your 2013 earned income to get a ball park figure. This does not include savings and investments. For instance, someone taking early retirement and drawing an “income” from retirement funds, that is their “earned income”. A business startup that is not taking salary at the beginning of the year but will take income that over the 2014 plan year is over these amounts will qualify for a subsidy.

What if I don’t make enough money to have to file taxes or a tax return, will I still be eligible for financial assistance?

Yes. You can receive the advanced premium tax credit if you haven’t paid taxes in the past or have not earned enough money to file taxes or a tax return. However, if you receive the tax credit, you will need to file a tax return the following year.

If a customer is determined eligible for Medicaid or CHP+ can they chose to purchase a private health insurance plan through the Marketplace?
Individuals may dis-enroll from Medicaid or CHP+ and purchase a health plan through the Marketplace. However, these individuals will not be eligible to receive tax credits or cost sharing reductions to help lower their costs of coverage.

I am experiencing technical problems with the Colorado Healthcare Exchange? What’s going on and can you help me?
The exchange is new, it’s clunky and has numerous problems with error messages.There have been statements made on CNN and Fox News that nationally, it’s questionable about what is going on with the data that has been entered. It’s one of the reasons you want to have a broker involved as an extra person to make sure your coverage is entered and approved.

The broker will make sure that your coverage is in place and follow up with the exchange to get reports on approval for coverage, proof of coverage and making sure you get your new insurance ID card.

When is open enrollment for Individuals?
Open enrollment starts November 1 for January 1 effective date
to purchase a a health insurance plan direct or if you qualified on Connect for Health Colorado. The next open enrollment date will be in November 1 2015 and  ONLY for a 2016 effective date unless you have a qualifying event.

I am on Specialty Level Medications or Injectables. How will they be covered in 2016? Please check the Prescription Formulary for the insurance plan you are evaluating. If you are taking a tier 4 or tier 5 level medication some of the new insurance plans both inside and outside the exchange have a CLOSED FORMULARY. If the medication is not listed, it’s NOT covered. Please, please make sure your meds are covered by that insurance company before you enroll for 2016. We have the formulary documents to look up the drugs, call me!

I am on maintenance drugs for: Asthma, Allergies, High Cholesterol, Menopause, Diabetes, etc.What limitations do I have when I pick a plan? Anthem Clear Protection is Generic Only. Some of the other plans are Generic (Tier 1) only. This means after the Rx copay for generic, Tier 2-5 drugs are NOT COVERED on a plan that says “GENERIC ONLY”. Please be aware as you pick a plan. If you choose a plan with Deductible and Co insurance and no Rx copay plan, your Rx will be under that deductible. For example the Asthma drug Advair might cost $400 with a contract amount from the insurance company might be $180 which would apply toward combined and Medical/Rx deductible. Several of the health insurance plans both on and off the exchange say N/A for Tier 5 drugs. This means it’s not covered and you need to find a different health insurance provider.

I have an HSA now and may switch to a non HSA plan what happens to the money in my account? You can keep the account but it’s not tied into a plan. The bank will audit. If there is no medical plan associated with the account, it may be converted to a regular savings account. You cannot fund the account but can spend the funds down to zero for qualified expenses for any qualified medical expense billed by the MD or hospital but not towards the deductibles or co-pay. You use this instead of your copay or deductible until the account is emptied out.

Are Smokers charged more for health insurance?  Each family member who smokes will have a smokers load on their rates. Some insurance companies are loading 15% on their rates.

I live in outside of the Denver/Colorado Springs area. What are my choices?  Anthem HMO and RMHP HMO for individuals. Cigna Individual is in Denver/Boulder and Colorado Springs and Summit/Eagle

EPO works like an HMO has NO out of network coverage, but you may choose a specialist without permission from a PCP. Out of network and out of state is considered out of network unless it’s an emergency, just as it is with any HMO.This may not be appropriate for folks with children who live out of state. Chiropractic is covered if it’s a Cigna or Cofinity network provider depending on the network as an “other office visit”copay

How Do I Find Out If My Doctor is In The Network? Don’t assume that your MD is in the network in if you stay with the same insurance company. A switch to the exchange and/or individual plans outside of the exchange may have a different network that is smaller than the network usedin previously.

Network List and Links:

Provider Directories


Anthem Blue Cross and Blue Shield / HMO Colorado Pathway HMO, Mountain HMO, PPO  Click on Find A Doctor

Humana Individual HMO Exchange, Non Exchange Individual/Group HMO, PPO Click on Coverage type, individual then: Colorado HMOx for HMO and NPOS for PPO

Kaiser Permanente HMO

Rocky Mountain Health Plan Click on Find A Provider (top of page above navigation) 

United Healthcare Group 2+ Non Exchange UHC

Colorado Choice Health Plans of Front Range   Compass HMO  Navigate EPO Networks

All the questions about health insurance and health care reform have me thinking about all of my coverage.

What other options are available to help my family and I round out our coverage and fill the gaps?
As your broker, we can look at all the coverage you currently have in place and supplement your health insurance where needed. Items we think should be reviewed/audited yearly:

  • Are you and/or your children active in sports, sports leagues, skiing, mountain biking, dirt biking, etc? Have you experienced a sports injury? What did you pay for a broken bone or surgery for a torn ACL?
    Accident coverage is inexpensive and helps pay your deductible with the high deductibles on these new health insurance plans. We have plans that cost around $1/day and can cover those big bills. A broken bone and minor surgery can easily set you back $7500-$12,000 (deductible/coinsurance)

  • Do you have adequate life insurance in place? A good rule of thumb is to have a minimum of ten times your salary and if youplan on sending kids to college and your spouse does not have nearby help should something happen to you, I like to use the rule of $500,000 to $1million for each child you have to fund care and the income lost over the many years you are gone to take care of that college funding. (ASK STACEYher personal story of a friend in Texas and how $1 million gave one of her closest friend’s the ability to grieve and take care of two bright girls (that are on a path to Hollywood today with one in an ABC Family movie this fall) when she was unable to find a job after a lay off and her ex died in atragic DUI hitting him).

  • Doyou have disability coverage?
    SSDI does not kick in unless you are almost a vegetable and can take 2 years toqualify for usually a $800-$1000 amount. Can you live on this? We have affordable options to “continue your salary” if you are disabled.

  • Does cancer, heart disease or diabetes run in your family?
    Critical Illness coverage is a popular option to help cover high deductibles and cover the cost of non medical items, travel for treatment and the peace
    of mind to have extra cash on top of your (60%) short term disability payment to pay your mortgage and utilities while you recover. For a low cost you can cover you and your family and if you die of other causes, one of our plans PAYS BACK ALL PREMIUMS (for death of other causes)…so you never lose.

  • Are you over 50 and have you experienced the cost of and extended care facility with a parent or grandparent?
    over $70,000 a year today. There are some great options that you can lock into with hybrid products that combine life insurance and long term care and help protect your nest egg.

  • Do you have a health condition and know you can’t qualify for life insurance or long term care coverage?
    We have excellent short term care policies that are under $1 a day in cost that pay a daily benefit for home health care only for one year and the app doesn’t ask a lot of questions. Your health insurance has limited home health care, nursing and rehab that is usually to 15 days. What will you do when that runs out?

Call 303-471-9424 or Contact Us for a quote now: Contact Form

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