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Healthcare and The Incoming Administration

The attached article – Donald Trump Walks Back His Stance On Obamacare shows a possible change in direction of the incoming administration and it’s not totally unexpected.

YOCG Tuesday 2 2 16 CANVAThere are so many people covered by insurance now that were never covered before it would almost be impossible to unwind what’s already been done and put something else in place that does not look like just about the same thing.  You know that old saying…if it looks like a duck and quacks like a duck…its a duck.   Maybe its a Trump duck instead of an Obama duck….but its still a duck.  

The affordable care act (Obamacare) was based on a few core principles. The most important ones in my opinion are…

1. No one should be turned down for any pre-existing medical condition

2. People who could not afford insurance would get subsidies or some kind of assistance to help with the cost

3. Everyone would be required to have insurance that consists of what is called MEC (Minimum Essential Coverage). This is also called the “Individual mandate”

It’s these principles that define Obamacare. Everything else in my opinion, surrounds these principles and if changed, really does not effect the basic core principles.  Some examples of things that could be changed that would lower the cost of coverage to most people include….

 – Should pregnancy coverage be included in all policies?

 – Should mental health coverage be included in all policies?

 – Should rehab coverage be included in all policies?

YOCG Tuesday 11 24 15 CANVAMaybe these coverage’s should be options like when you buy a car.  Everyone gets the basic car but if you want a radio it’s extra, if you want bigger tires it’s extra, if you want a sunroof it’s extra, you get the point.

I think we need to bring healthcare coverage back to its original intent, to cover you for what you want to be covered for and not what the government says that you should be covered for.  Of course everyone should have at least basic well-care and hospitalization coverage but should everyone have to pay for all the options? 

Read the article HERE

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2017 Open Enrollment…Are you READY?

It’s that time of year again!  Get ready to start thinking about open enrollment and what you need to do to make sure you and your family have health insurance coverage.

Here is what you need to know!


Open enrollment for 2016 is CLOSED.  BUT, If you still need coverage for the rest of 2016, you can get it but, only if you qualify. 

To qualify you need to meet one of these two criteria:

  • Special Enrollment Period due to a life event — like losing health coverage, getting married, or having a baby.
  • You qualify for Medicaid or the Children’s Health Insurance Program (CHIP).

You can apply for these programs any time throughout the year.

Let’s Brush Up On The Marketplace

About The Marketplace:

Who is it for?  The Marketplace is for individuals who do not have health coverage for the coming year.  That means, you do not have coverage through:

  • Your employment
  • Medicare
  • Medicaid
  • The Children’s Insurance Program (CHIP)
  • Another source providing qualifying coverage

How Much It Costs:

Health insurance through the Marketplace depends on your estimated income for the coverage year.  Did you know?  In 2017, roughly 8 out of 10 of uninsured people who are eligible for Marketplace coverage will qualify for financial assistance.*  The financial assistance  provided goes towards lowering the cost of the monthly premiums and in some cases is can also help with things like deductibles and copays.  Get an idea of what that could mean for you HERE.

Discover What The Marketplace Insurance Covers:

Essential health benefits – Every plan must include the following:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
  • Pre-existing conditions, including pregnancy
  • Preventive care
  • Birth control coverage
  • Breastfeeding coverage

Pre-existing conditions, including pregnancy

Preventive care

Get a list of what that includes for:

What If You Do Not Get Health Insurance?

If you can afford health insurance and fail to obtain qualifying health coverage for the 2017 year, you may be fined.  This fine is referred to the “individual shared responsibility payment”. 

Fees are calculated in two different ways.  They are:

  • A percentage of your house hold income
  • Per person

You will be required to the highest rate calculated.

Fines for 2017 have not been released as of yet.

Do you have questions about your health insurance coverage for 2017?  I can help!  Contact me, Your Obamacare Guy!  I can be reached at:  (813) 391-3448 or email address:

* source:  http://www.HealthCare.gove/quickguide

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Open Enrollment & Obamacare Changes YOU Need to Know About!

Healthcare Open Enrollment is RIGHT Around the Corner! 

There are LOTS of Changes YOU Need to Know About!

yocg-tuesday-9-6-16-canvaHealthcare open enrollment begins on November 1, 2016 and runs until January 31, 2017 and it won’t be business as usual.  There will be several carrier changes for 2017. 

Before we get into the specific changes, there are some dates you need to put on your calendar for the open enrollment period:

  • November 1, 2016:  Open Enrollment Begins
  • December 15, 2016:  Meet this enrollment deadline to ensure coverage begins on January 1, 2017
  • December 31, 2016:  Coverage ends on this date.  If you have NO changes to your plan, your plan will be auto-renewed
  • January 31, 2017:  This is the VERY LAST day you can apply for 2017 healthcare coverage

If you miss these deadlines, you cannot enroll again until November 1, 2017 unless you have special “life event” changes take place.  Life event changes include:  having a baby or losing your job.

Did you know?

If you do not enroll in Obamacare or have an approved form of health insurance during 2017, you will be fined 2.5% of your income or $695 per adult – whichever is higher.  Please note that the amounted listed is only an estimation as the higher 2017 dollar amount has not been released as of yet.

Those living at poverty levels can enroll at any time in the Medicaid or CHIP (Children’s Health Insurance Program).  These programs do not have a specific enrollment period or timeframe to adhere to.  Please note, there are some restrictions to adhere to such as income restrictions.


yocg-wednesday-9-1-16-canvaAt the beginning of this article, I noted there were going to be changes in the Florida Marketplace.  There will be some carriers leaving and some new additions too!

Let’s first say good-bye to:

  • United-Healthcare
  • Aetna

Say Hello to:

  • Cigna – they exited the Florida Exchange in 2015 but are coming back in 2017
  • Molina – They are expanding from South Florida to the Tampa Bay area
  • Harken Health (a subsidiary of United Healthcare) is planning to enter the exchange in the Miami and and Fort Lauderdale area

Of Note:

Humana plans to scale back it’s participation in the Marketplace but will remain in the Florida Exchange system. 

Other changes coming down the pike in 2017 include rate changes that have not been approved by the state yet.   

Other Obamacare changes people can expect to see in 2017 are:


When you select a healthcare plan, there are usually two things you ask:

1)  How much is it going to cost me

2)  Is my doctor or the hospital I prefer in my plan

A common complaint last year was inaccurate doctor and hospital information.  The new rules mandate that:

  • Insurance providers are required to give consumers a 30-day notice when a doctor is being removed from a network
  • If a doctor/provider is being removed from a network and a patient is in active care/treatment with the physician being removed, the insurance company must allow for up to 90 days treatment under the physician’s care

Reduction in “Surprise” medical bills from out-of-network providers

Many patients have complained about receiving unexpected invoices and bills from out-of-network doctors, even when the patient thought the doctor was in network.  The new rule calls for:

  • Ancillary care amounts to be applied towards a patient’s yearly out of pocket maximum expenses

Note, this rule only applies to those instances where the insurer has not given patients the correct notification that they will be receiving care from individuals outside of the network.  The general rule is that a patient must be notified that they will receive care from an out of network provider within 48 hours.

Better Explanation of Out-Of-Pocket Expenses/Costs

During 2017, insurers are to offer plans with a standard set of coverage costs (deductibles and copays).  With this information easily attainable, the patients will better understand the out-of-pocket fees associated with the plan they select.

Do you have specific questions about open enrollment and how the 2017 marketplace changes could affect you?  Contact me, Your Obamacare Guy!  I can be reached at:  (813) 391-3448 or email address:

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Physician Referrals, YOU Have A Choice!

Physician Referrals, YOU Have A Choice!

Health care and visiting the doctor has become increasingly complicated to navigate. Rules are always changing.  Life is busy which makes it hard to keep up with the changes.  Good news!  I am here to help!  So, let’s dive in!!!

Wednesday 7 6 16When do I need a referral?

Referrals are generally required when you need to see a specialist for a condition that your regular primary care physician cannot treat.  Not all specialists need a referral.  The services that DO NOT require referrals are:

  • In network:
    • Obstetrician/gynecologist
    • Urgent care centers or walk in clinics
    • Eye examinations
    • Mental health disorder and substance abuse services
    • Pathologist
    • Radiologist
    • Anesthesiologist
    • Emergency room visits/admissions
    • Non-physician services such as:
      • Outpatient labs
      • Diagnostics
      • Physical Therapy
      • Durable medical equipment

How do I obtain a referral for a specialist?

Once your primary care physician determines a specialist is needed, to help you with your condition, a referral is given.

A Referral is an authorization for you to see a specialist.

In some cases, your physician may give you a recommendation of who to see along with his referral.  A recommendation is exactly what it sounds like.  It is a suggestion of who you might want to consider seeing for treatment, not a mandate.  This is great news!  Why?  For many reasons!  Check them out:

  • Many times, your primary physician may recommend a specialist who is not in your network.  This can be a very expensive option for you.
  • You have the opportunity to research and find the perfect specialist for you within your health insurance network
  • In some cases, referrals are generated due to a quid pro quo arrangement between doctors.

Now that you have your referral in hand, it is time to select your specialist.  One of the first things you should do is fire up your computer and search for the doctor in your insurance plan’s database.  Not sure who is in your carrier’s database or where to even find the database?  No worries, use this handy tool:  Dave’s Doctor Search.  Here you will find all of the doctor’s listed in the each of the major health insurance carriers.

Select at least three specialists you are interested in possibly using for treatment and learn more about them.  Some of the things you will want to look for are:

  • Is the doctor licensed?  You can verify this by visiting your state’s physician licensing board
  • Is the physician board certified?  A board certified physician is one who demonstrates exceptional expertise in a specialty or subspecialty.  They are certified and recognized by the ABMS Member Board.  Qualifications to be recognized by this board includes rigorous testing and peer evaluations.  These evaluations and tests are engineered and administrated by other specialists in the same field of specialty.
  • Consider the age of the doctor.  Are they older and considering retirement, are they younger and have a passion for cutting edge technology and techniques or have they been practicing a long time giving them ample experience to treat your condition well?
  • Discover how long the doctor has been practicing by visiting online doctor listing sites.
  • Have there been interruptions in their practice and why?
  • What hospitals is the doctor affiliated with and how are those hospitals ranked?
  • Has the doctor experienced any reprimands or malpractice suits?
  • Consider researching doctor ratings sites and review sites.
  • Has the doctor authored any papers, studies or conducted research in the field you are looking to get treatment in?

There is so much to consider when selecting a doctor and a specialist!  The most important thing to remember is that YOU get to make the choice on who treats you.  Take control of your health and your healthcare by selecting the physician that makes the most sense for you and your health goals.

Remember, the referral you receive from your primary care physician (PCP) is the authorization you need to go to the specialist.  The name of a doctor they give is a recommendation only.  Do your homework and find the right fit for you.

Do you need help navigating your way through today’s healthcare arena?  I can help!  Contact Dave, Your ObamaCare Guy for more information at: (813) 391-3448 or email me at

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SureMed…It’s What You Have Been Waiting For!

SureMed…It’s What You Have Been Waiting For!

YOCG Wednesday 5 4 16 CanvaWhat if I told you there was a healthcare solution allowing you the opportunity where your entire family can talk to a physician anytime, for only $20 a month!?!  It’s true!  Without any other additional or hidden charges either!  20 dollars…that’s it!

Great news!  This plan IS a reality!!!  PLUS…your own health insurance plan may cover prescriptions if one is called in!

Interested?  Read on!

SureMed offers a unique service that gives you access to a physician by phone 24/7 without being charged an additional consultation fee.

This service completely revolutionizes visiting the doctor!  Imagine…

  • Speaking to a U.S. licensed, board certified physician and getting your questions answered from the comfort of your own home!
  • Receiving advice and consultation from knowledgeable, board certified physicians with an average of 15 years practice experience!
  • Being diagnosed via the phone or video consultation!
  • The pleasure of avoiding crowded waiting rooms, busy walk-in clinics and additional germs found in those places!
  • Quick response time!  Call backs from qualified physicians take place within an average just 16 minutes!

What can be diagnosed over the phone or by video consultation?

YOCG Thursday 5 5 16 CanvaSureMed has made it easy for you to receive consultation, diagnoses, and prescriptions over the phone for common illnesses like:

  • Colds
  • Flu
  • Poison Ivy
  • Respiratory Infections
  • Bronchitis
  • Allergies
  • Pink eye
  • Sinus Problems
  • Urinary Tract Infections
  • Ear Infections
  • Non-emergency illnesses

Treatment Recommendations

The doctor can advise patients on the treatment actions to be taken and may even prescribe medications such as antibiotics and other substances not controlled by the DEA or other medications which are susceptible to abuse.  If a prescription is required to treat the illness diagnosed, the doctor can have it called in to the local pharmacy of your choice.

Check out what else is included…

The $20/month program includes ALL of these amazing benefits:

  • Doctors by phone
  • Counselors by phone
  • Dental discounts
  • Vision discounts
  • Prescription discounts
  • Retail health clinic discounts
  • Medical bill saver – medical billing advice and negotiation help
  • Vitamin discounts and price comparison
  • Lab discounts
  • Diabetic supplies discounts
  • MRI & CT Scan discounts
  • Hearing aid discounts
  • Durable medical equipment discounts

It almost sounds too good to be true but it is!

If you have questions about this plan and want more details, call me!  I would love to talk you about this incredible opportunity for you and your family!

Call me, Your Obamacare Guy at (813) 391-3448 or email me at

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The Plain English Guide to Understanding Health Insurance Deductibles, Coinsurance and Maximum Out-of-Pocket Expenses

YOCG Tuesday 11 24 15 CANVAWhether you just enrolled or you are getting ready to enroll in a new health care plan there are 3 things you need to clearly understand regarding your new policy.  They are:

  1. Deductibles
  2. Coinsurance
  3. Maximum Out of Pocket Expenses

Many times the policy you have is written in industry jargon that it is hard to understand just what is exactly being said.  We are going to cut through the jargon for you and simplify the terms so you completely understand this portion of your health insurance policy.


A deductible is the amount you pay for healthcare services before your health insurance policy begins to pay.  Below is an example:

  • Jane’s health insurance deductible is $1,000.
  • In most cases, other then the items below, Jane will need to pay 100% of her medical and pharmacy bills until she has paid out $1,000 ….
    • Doctor co-pays
    • Medication co-pays
    • Annual wellness checkup
  • Once Jane has met her deductible amount of $1,000 she shares the cost of her plan by paying coinsurance.


Coinsurance is your portion or share of the costs of healthcare.   Depending on the type of health insurance plan you have, your percentages may vary.

Below is an example:

Jane enrolled in a health insurance plan that included a coinsurance program.  The coinsurance program Jane’s health insurance carrier provided was an 80/20 plan.  The 80/20 plan means that after Jane meets her deductible of $1,000, the insurance company will pay 80% of healthcare services.  Jane will be responsible for 20% of the costs up to her maximum out of pocket limit.

For example:

After Jane meets her $1,000 deductible, she makes an appointment to see her doctor.  Since Jane has met her deductible, coinsurance is now available for Jane to use.  Jane’s health insurance offers an 80/20 coinsurance plan.

For simplicity sake, let’s say it costs $1000 for a medical procedure.  Based on Jane’s 80/20 coinsurance plan, this is how much Jane and the insurance company will each pay to cover the cost of her visit to the doctor.

  • Jane’s health insurance company will pay 80% = $800
  • Jane will pay 20% = $200

Its important to note that once Jane hits her maximum out of pocket limit the insurance company pays 100%

Sometimes people use the terms co-insurance and co-pay interchangeably.

Please know, they are two very different things.

A co-pay is a specific, fixed dollar amount you must pay every time you visit a doctor.  It is not a percentage of doctor fees as described above. To find out what your plan requires, call the customer service number on the back of your insurance card or the insurance agent who services the policy.

YOCG Monday 11 23 15 Canva-2Maximum Out-Of-Pocket Expenses:

An out-of-pocket expense is a non-reimbursable expense paid by the patient.  This is most you will pay for covered services during a health insurance policy period.   A health insurance policy period is usually a year.  The year is usually based on the calendar year starting January 1 and ends December 31.

What IS Included in Maximum Out-Of-Pocket Expenses:  

All of these items go toward your Maximum Out-Of-Pocket Expenses.  Please note that if your plan does not cover a particular service, or the service is not an essential benefit, it may not count toward your maximum.  You would need to clarify this with your health insurance plan.

  • Your yearly deductible
  • Includes cost sharing after the deductible is met
  • In most cases the co-pays

What is NOT Included in Maximum Out-Of-Pocket Expenses

  • Premiums
  • Healthcare services your health insurance does not cover

The maximum out-of-pocket limit for those on Obamacare compliant Plans:

  • Individual: $6,850
  • Family: $13,700
  • In many cases the amounts are lower based on income and family size.

Hopefully our guide gave you more clarity about deductibles, Coinsurance and Maximum Out-of-Pocket Expenses.  The best advice for you to follow is; talk to a professional about health insurance and get the guidance you need to ensure you are selecting the plan that is the best for you and your family’s situation.

Are you unsure who you should talk to?  Call me, Your Obamacare Guy!   You can reach me at:  (813) 391-3448 or email me:

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Subsidies, Deductibles & Premiums…OH MY!

Obamacare Guy Thursday 10 15 15Open Enrollment has OFFICIALLY begun!  As of November 1, 2015, you can get covered, change health plans or upgrade your current health plan without needing a change in life status.  AND…Right about now you may be in the midst of learning more than you ever needed to know about your income and how it relates to the Affordable Care Act’s (a.k.a. Obamacare) subsidies and deductibles.

This blog post is going to help you tremendously as we explore what a subsidies are, how you get them and how you can qualify for lower deductibles.

What Are Subsidies?

A subsidy is financial assistance you receive to help pay for health insurance coverage. A subsidy reduces your cost for insurance.

You may also qualify for reduced deductibles, and reduced co-pays.

Who Benefits From Subsidies?

Subsidies were designed to help low to moderate income Americans afford health insurance coverage.

To receive subsidies, you must have coverage on a plan in the Marketplace.

There are 3 types of subsides or cost assistance a person can receive.  They are;

  • Advance Premium Tax Credits which are used to lower premiums
  • Cost Sharing Reduction to help lower out-of-pocket costs
  • Medicaid and CHIP

How are Subsidies Calculated?

Your Obamacare Guy Tuesday 10 13 15 CANVASubsidies are calculated based on income and are available to people and their families who have an income level between 100-400% of the Federal Poverty Level.  Many people refer to this as the “FPL”.

NOTE:  The FPL or Federal Poverty Level adjusts every year to account for inflation.  This adjustment allows more citizens to quality for subsidies.

Specifically, the calculation used is something called MAGI or Modified Adjusted Gross Income.

MAGI is sum of the following:

Adjusted Gross Income +
Non-Taxable Social Security Benefits +
Tax-Exempt Interest +
Excluded Foreign Income
= MAGI (Modified Adjusted Gross Income)

Once you qualify for subsidies there are some points you should be aware of:

  • Subsidies are only valid on Plans purchased in the marketplace
  • Your marketplace health insurance plan cannot cost you more than 9.5% of your income AFTER tax credits are applied
  • The amount of cost assistance you can gain is based on the second lowest cost of the Silver Plan in your state’s marketplace

Who is NOT Eligible for Subsidies?

  • People reporting over 400% of the FPL will not be eligible for cost assistance
  • Those who have access to affordable, employer-based health insurance
  • People eligible for Medicare
  • Those who fall into the Medicaid gap

NOTE:  People who are making under 138% of the FPL are eligible for Medicaid.

When can I Apply for Subsidies?

Open enrollment is the PERFECT time to apply for subsidies and cost assistance.  If you don’t apply during open enrollment, you will need to wait until the following year’s open enrollment period or if you experience a life qualifying event.

Exploring Deductibles…

Obamacare Guy Tuesday 10 6 15 CANVAWhat is a deductible?

This is the amount of money you need to pay out-of-pocket for covered services before you insurance begins to pay.

This amount does NOT include:

  • Insurance Premiums
  • Costs that are NOT covered by your plan
  • Deductibles re-set every policy period

What happens after I meet my deductible?

Once you meet your deductible, your health insurance plan will pay it’s portion of your coinsurance.

Now that we know the basics of deductibles, discover how Obamacare has impacted them.

Here are some FAST FACTS pertaining to IN-NETWORK deductibles:

  • Obamacare mandates that major medical plans must meet specific cost sharing deductibles
  • Deductibles cannot be hight than out-of-pocket limits
  • Individual out-of-pocket limits are $6,600 (2015 figure)
  • Family out-of-pocket limits are $13,200 (2015 figure)

Deductibles – The More You Know…

Here are some quick tips you should be aware of when thinking about deductibles.

  • Deductibles start when your policy begins
  • Policy periods usually run from January 1st and ends December 31.  To ensure that you are taking full advantage of your policy period, make sure you are enrolled in a plan by December 15.
  • If you switch your plan mid-year, you may lose any deductibles already utilized
  • If switching plans during the year, try to use the same carrier to see if deductibles can be rolled over
  • Low deductible plans usually have higher premiums
  • High deductible plans tend to have lower premiums
  • Premiums do not count towards your deductible
  • Co-insurance usually does not start until deductibles are met
  • Co-pays usually go toward deductibles and out-of-pocket maximums

Obamacare Guy 9 30 15 CanvaThere is A LOT to consider during open enrollment and it can be confusing.  The best thing you can do for you and your family is to get sound advice from a professional.  As Your Obamacare Guy, it is my mission to help you get covered with the best plan and help you get the subsidies you need.

Call me today for help navigating your options when it comes to health insurance:  (813) 391-3448 or email me:

Glossary of Terms:

A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.

Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay coinsurance after you’ve met your deductible. For example, if the health insurance plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your 20% coinsurance payment would be $20. The health insurance plan pays the rest.

Cost Sharing:
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.

The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 for covered services. Some plans pay for certain health care services before you’ve met your deductible.

A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.

(The amounts below are 2015 numbers and used for calculating eligibility for Medicaid and the Children’s Health Insurance Program (CHIP). 2014 numbers are used to calculate eligibility for savings on private insurance plans for 2015.

•$11,770 for individuals
•$15,930 for a family of 2
•$20,090 for a family of 3
•$24,250 for a family of 4
•$28,410 for a family of 5
•$32,570 for a family of 6
•$36,730 for a family of 7
•$40,890 for a family of 8

The figure used to determine eligibility for lower costs in the Marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have.

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Health coverage that’s obtained through financial assistance from programs to help people with low and middle incomes.

Glossary of terms were provided by: