OnlineNavigator.org logo

This information was current as of the beginning of 2017 but does not include any changes made by the federal government under the Trump administration.

OnlineNavigator health insurance exchange Q&As

CONTENTS

General Q&As

What is a health insurance exchange?
What is OnlineNavigator?
What is a navigator?
Is navigator training available?
How can I find a government-appointed navigator?
How is a navigator different from an agent or broker?
Do navigators work for non-government insurance exchangers? If so how are they paid?
What is the advantage of using a navigator?
When is a health insurance navigator better than an insurance agent?
When is it not useful to use a health insurance navigator?
How do I become a navigator?
Who provides OnlineNavigator service?

Eligibility

Who is eligible to use OnlineNavigator service?
What is required to use OnlineNavigator service?
How is OnlineNavigator service delivered?
When is OnlineNavigator service available?
What is the cost of OnlineNavigator service?
Why is OnlineNavigator service offered without a fee?
What if I'm not eligible for OnlineNavigator service?

Pricing and subsidies

How do I find out the cost of health insurance and whether I qualify for free coverage or a premium subsidy?

How do I calculate income for purposes of determining eligibility for a premium subsidy?

What if I do not know my Adjusted Gross Income?

Is it ethical for wealthy people to take the Obamacare premium subsidy?

Can I get a premium subsidy if I enroll on a private insurance exchange?

Enrollment

How do I enroll in coverage?
What information do I need to provide?
What about privacy?

Benefits

What benefits are available?

Payment

Who pays for the coverage?
How will I know if I qualify for an insurance subsidy?
How much is the insurance subsidy?
Who pays for OnlineNavigator service?

Claims

How do I file a claim for benefits in an insurance plan?

Limitations and Warranty

What are the limitations of OnlineNavigator service?
What is the satisfaction guarantee and refund policy?

GENERAL TOPICS

What is a health insurance exchange?

“Exchange” in this context simply means “marketplace.” We exclusively support online exchanges and are not involved with in-person community based enrollment. The federal and state governments may use the term in different contexts. Commercial insurers also have health insurance exchange. The products and services are expected to vary among thee different exchanges however the availability and pricing of qualified health insurance should be the same regardless of the exchange.

Each state will have at least one insurance exchange serving individual residents and small businesses who buy their health insurance directly. Some health insurance exchanges will be operated by insurance companies, other commercial businesses and non-profit entities. Employers may opt to have employees use an exchange to find insurance to replace their current health benefit plans in order to allow employees access to more insurance choices. Consumers will likely notice a wide difference in the products and services available among different insurance exchanges, however any specific insurance policy will be priced identically regardless of which insurance exchange is selected.

What is OnlineNavigator? 

OnlineNavigator is a personal advisory service that helps individuals and businesses understand their health insurance options, especially when considering the options available under the new health reform law. OnlineNavigator is designed as an easy-to-use, one-on-one personal service the supplements the automated online consumer health exchange resources offered by the U.S. Department of Health and Human Services, state governments and other commercial sources. Our focus is to help expand understanding of health insurance options in connection with the federal health insurance clearinghouse and state health insurance exchanges.

OnlineNavigator is a privately operated business not affiliated with any government entity, health plan or insurance company.

What is a navigator?

A navigator is the term used by the Affordable Care Act to refer to a health insurance adviser paid by the government, a government-funded entity, or an insurance exchange to provide advice to individuals and businesses. The navigator's role will be further defined by the U.S. Department of Health and Human Services, the state governments and the commercial health insurance exchanges in the future.

 OnlineNavigator is not a government-sponsored navigator and is not connected with the federal or state government's navigator programs. Additionally, there is no expectation that OnlineNavigator service will resemble the government's navigator services. Our service is an independent and unaffiliated service operating outside of the norms of the government-sponsored navigator service.

Is navigator training available?

The federal government offers excellent online training and certification. It is free and available at your own schedule. I’ve taken all of them and was favorably impressed. See https://marketplace.cms.gov/technical-assistance-resources/training-materials/training.html

How can I find a government-appointed navigator?

OnlineNavigator will make a referral to a government-sponsored navigator program for more assistance however at this time we have no functional referral arrangements and the process for making referrals has not yet been developed. We expect this service will be developed in the future. In the meanwhile, see the list of navigator grant recipients in your state.

How is a navigator different from an agent or broker?

Both help individual enroll in insurance. The primary differences are the business structure and the form of compensation. The agent or broker is paid a commission by the heath plan. A navigator is paid a fee by the government or insurance exchange. Agents and brokers are generally required to maintain higher levels of training, licensing and continuing education than navigators but that training might not focus on qualified health plans. Each state may modify the rules for its own insurance exchange navigators.

This Q&A is provided as incidental discussion only; there is no implication that OnlineNavigator resembles either a navigator or agent or broker.

Do navigators work for non-government insurance exchangers? If so how are they paid?

These details are not yet available so we do not know. For now, we presume that insurance navigators on non-governmental exchanges are treated the same as agents or brokers.

This Q&A is provided as incidental discussion only; there is no implication that OnlineNavigator resembles either a navigator or agent or broker.

What is the advantage of using a navigator?

A health insurance navigator provides assistance with qualified health insurance plans that are typically not available through insurance agents. These include public insurance plans and non-commissionable insurance options.

This Q&A is provided as incidental discussion only; there is no implication that OnlineNavigator resembles either a navigator or agent or broker.

When is a health insurance navigator better than an insurance agent?

If you want personal help finding insurance to cover a pre-existing medical condition, are seeking entry in to a public health plan like Medicare or Medicaid, child-only coverage, COBRA or HIPAA conversion plan or want assistance completing an insurance application form then a navigator can typically provide more useful assistance than an insurance agent.

This Q&A is provided as incidental discussion only; there is no implication that OnlineNavigator resembles either a navigator or agent or broker.

When is it not useful to use OnlineNavigator?

We are not qualified for nor prepared to assist with enrollment in Medicaid plans or similar plans meant for low income individuals.

This Q&A is provided as incidental discussion only; there is no implication that OnlineNavigator resembles either a navigator or agent or broker.

 

How do I become a navigator?

States or their contracted lead agencies will hire in-person assistors later in 2013. We suggest reading the postings on the LinkedIn health insurance navigators discussion group for more information.

Who provides OnlineNavigator service?

OnlineNavigator service is provided primarily by the principal Tony Novak. Other advisers provide support and respond to routine inquiries. Neither OnlineNavigator nor Tony Novak is affiliated with on a candidate for any state agency navigator contract but we may provide service to or join with another entity that intends to provide this service to a state exchange.

Tony Novak is an accountant and licensed health insurance agent in all states with more than 25 years experience as a health reform advocate. He is trained as a compensation planner and has worked as a benefits accountant and adviser for the various companies that make up the Freedom Benefits network. His articles and recordings about health reform and health insurance planning are reproduced in dozens of traditional and online media publications. Contact information is available on this site and a more detailed biography and list of credentials is available at www.tonynovak.com.

ELIGIBILITY AND AVAILABILITY

Who is eligible to use OnlineNavigator service?

Individuals who are employees or memgers of contracted groups are eligible for service. to check eligibility call (800) 609-0683 or email tnovak@onlinenavigator.org.

OnlineNavigator service is offered only in English language. The navigator reserves the sole right to determine whether service will be offered. (Sorry we do not have service available to non-English speaking individuals).

While only legal residents of the United States can get government-provided financial subsidies for insurance premiums, OnlineNavigator provides assistance with insurance designed for immigrants and visitors regardless of their legal status.

What is required to use OnlineNavigator service?

Users must have the ability to use a personal computer and have a personal e-mail account. We support enrollment in online insurance exchanges only; paper enrollment is not available.

Please note that while OnlineNavigator service can be provided to a person using a mobile Internet device like a Blackberry, IPhone or IPads, most insurance enrollment Web sites do not support these devices. For this reason we recommend that you use OnlineAdviser service when you are at a personal computer.

Since the insurance and if applicable, the OnlineNavigator service must be paid for through an electronic transaction, a bank account or credit card account is also required.

How is OnlineNavigator service delivered?

At this time, only e-mail service is available as a first contact. Telephone service, if available, will be offered in the email response.

When is OnlineNavigator service available?

Services are offered on a limited "first come, first served" basis during east coast business hours. Requests for service outside these hours will be granted based on availability of a navigator.

Availability of a navigator service varies but is generally expected to be available within one business day of the date of payment or other time requested, if later. You can request a specific appointment time or call without an appointment. Busiest times are the last day of the month and the first two days of the month. Mondays and Fridays are busier than other days.

What is the cost of OnlineNavigator service?

OnlineNavigator service is offered at no cost to the user.

Why is OnlineNavigator service offered without a fee?

The employer or association pays the cost of service.  The adviser may be paid a fee to advertise, review, endorse or refer users from any of the other companies, insurance exchanges or related programs mentioned.

What if I'm not eligible for OnlineNavigator service?

Other support options are expected to be available for health insurance enrollment although the current situation is uncertain. Also, traditional insurance agents and social assistance programs are available that provide similar services without a fee outside of the insurance exchange.

OnlineAdviserTM is a service similar to OnlineNavigator that offers consumer support by telephone and email for online transactions for products and services other than health insurance. See www.onlineadviser.org for details on this service.

PRICING

Do I qualify for a health insurance premium subsidy?

If your income falls below the minimum amounts shown below for your family size, you may qualify for coverage under your state’s Medicaid program that provides overage at no cost. But if your state is not expanding Medicaid in 2014-and you don't qualify for Medicaid under your state's rules--you can’t get lower costs on Marketplace coverage based on your income. If your falls below the maximum amounts shown below for your family size, you may qualify for a subsidy to pay part of the cost of your health insurance. If your income is higher than the maximum in the range for your size household, you would have to pay the entire cost of a Marketplace insurance plan.

  • for individuals: 11,490 to $45,960
  • for a family of 2: $15,510 to $62,040
  • for a family of 3: $19,530 to $78,120
  • for a family of 4: $23,550 to $94,200
  • for a family of 5: $27,570 to $110,280
  • for a family of 6: $31,590 to $126,360
  • for a family of 7: $35,610 to $142,440
  • for a family of 8 or more: $39,630 to $158,520

See https://www.HealthCare.gov/will-i-qualify-to-save-on-monthly-premiums/ for more information.

How do I calculate income for purposes of determining eligibility for a premium subsidy?

Eligibility for subsidized health insurance or Medicaid* through the health insurance exchanges is based on household Modified Adjusted Gross Income (MAGI). For most people MAGI will be the same as the more familiar "Adjusted Gross Income" or "AGI". To calculate MAGI, start with AGI and make the following adjustments shown below:

Three Step Calculation of Modified Adjusted Gross Income (MAGI)

STEP 1: Start with Adjusted Gross Income (AGI) that can be found directly on a personal income tax return:

Use Line 4 on a Form 1040EZ or Line 21 on a Form 1040A or Line 37 on a Form 1040, depending on which type of tax return is used. In cases where multiple tax returns are filed for the same household (for example, when a minor child reports income separately from the parents), then the incomes are combined.

STEP 2: Add back:

Non-taxable Social Security benefits (Line 20a minus 20b on a Form 1040), Tax-exempt interest (Line on 8b on a Form 1040), Foreign earned income and housing expenses for Americans living abroad (calculated on a Form 2555)

STEP 3: (Applicable only if you are determining Medicaid eligibility) Subtract:

Scholarships, awards, or fellowship grants used for education purposes and not for living expenses, Certain American Indian and Alaska Native income derived from distributions, payments, ownership interests, real property usage rights, and student financial assistance ( Note that an amount received as a lump sum is counted as income only in the month received).

The resulting number is Modified Adjusted Gross Income.

*Medicaid eligibility is generally based on MAGI for parents and childless adults under age 65, children and pregnant women, but not for individuals eligible on the basis of being aged, blind, or disabled. For more information see Internal Revenue Code Section 36B(d)(2)(B) and Public Health and Welfare Code Section 435.603(e).

What if I do not know my Adjusted Gross Income?

For most people, "Adjusted Gross Income" that is used to calculate eligibility for a premium subsidy can be obtained directly from a personal federal income tax return. If a tax return is not available, AGI can be calculated manually:

Include wages, salaries, tips, etc., taxable interest, taxable amount of pension, annuity or IRA distributions and Social Security benefits, business income, farm income, capital gain, other gains (or loss), Unemployment compensation, ordinary dividends, alimony received, rental real estate income, royalties, partnerships, S corporation income, income from trusts, taxable refunds, credits, or offsets of state and local income taxes, and other taxable income as defined by IRS.

Do not include Supplemental Security Income (SSI), veterans’ disability payments, workers’ compensation or child support received. pre-tax contributions, such as those for child care, commuting, employer-sponsored health insurance, flexible spending accounts and retirement plans such as 401(k) and 403(b), are not included in AGI but are not listed above because they are already subtracted out of W-2 wages and salaries.

Exclude Certain self-employed expenses (the deductible part of self-employment tax; SEP, SIMPLE, and qualified plans; health insurance deduction), student loan interest deduction, tuition and fees, Educator expenses, IRA deduction, Moving expenses, penalty on early withdrawal of savings, Health Savings Account deduction, alimony paid, domestic production activities deduction, certain business expenses of reservists, performing artists, and fee-basis government officials.

Is it ethical for wealthy people to take the Obamacare premium subsidy?

The question comes up for people, especially self-employed individuals, who report substantial net worth but low taxable income. While we hesitate to make any declaration on a topic of ethics that is expected to have broad interpretation, we can offer these points:

It is both legal and generally considered ethical to arrange your financial affairs to minimize taxes. In 1917 Judge Learned Hand, one of the most influential Justices of the Supreme Court wrote "Any one may so arrange his affairs that his taxes shall be as low as possible; he is not bound to choose that pattern which will best pay the Treasury; there is not even a patriotic duty to increase one's taxes". That opinion forms the basis of the ethics of tax and benefits planning today. Since federal subsidies are intentionally designed to be based on taxable income and not on assets or wealth, it follows that there is no ethical conflict for a person with low taxable income to obtain the premium subsidy regardless of assets or wealth.

Can I get a premium subsidy if I enroll on a private insurance exchange?

Yes, but not yet. Private firms have contracted with he government to offer this service to the public but the technology is not yet worked out. Unlike the government exchanges, the private insurance exchanges are not legally bound to offer service by a specific date regardless of the availability or quality of the features. Although no specific launch date has been announced, some people familiar with the exchange launch feel that this technology will be available on most private insurance exchanges by early in 2014.

Some states are likely to be slow to allow subsidies for enrollment through a private exchange. Since the states have made a substantial investment in their exchange that generally does not work as well as the private insurance exchanges, limiting availability of the subsides are being used to ensure return on investment of the state exchanges.

INSURANCE ENROLLMENT

How do I enroll in coverage?

All of the health plans supported through this service can be accessed through the online insurance exchanges. Enrollment may be completed online on your own without the assistance of a navigator or agent however these services may be available for those who want personal assistance.

What information do I need to provide?

The only information absolutely required by the navigator is your name, date of birth, address, social security number, email address and telephone number. Additional information like health history, household or business budget, income tax  data and preferred medical provider is not mandatory but is likely to result in better recommendations.

Information for businesses is different and varies depending on the size, legal structure and location of operations of the firm. The primary data  needed is employee census, including salary data and the firm's benefit strategy (the intent, if any, to fund part or all of health benefits through employer contributions or voluntary salary deductions).

Information required on an insurance application varies widely for 2012 and 2013 but is expected to become standardized in 2014. Some required details on medical history and a few may request that you provide a copy of your medical records. Other insurance companies simply request basic identity information. Until 2014 an insurance company may decline to issue coverage based on your medical history.

None of the health insurance companies require a medical exam or laboratory test as a requirement in the insurance application process.

What about privacy?

The health insurance navigator does not release your private information to anyone in the course of providing this service. Private information that you provide to the navigator is used only for the purpose of making recommendations. During the process of making an application for insurance the navigator may assist you in releasing information as specifically intended to a health insurance company.

Health insurance companies have their own privacy policies and are subject to the federal health information privacy law known as HIPAA.

The navigator does not retain or store protected health information as defined by HIPAA law, does not have access to insurance company records and does not meet the requirements of a covered entity under the law.

See our privacy policy for more information.

BENEFITS

What benefits are available?

Four basic health standardized health insurance plans are authorized by federal health reform law to begin in 2014 although the details of the standardized coverage are not available at this time.

For 2012 and 2013 the benefits vary widely from state-to-state and from month-to-month. Some health plans may have income limitations and health eligibility requirements prior to 2014.

PREMIUM PAYMENTS

Who pays for the insurance coverage?

Beginning in 2014 Individuals who earn less than the income amounts determined by state guidelines qualify for government-subsidized health insurance. Individuals pay the remainder of the cost for their own coverage. For 2012 and 2013 individuals pay the entire cost.

Businesses may pay for the cost of health insurance coverage for their own employees, or they can split the cost with the employee. Businesses that pay for coverage may be eligible for a tax credit.

How do I know if I qualify for an insurance subsidy?

The exchange will verify your residency status and the income you report at the time you apply for coverage and then confirm the amount of the subsidy.  Subsidies are only available for certain types of basic health insurance coverage. Subsidies are not available for limited benefit insurance, mini-med plans and supplemental insurance. The exchange can help you estimate the amount of the subsidy before you actually apply for coverage. See the comments on this issue above.

How much is the insurance subsidy?

The subsidy is based on a sliding-scale subsidies determined by income for individuals and families who earn up to four times the federal poverty level (about $44,700 for singles or $92,200 for a family of four). If your income exceeds these amounts, there is no subsidy. See the comments on this issue above.

The government’s subsidy is based on the premium cost for the second-lowest-cost insurance plan at the "silver" coverage level that is available in your area. You may select a higher or lower cost insurance and the difference in cost does not change the amount of the subsidy.

A family of four headed by a 40-year-old making $35,000 will get a $10,742 subsidy towards the annual premium cost of $12,130. They’d have to pay $1,388, about 4 percent of their income, or about $115 a month. If the insurance they select costs more, then their expense will be higher.

A similar family making $90,000 will get a $3,580 subsidy. They would have to pay $8,550 of the same $12,130 policy premium. That works out to more than 9 percent of their income, or about $710 a month. If the insurance they select costs more, then their expense will be higher.

OnlineNavigator can help you estimate the amount of the subsidy before you apply for coverage.

Who pays for OnlineNavigator service?

A payment plan is not determined at this time and may depend on the development of the health insurance market in 2014 and beyond.

CLAIMS AND ASSISTANCE

How do I file a claim for benefits in an insurance plan?

OnlineNavigator is not authorized to provide policyholder service or assist with a claim. We will provide the contact information of the member service resources for your health plan.

LIMITATIONS AND REFUNDS

What are the limitations of OnlineNavigator service?

Services are limited to the specific functions described in the terms of service. The navigator can offer only the options available on the health insurance clearinghouse or exchange and cannot modify any offer of a health plan provider. The navigator cannot act on behalf of the health plan or provide customer services to health plan members.

OnlineNavigator service is limited in both scope and availability. The adviser incorporates reference to these limits on an individual or case-by-case basis in the course of providing service.

What is the satisfaction guarantee and refund policy?

No refund or satisfaction guarantee is offered for the basic navigator service. Refund is available for the paid enhanced enrollment service if you are not satisfied with the service.