Pioneers in 5 Star Service • Ronstadt Insurance • Tucson, AZ • 520-721-4848

Health Insurance FAQs

1)Do Individual Health Policies differ from Employer Sponsored Group plans?

Coverage offered in individual health insurance policies used to differ greatly from group health insurance plans. It was very common for individual policies to exclude maternity coverage, or have limitations on mental health benefits. Individual health policies always excluded pre-existing conditions or could turn you down if your current health needs outweighed the cost of the premium you paid.  Employer sponsored group plans included these coverages as standard, and mostly did not exclude pre-existing conditions or decline to offer to policyholders.

Today, with the passage of the Affordable Care Act (ACA), both individual policies and employer sponsored group policies must cover the “10 Essential Health Benefits”, (click here to download The 10 Essential Health Benefits), to be considered a “Qualified” health insurance policy. Individual health insurance consumers may no longer “carve-out” coverages like maternity, or pediatric dental & vision regardless of their age or gender.  

2) What is a Qualified Health Insurance Policy?

The Affordable Care Act (ACA) requires that all health plans offered through either, direct from the insurance company or through an employer meet the Minimum Essential Coverage” rule.  (Click here to read more)  As well as meet certain levels of “Actuarial Value” referred to as “Metal Levels” —Bronze, Silver, Gold and Platinum.  (Click here to download more on “Metal Levels“)

Metal levels are intended to allow consumers the opportunity to compare plans with similar levels of coverage in order to help make better informed decisions about the  coverages. The thinking was that carriers would offer similar policies for all levels in the same metal tier (all silver plans, for example). Consumers could then focus on other policy factors, such as the premiums and physician networks, when selecting a health plan.  This is not always the case.

3) Do I have to buy a Qualified Health Insurance Policy?

No, but starting on January 1, 2014, every American and legal resident, unless they are eligible for Medicaid/AHCCCS, Medicare, Indian Health Services or certain Military Coverage, must pay a penalty/tax to the federal government when they do not.  This part of the ACA is called the Individual Mandate.  

(Click here to read more)

4) When can I sign up for a Qualified Health Insurance Policy?

The days of signing up for insurance whenever you wanted are gone. Today, the only way you can sign up for an individual policy that qualifies as Minimum Essential Coverage and does include any pre-existing condition limitations is either at Open Enrollment, January 1st of every year, or if you have a “Special Election Period” (SEP).  These include:

  • Birth
  • Adoption
  • Marriage
  • Divorce
  • Lose of prior coverage

If you are signing up for an employer sponsored group plan, the SEP rules also apply, in addition to:

  • Satisfying a new hire waiting period

5) What makes a Qualified Health Insurance Policy “Affordable”?

Your income.  Seriously, the Affordable Care Act defines “Affordable Premiums” as not exceeding 9.5% of your household income for families without employer sponsored health plans and 9.5% of your W-2 for individuals and families with employer sponsored health plans.

For individuals and families that do not have Employer Sponsored Health Insurance – you could qualify for a tax credit to pay a portion of your premiums based on your household income.

For individuals and families that are eligible for an Employer Sponsored Health Insurance – If your employer offers you one or multiple qualified plans to choose from and your employer subsidizes your “Employee Only” premiums so you don’t pay more than 9.56% of your W-2 wage for Employee Only coverage of a Bronze plan, you and your family are NOT eligible for government tax credits.  No double-dipping!

6) This is all so confusing, can you help me and how much will it cost me?

We represent all the top carriers and it doesn’t cost you a penny more to gain access to our expertise. Broker commissions are already built into the premiums, so we suggest you take advantage our the service we can offer you at no additional cost.    

7) Don’t I have to buy my Qualified Health Insurance Policy though

Absolutely not!  The one and only reason you would ever want to consider creating and account and applying for coverage on, is if you qualify for assistance from the government to pay the policy premium.  If you do not qualify (see chart below), do not waste your time.  We can show you all the options in Arizona and help you pick the right one, based on your budget, the benefits you feel comfortable with and the your doctors network preference.

Let us help find the best policy for you!

Give us a call (520) 721-4848 to set up an appointment.


Information taken from the National Association of Health Underwriters website and the IRS website