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Explain These 3 Healthcare Components to Every Client

As healthcare issues continue to evolve and increase in complexity, clients will turn to you for advice when it comes to finding a plan that fits their needs. As a CPA, there are three key areas of Medicare and the Affordable Care Act that you should have a strong understand of and be able to explain to your clients to avoid any mistakes.

When They Should Enroll


Each of Medicare’s many moving parts has its own enrollment requirements. For example, the enrollment process for Medicare Part A (hospital insurance) is fairly straight forward and can be done online. But Medicare Part B (medical insurance) is much more complex.

There are three enrollment periods for Medicare Part B: initial enrollment around the 65th birthday, special enrollment for those that had active group coverage beyond age 65 and general enrollment during the first quarter of every year. The general enrollment in the first quarter only applies to individuals that did not qualify for special enrollment or didn’t enroll during the initial enrollment. Since the general enrollment period is considered a punitive period, it comes with penalties on lifetime premiums and gaps in coverage. It’s critical for your clients to meet enrollment deadlines in order to avoid any penalties.

The Affordable Care Act

The ACA restricts enrollment to one set period per year. During this time, individuals can purchase coverage from the health insurance marketplace, but are locked into that plan once the period ends until the following year. The only exceptions to this are major life events that create a special enrollment opportunity. The open enrollment period for 2016 runs Nov. 1, 2016 through Jan. 31, 2016.

What Qualifying Events Are

Qualifying events that create a special enrollment opportunity for both Medicare and the ACA are:

·      26-year-old children losing eligibility for coverage on their family’s plan

·      Job loss

·      COBRA ending

·      Marriage

·      Divorce

·      Retirement

·      Death of a spouse

·      Relocation


If you have Medicare clients that relocate, this could affect their Medicare Advantage or Medicare Part D enrollments. Many private Medicare supplements are not portable and many states allow underwriting of applications for new supplements outside the initial enrollment period. In other words, this means that there is no qualifying event protection and an application can be denied.

The Affordable Care Act

Under the ACA and HIPAA, a person has 63 days from the date of the qualifying event to apply for new coverage outside the annual open enrollment period. The documentation required is up to the discretion of the new insurer.

Who is in their Provider Network


Medicare offers a wide choice of providers, though in some areas doctors are opting out because they prefer cash payment. The Medicare Advantage plans are different, so it’s important to explain to your client the network and out-of-network benefits. Though there are more Advantage plans than in the past, make sure your clients are familiar with the network restrictions if they are enrolling in a HMO-type (Health Maintenance Organization) product.

The Affordable Care Act

The ACA has led to an increase in insurance products, but with a more limited network of physicians and hospitals. It’s important for all clients to understand their provider network before choosing a plan, but it especially important for clients who are battling a serious illness or have residence in more than one state.

In the case of clients who reside in more than one state, out-of-network benefits provide little protection for them. This is because there is no contact between the provider and insurer, so there are no limits to what an out-of-network provider can charge. 

Register for our webinar to learn the key issues you should be aware of when it comes to Medicare.

This article was sourced from the AICPA Blog.

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