Alemay Business Insurance
Health insurance and ACA Marketplace coverage, explained before you choose a plan
Choosing health coverage should not come down to whichever monthly premium looks smallest. The deductible, the network, your prescriptions and your out-of-pocket exposure matter just as much.
Alemay Business can assist with health coverage options within the scope of applicable licenses and may coordinate with appropriately licensed professionals when a product, carrier or jurisdiction requires it — including ACA Marketplace coverage when it applies to your situation.
English and Spanish, with a Miami office and virtual service when the plan and jurisdiction allow.
At a glance
- Service
- Health coverage review, plan comparison and enrollment support for individuals and families, including ACA Marketplace coverage when it applies.
- Who it is for
- People and families who need to obtain, review, renew or simply understand their health coverage.
- Access
- Assistance within applicable licensed authority, with appropriately licensed professionals involved as the product, carrier or jurisdiction requires.
- Where
- Miami and South Florida, and virtually where plans and licensing allow.
- How to start
- Schedule a consultation or reach out on WhatsApp.
Alemay Business Insurance
What this service helps with
To compare coverage properly you have to look at what you pay to keep it, what you could pay when you actually need care, which doctors and hospitals participate, which medications are covered and what rules the plan applies.
For Marketplace coverage, projected household income and household composition can affect certain tax credits and other financial assistance under the applicable rules. That is why the information you report should be kept current.
Our role is to make the decision understandable: organize your information, review the options available and stay with you through enrollment, mid-year changes and renewal.
Health insurance and ACA Marketplace coverage are not the same thing
Health insurance
The broad category of medical coverage. It can come from an employer, from a public program, or from the individual and family market. Each source has its own rules, costs, enrollment timing and options.
ACA Marketplace coverage
One specific channel through which eligible individuals and families can apply for, compare and enroll in individual or family plans under the applicable rules of the Affordable Care Act. It is one path to health insurance, not a synonym for it.
How the Marketplace works
The Health Insurance Marketplace is a system for applying for and comparing individual and family health plans that are eligible under the applicable ACA rules. Eligibility and financial assistance are determined under Marketplace rules based on the information reported and the applicable requirements.
When the process involves the Marketplace, Alemay Business works within applicable licensed authority and coordinates with the professional who holds the licenses, registrations, certifications or authorizations that apply to the product, jurisdiction and coverage year.
Important clarifications
- HealthCare.gov operates the federal Marketplace used in many states
- Some states operate their own Marketplace
- Private insurance carriers issue the plans
- The Marketplace is not the insurance carrier
- Alemay Business is not the Marketplace
Alemay Business is a private company and is not HealthCare.gov, the Health Insurance Marketplace, CMS or a government agency.
This may be for you if
- You do not currently have health coverage
- You lost or are about to lose coverage through an employer
- You are self-employed or work as an independent contractor
- You are covering a household rather than just yourself
- Your family recently grew
- Your household or income changed during the year
- Your current plan costs more than it used to
- You want to check whether your doctors participate in a plan
- You take prescriptions and want to understand how a plan covers them
- You are renewing coverage and want to review it first
- You are comparing plans and the terminology is not clear
- You received a Form 1095-A and are not sure what to do with it
Who does what: the Marketplace, the licensed professional, the carrier and Alemay
The Marketplace
- Processes the corresponding application
- Determines the eligibility results that belong to it
- Calculates or reports certain financial assistance under applicable rules
- Allows available options to be compared
- Facilitates enrollment
The licensed professional
- Explains how the process works
- Handles application and enrollment within their authority
- Reviews the options available to them
- Walks through plan features with the consumer
The insurance carrier
- Issues the policy
- Administers the coverage
- Determines and administers the provider network
- Applies benefits, costs and plan rules
- Processes claims under the contract
Alemay Business
- Understands your situation
- Organizes your information and documentation
- Identifies which process may apply
- Assists within applicable licensed authority
- Coordinates licensed professionals when required
- Connects coverage and tax preparation when relevant
Neither the licensed professional nor Alemay Business makes the eligibility determinations that belong to the Marketplace, or the issuance, network and benefit decisions that belong to the insurance carrier.
Open Enrollment and Special Enrollment Periods
Timing matters as much as the plan you pick. Enrollment in Marketplace coverage generally happens in one of two ways.
Open Enrollment
The regular annual window when Marketplace coverage can be requested, changed or renewed. Each coverage year has official dates, and those dates should be verified for the specific year rather than assumed from a prior year.
Special Enrollment Period
Outside Open Enrollment, enrolling generally requires eligibility for a Special Enrollment Period based on a qualifying life event or another applicable circumstance, subject to the rules and verification requirements in effect.
- Loss of certain qualifying coverage
- Marriage
- Birth
- Adoption
- Certain changes in residence
- Other circumstances recognized under Marketplace rules
These are general examples. Not every life change creates a Special Enrollment Period: whether an event qualifies depends on the circumstances and on the rules in effect, and documentation or verification may be required. Windows can also be limited, so it is worth reviewing a change as soon as it happens.
What affects Marketplace eligibility and financial assistance
Eligibility and financial assistance are determined under applicable Marketplace rules based on the information reported and the applicable requirements. We help you organize and report that information accurately; we do not determine the outcome.
No one can promise a subsidy, a premium tax credit amount or a particular premium before the applicable determinations are made.
Information that can matter
- Projected household income
- Household size and composition
- Coverage available to the household
- Other applicable circumstances
Changes during the year can change your coverage picture
Marketplace coverage is based on the information reported. Reporting material changes promptly may affect eligibility, the plan options available and any advance premium tax credit amount applied to your premium.
- Income goes up
- Income goes down
- Marriage
- Divorce
- Birth or adoption
- The number of dependents changes
- A change of address or residency
- Gaining or losing other qualifying coverage
- Employment changes
- Other relevant changes
Some of these changes may also affect whether a Special Enrollment Period is available, which is a separate determination under the applicable rules.
The premium is only part of the cost
- Premium
- The amount you pay to keep the coverage in force.
- Deductible
- The amount you generally pay for certain covered services before the plan begins to share certain costs, subject to the plan's rules.
- Copay
- A fixed amount that may apply to certain services under the terms of the plan.
- Coinsurance
- A percentage of the cost of certain services that may be the member's responsibility under the terms of the plan.
- Out-of-pocket maximum
- A limit that applies to certain covered in-network expenses during the plan year, subject to the corresponding terms.
- Network
- The doctors, hospitals, facilities and other providers that participate with the plan.
- Drug formulary
- The list and structure through which a plan covers certain prescription medications.
Two plans with similar premiums can produce very different financial experiences once you actually use the coverage.
Networks, prescriptions and benefits are plan-specific
Provider networks, drug formularies, benefits and cost sharing are set by the plan and the carrier, and they can change. If a particular doctor, hospital or medication is important to you, verify it against the actual plan information before enrolling.
Providers worth checking
- Primary care doctor
- Specialists
- Hospital
- Clinic
- Medical center
- Laboratory
- Other providers relevant to your care
Prescriptions worth checking
- Whether the medication appears on the formulary
- Tier, where applicable
- Applicable copay or coinsurance
- Pharmacy
- Restrictions
- Prior authorization
- Quantity limits when they apply
- Covered alternatives when applicable
HMO
Usually built around a specific network, and may require a primary care doctor and referrals for certain services, depending on the plan's rules.
PPO
May offer more flexibility to see certain providers, with different costs in network and out of network depending on the plan's rules.
EPO
Usually concentrates coverage among participating providers, with its own rules for out-of-network care depending on the plan.
Other structures
Other structures may exist depending on the market, the coverage year and availability. Not all of them are offered in every market.
No network structure is better or worse on its own, and metal categories such as Bronze, Silver, Gold and Platinum mainly describe how costs are shared — they are not a rating of medical quality.
Categories of benefits ACA-compliant plans generally address
- Outpatient care
- Emergency services
- Hospitalization
- Pregnancy, maternity and newborn care
- Mental health and substance use disorder treatment
- Prescription drugs
- Rehabilitative and habilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services
How each of these is covered, and at what cost, still depends on the specific plan and carrier.
Comparing plans and reviewing a renewal
Plans, prices, networks and formularies can change from one coverage year to the next, so a renewal deserves the same review as a first-time enrollment. These are the points we go through with you:
- Premium
- Deductible
- Out-of-pocket maximum
- Network
- Doctors
- Hospitals
- Medications
- Copays
- Coinsurance
- Benefits
- Household composition
- Projected income
- Financial assistance available
- New options
Marketplace coverage and your tax return
Some eligible Marketplace enrollees may qualify for advance premium tax credits under the applicable rules. Actual eligibility and the amount depend on the applicable law and rules and on the household information reported.
A Marketplace enrollee may receive Form 1095-A. If advance premium tax credits were paid on your behalf, they generally must be reconciled on your federal income tax return using Form 8962. Changes in household or income during the year can affect that reconciliation.
Tax preparation is a separate service. If you receive a Form 1095-A or want help with your return, our Personal Tax Preparation team can take it from there.
Before you file
- Confirm your Form 1095-A is accurate
- Check that it reflects the coverage and months that apply
- Have any mid-year changes documented
- Keep the information reported to the Marketplace consistent with your return
This section is general information, not individualized tax advice.
How we work your case
- 01
We understand your situation
Who needs coverage, what you have today and what you are trying to accomplish.
- 02
We look at timing and the applicable process
Whether the case points to Open Enrollment, a possible Special Enrollment Period or another applicable path.
- 03
We organize the information
Household composition, projected household income, current coverage and the details the process requires.
- 04
Available options are reviewed
The appropriately licensed professional reviews the plans available and features such as premium, network, deductible, prescriptions and out-of-pocket costs.
- 05
Application and enrollment
Before anything is submitted, you review and confirm that the information reported is accurate, and the required consent for the corresponding assistance is documented. The Marketplace and the carrier determine the results that belong to them.
- 06
Follow-up
Mid-year changes, renewal and coordination with your tax preparation when it applies.
We do not promise effective dates or processing timelines: those depend on the Marketplace, the carrier and the information available.
What information we may need
Depending on the process that applies, we may ask for:
- Names of household members
- Dates of birth
- State of residence
- ZIP code
- Household composition
- Current coverage
- Access to employer coverage
- Projected household income when applicable
- Doctors who matter to you
- Preferred hospitals
- Medications
- General coverage needs
- Documentation requested by the Marketplace or the insurance carrier
Protect your information: please do not send your SSN, detailed medical history, full policy numbers, banking information or sensitive financial or medical documents through WhatsApp, public forms or unauthorized channels. We will point you to the appropriate secure channel.
What our service can include
- Initial consultation
- Coverage-needs review
- General education about ACA / Marketplace coverage
- Identification of the applicable enrollment period
- Review of a possible Special Enrollment Period
- Household composition organization
- Projected household income organization
- Coordination with the appropriately licensed professional
- Comparison of available options
- Premium review
- Deductible review
- Copay and coinsurance review
- Network review
- Doctor and hospital review
- Prescription coverage review
- Application
- Enrollment
- Documentation
- Renewal
- Mid-year changes
- Form 1095-A and Form 8962 coordination when applicable
- Coordination with our Personal Tax Preparation service
- Follow-up
Not all of these apply to every client: the scope depends on the case, the plan and the jurisdiction, with regulated functions handled within applicable licensed authority.
What we do and what we do not promise
What we do
- Review your coverage needs
- Explain the terminology in plain language
- Assist within applicable licensed authority
- Coordinate appropriately licensed professionals when required
- Help you organize your information
- Review the options available
- Support the application and enrollment process
- Explain how Marketplace coverage connects to your tax return
- Help you review changes during the year
- Coordinate renewal and follow up
What we do not promise
- Eligibility
- A Premium Tax Credit
- An APTC amount
- Cost-Sharing Reductions
- Medicaid
- CHIP
- A Special Enrollment Period
- A specific plan
- A specific insurance carrier
- A specific doctor in network
- A specific medication covered
- A specific premium
- Free coverage
- A “$0 premium”
- A $0 deductible
- Approval
- An exact effective date
- A specific amount of savings
- A refund
- A tax outcome
What is outside anyone's control here
- Marketplace eligibility determinations
- Premium tax credit or cost-sharing reduction amounts
- Marketplace and carrier processing, plan availability, policy issuance where applicable and effective dates
- Which plans a carrier offers in your area
- Which providers participate in a plan's network
- Which medications appear on a plan's formulary
- Premium, deductible and cost-sharing amounts set by the plan
- Changes carriers or the Marketplace make from one coverage year to the next
Why Alemay Business
Coverage and taxes under one roof
The same team can support your Marketplace coverage and, as a separate service, your federal income tax return. If advance premium tax credits were paid on your behalf, they generally must be reconciled on your federal income tax return using Form 8962.
Total cost, not just the premium
We look at how a plan would behave when you actually use it, not only at the monthly payment.
Network review
We help you review which providers participate according to the plan's information so you can verify before you decide.
Prescription review
We look at how a plan structures coverage for the medications you take today.
Licensed professionals
Regulated functions are handled within applicable licensed authority for the product, jurisdiction and coverage year.
Partner network
When a case calls for another license, specialty or jurisdiction, we bring in the appropriate professional.
Follow-up through the year
Mid-year changes, renewal and document coordination when it applies.
Bilingual service in Miami
English and Spanish. 9380 SW 72 ST, Suite 230B, Miami, FL 33173. Virtual service when the product and jurisdiction allow.
Availability by jurisdiction
Plan and professional availability is confirmed based on the state, the market and the coverage year.
A coordinated team around your coverage
Alemay Business assists within the scope of applicable licenses and works with the appropriately licensed professional for the product, the authorization and the jurisdiction involved.
Stay connected with Alemay through Ale app
Ale app is the digital platform of Alemay Business. From your phone, you can explore our services, access helpful resources, schedule appointments and stay connected throughout the process.
Frequently Asked Questions about health insurance and the ACA Marketplace
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Schedule a consultation with Alemay Business to review who needs coverage, which enrollment path may apply and how the available options compare on cost, network and prescriptions.
Alemay Business is a private company and is not HealthCare.gov, the Health Insurance Marketplace, CMS, a government agency or an insurance carrier. Health coverage is assisted within the scope of applicable licenses, with appropriately licensed professionals involved when the product, carrier or jurisdiction requires it. Eligibility and financial assistance, including any premium tax credit, are determined under applicable Marketplace rules based on the information reported and the applicable requirements. Plan availability, premium, provider network, formulary, deductibles, copays, coinsurance and covered benefits depend on the specific plan and carrier and may change. Enrollment outside Open Enrollment may require eligibility for a Special Enrollment Period based on a qualifying life event or other applicable circumstance, subject to the rules and verification requirements in effect. Nothing here guarantees eligibility, enrollment, Marketplace or carrier processing, policy issuance, a premium, a subsidy amount, plan availability, provider participation, prescription coverage, benefit levels, an effective date, savings, a refund or any tax outcome. This page is informational: the plan documents control, and nothing here is individualized medical, tax or legal advice.
Alemay Business · 9380 SW 72 ST, Suite 230B, Miami, FL 33173 · 305-300-2346 · business@alemaybusiness.com · Fax 305-402-0706