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Tag Archives: Health Reform Update

Seven Tips to Navigate Health Reform

CMS Announces Special Enrollment Period for Tax Season

Eligible consumers have from March 15 through April 30 to enroll in coverage


The Centers for Medicare & Medicaid Services (CMS) announced today a special enrollment period (SEP) for individuals and families who did not have health coverage in 2014 and are subject to the fee or “shared responsibility payment” when they file their 2014 taxes in states which use the Federally-facilitated Marketplaces (FFM). This special enrollment period will allow those individuals and families who were unaware or didn’t understand the implications of this new requirement to enroll in 2015 health insurance coverage through the FFM.

For those who were unaware or didn’t understand the implications of the fee for not enrolling in coverage, CMS will provide consumers with an opportunity to purchase health insurance coverage from March 15 to April 30.  If consumers do not purchase coverage for 2015 during this special enrollment period, they may have to pay a fee when they file their 2015 income taxes.

Those eligible for this special enrollment period live in states with a Federally-facilitated Marketplace and:

  • Currently are not enrolled in coverage through the FFM for 2015,
  • Attest that when they filed their 2014 tax return they paid the fee for not having health coverage in 2014, and
  • Attest that they first became aware of, or understood the implications of, the Shared Responsibility Payment after the end of open enrollment (February 15, 2015) in connection with preparing their 2014 taxes.

The special enrollment period announced today will begin on March 15, 2015 and end at 11:59 pm E.S.T. on April 30, 2015.  If a consumer enrolls in coverage before the 15th of the month, coverage will be effective on the first day of the following month.

Here are seven vital tips to navigate health reform for 2015 and beyond. Be sure to download the PDF flier with this information to print and share.

ONE:  As of January 1, 2014—All new plans on or off the federal exchange marketplace are guaranteed issue with no exclusion of pre-existing conditions—which means the insurance company cannot deny you for coverage and they can’t exclude any of your medical conditions. Read More…

Will congress defund health reform?

Defund or Delay? Don’t Count On It.

National Health Underwriters reports,

It’s been widely reported that when Congress returns from August recess, some Republican lawmakers hope to tie defundreform defundinging of health reform provisions to the overall federal government funding continuing resolution that needs to be passed by September 30. Many of these lawmakers have proclaimed defunding as their last and best hope to stop health reform implementation. As an alternative, some conservative groups have endorsed a one-year delay of all of the provisions of the law slated to take effect on January 1, 2014.

Not everyone in the GOP agrees. Many conservative thought leaders and political leaders, including Representative Paul Ryan, Senator Tom Coburn, Mitt Romney among others, have said they think the defunding plan is a bad one. Representative Tom Cole, who before being elected to Congress was a national GOP pollster and political operative, has even predicted that going forward with a defunding strategy could cost the GOP the House of Representatives in the 2014 midterm elections. Polling data bears that out—a recent health policy tracking poll shows that by a 2-1 margin voters say they will be less likely to vote for their member of Congress in 2014 if they support a health reform defunding effort tied to a government shutdown.

It’s important to know that the train has left the station.  Health Reform and 90% of its major provisions will spring to life on 01/01/2014. It’s important to get a game plan to determine how you will navigate health reform.  All politics aside, there are some critical decision (with potentially long term impact) that each of us must make this fall. Finding the right health insurance quotes in Ohio will take time and a clear understanding of where you fit into the system.

Here is a partial list of the provisions set to arrive in 2014.

  • All health products will be guarantee issue with no pre-existing condition exclusions.
  • No health status rating; ratings limited to
    • Age 3:1
    • Tobacco 1:5:1
    • Family Size
    • Geography (notice how your medical claims history and prescription use has no impact on how much you pay)
  • Health Insurance products must exhibit at least 60% “actuarial value”, must cover “essential health benefits”
  • Employer mandate (penalty delayed until 2015 but measurements for penalty will occur in 2014)
  • Individual mandate (all individuals are required to have health insurance, starting 01/01/2014)
  • Exchanges – an online marketplace where those eligible for federal subsidy will buy health insurance (starts 10/01/2013)

Many individuals are more comfortable with professional assistance when making decisions that involve detailed and confusing material.  Evaluating Health Reform coverage, federal subsidy money available and the complex enrollment on the exchange marketplace is unlike any other healthcare program you have evaluated in the past.  Mistakes can be costly.  This is why we developed our Health Advocate Program.

A Health Advocate will provide one on one consulting is designed to provide you the information and assistance you need as you navigate through all your options so you can confidently choose what is best for your personal situation.

About The Author…

matt_81x106 Matthew Byrne has made a career helping people find affordable health insurance in Ohio. He is the founder of MyHealthQuoter.com, a Dublin-based brokerage providing health insurance quotes in Ohio, and additional services for individuals, families and corporations. Mr. Byrne is a subject matter expert speaking frequently about Health Care Reform, Defined Contribution Programs, COBRA, and Medicare. He can be reached at (614) 336-3636, and online at www.MyHealthQuoter.com.

Need a Health Reform Speaker? Find Matt on COPEC! http://copeceducation.org/speaker/Matthew.Byrn

Navigating Health Reform – First Dollar Coverage & Preventive Care?



One of the most common questions people ask is “Why should I buy health insurance if I am healthy? And what do I get for my premium dollar?” If your plan is health reform compliant, then it should provide preventive care at no out-of-pocket cost. And that’s not a bad start.


Read More…

Apples and Oranges: Understanding the Four Levels of Health Care Coverage

apple-orangeOne of the most common—and justified—complaints heard from consumers when it comes to choosing heath insurance plans is the difficulty in comparing different plans, whether it is from the same carrier or across different carriers. It has likened to the challenge of comparing “apples to oranges,” as the old saying goes. That’s one of the reasons the Patient Protection and Affordable Care Act (PPACA) has established what it refers to as the Four Metal Levels of Health Care Coverage. Read More…

Switching Up Your Grandfathered Health Plan: Hit the Gas or the Breaks?

4364595229_e4b455182c_mA few weeks ago I posted an article about some of the changes in President Obama’s Patient Protection and Affordable Care Act (PPACA or, “Obamacare”)—changes that were not forthcoming but were already here. This is still news to many people, despite the fact that the vast majority of change is due to go into effect come January, 2014.

Most of those previous changes went into effect in September, 2010. If your health plan predates that time, it is likely “grandfathered,” which means that it is not subject to most of the new mandates. Because of these mandates, according to the PPACA,  the vast majority of policies issued since September, 2010 must now include: Read More…

Navigating Health Reform (Part 6 of 7) (Medicare)

MyHealthQuoter.com provides Medicare Supplement, Medicare Advatnage Plans and Part D drug coverage for Medicare Elligible Recipients. Our brokers are informed, available and reliable. We’ll give you honest answers without the sales pressure. Call (866) 577-3620.

Below is a helpful timeline that shows what legislative changes are coming based on PPACA Health Refrom from the Obama Administration.

This is part of a 7 part series called Navigating Health Reform, please review some of our past entries.

Part 1: http://www.ohioindividualhealthinsurance.net/?p=422
Part 2: http://www.ohioindividualhealthinsurance.net/?p=432
Part 3: http://www.ohioindividualhealthinsurance.net/?p=437
Part 4: http://www.ohioindividualhealthinsurance.net/?p=444
Part 5: http://www.ohioindividualhealthinsurance.net/?p=510
Part 6: http://www.ohioindividualhealthinsurance.net/?p=524
Part 7: http://www.ohioindividualhealthinsurance.net/?p=625

Reduces annual market basket updates for inpatient and outpatient hospital services, long-term care hospitals, inpatient rehabilitation facilities, and psychiatric hospitals and units and adjusts payments for productivity.

Implementation: Beginning fiscal year 2010; productivity adjustments added to market basket update in 2012

Implementation update: The Centers for Medicare and Medicaid Services has issued several proposed and final rules reducing annual market basket updates for different provider types: inpatient hospital services (Final Rule August 16, 2010; Proposed Rule for FY 2012 issued April 20, 2011), outpatient hospital services (Final Rule November 3, 2010), long-term care hospitals (Final Rule August 16, 2010; Proposed Rule for FY 2012 issued April 20, 2011), inpatient rehabilitation facilities and psychiatric hospitals and units (Proposed Rule January 27, 2011).


Provides a $250 rebate to Medicare beneficiaries who reach the Part D coverage gap in 2010.

Further subsidies and discounts that ultimately close the coverage gap begin in 2011.


Increases the Medicaid drug rebate percentage for brand name drugs to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%) and to 13% of average manufacturer price for non-innovator, multiple source drugs. Extends the drug rebate to Medicaid
managed care plans.

Implementation: January 1, 2010 for increase in Medicaid drug rebate percentage; March 23, 2010 for extension of drug rebate to Medicaid managed care plans Implementation update: The Centers for Medicare and Medicaid Services issued a State Medicaid Directors Letter on April 22, 2010 explaining the new rules.
On August 11, 2010 and September 28, 2010, CMS issued letters to state Medicaid directors with additional guidance on the prescription drug rebates. On January 6, 2011, CMS issued another letter with further changes pursuant to the ACA.


Establishes the Federal Coordinated Health Care Office to improve care coordination for dual eligibles (people eligible for both Medicare and Medicaid).

Implementation: March 1, 2010

Implementation update: The Federal Coordinated Health Care Office was created in September 2010. On December 30, 2010, CMS issued a notice in the Federal Register announcing the establishment of the Federal Coordinated Health Care Office.

Implementation: January 1, 2010.

Implementation update: In May 2010, CMS issued a consumer brochure with information about the Medicare Part D coverage gap. In June 2010, the first rebate checks were sent to Medicare beneficiaries who reached the Medicare Part D coverage gap, more commonly known as the “doughnut hole.”
As of March 22, 2011, 3.8 million beneficiaries had received a $250 check to close the coverage gap, according to an HHS report.


Requires pharmaceutical manufacturers to provide a 50% discount on brand-name prescriptions filled in the Medicare Part D coverage gap beginning in 2011 and begins phasing-in federal subsidies for generic prescriptions filled in the Medicare Part D coverage gap.

Implementation: January 1, 2011

Implementation update: On December 17, 2010, CMS sent a letter to pharmaceutical companies providing operational guidance for pharmaceutical manufacturers participating in the Medicare Coverage Gap Discount Program. According to the guidance, the Discount Program became effective
January 1, 2011. On June 28, 2011, CMS announced that nearly 500,000 people had received a discount on their brand-name prescription drugs, with an average savings of $545 per beneficiary.
As of August 4, 2011, 900,000 Medicare beneficiaries who hit the prescription drug doughnut hole received a 50 percent discount on their prescription drugs.


Provides a 10% Medicare bonus payment for primary care services; also, provides a 10% Medicare bonus payment to general surgeons practicing in health professional shortage areas.

Implementation: January 1, 2011 through December 31, 2015

Implementation update: On November 29, 2010, CMS published a final rule that implements the 10 percent incentive payment for primary care services.


Eliminates cost-sharing for Medicare-covered preventive services that are recommended (rated A or B) by the U.S. Preventive Services Task Force and waives the Medicare deductible for colorectal cancer screening tests; authorizes Medicare coverage for a personalized prevention plan, including a comprehensive
health risk assessment.

Implementation: January 1, 2011

Implementation update: On November 29, 2010, CMS published a final rule that will augment the benefits for the “Initial Preventive Physical Examination,” an annual visit for the purposes of developing a prevention plan for the patient. On December 2010, CMS released a Medicare Consumer Guide to
Preventative Services, including services that will no longer require cost-sharing (co-pays) in 2011 as a result of the health reform law. As of October 6, 2011, CMS reported that 20.5 million people had participated in the free Annual Wellness Visit or received other preventive services with no cost-sharing.


Creates the Center for Medicare and Medicaid Innovation to test new payment and delivery system models that reduce costs while maintaining or improving quality.

Implementation: Center established by January 1, 2011

Implementation update: On November 17, 2010, CMS issued a notice announcing the establishment of the Center for Medicare and Medicaid Innovation in its organization.


Freezes the income threshold for income-related Medicare Part B premiums for 2011 through 2019 at 2010 levels resulting in more people paying income-related premiums, and reduces the Medicare Part D premium subsidy for those with incomes above $85,000/individual and $170,000/couple.

Implementation: January 1, 2011

Implementation update: On November 4, 2010, CMS issued a fact sheet with Medicare premium information for 2011 reflecting higher premiums for Medicare beneficiaries whose incomes exceed a set threshold.
In January 2011, the Social Security Administration released a consumer publication reflecting the changes.


Restructures payments to private Medicare Advantage plans by phasing-in payments set at increasingly smaller percentages of Medicare fee-for-service rates; freezes 2011 payments at 2010 levels; and prohibits Medicare
Advantage plans from imposing higher cost-sharing requirements for some Medicare covered benefits than is required under the traditional fee-for-service program.

Implementation: January 1, 2011

Implementation update: The Centers for Medicare and Medicaid Services issued a letter to Medicare Advantage plans on April 5, 2010 announcing the freeze in 2011 payment rates at 2010 levels. On November 22, 2010, CMS issued a proposed rule updating the Medicare Advantage program. On April 15, 2011, CMS issued a final
rule updating the Medicare Advantage program.


Establishes an Independent Advisory Board, comprised of 15 members, to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds targeted growth rates.

Implementation: Funding available October 1, 2011; first recommendations due January 15, 2014


Allows providers organized as accountable care organizations (ACOs) that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program.

Implementation: January 1, 2012

Implementation update: On April 7, 2011, the Department of Health and Human Services published a proposed rule in the Federal Register defining Accountable Care Organizations and set out requirements for governance,
legal structure, transparency efforts and the incorporation of evidence-based medicine and quality efforts.

HHS also released facts sheets for providers and consumers, as well as fact sheets on legal issues and quality scoring in ACOs. The Federal Trade Commission and Department of Justice issued a joint policy statement on antitrust issues related to ACOs. On May 20, 2011, CMS issued a request for applications for the Pioneer ACO
Program, which is targeted at organizations that can demonstrate the improvements in quality and cost-savings
of a mature ACO.

Reduces rebates paid to Medicare Advantage plans and provides bonus payments to high–quality plans.

Implementation: January 1, 2012.

Implementation update: On February 28, 2011, the Centers for Medicare and Medicaid Services issued a letter to Medicare Advantage plans announcing payment rates for 2012 that included changes included in the health reform law.
On November 22, 2010, CMS announced a proposed rule updating Medicare Advantage plan payments.

Creates the Independence at Home demonstration program to provide high-need Medicare beneficiaries with primary care services in their home.

Implementation: January 1, 2012

Creates new demonstration projects in Medicaid for up to eight states to pay bundled payments for episodes of care that include hospitalizations and to allow pediatric medical providers organized as accountable care organizations to share
in cost-savings.

Implementation: January 1, 2012 through December 31, 2016

Establishes a hospital value-based purchasing program in Medicare to pay hospitals based on performance on quality measures and requires plans to be developed to implement value-based purchasing programs for skilled nursing facilities,
home health agencies, and ambulatory surgical centers.

Implementation: October 1, 2012.

Implementation update: On January 13, 2011, the Centers for Medicare and Medicaid Services issued a proposed rule that would implement a value-based purchasing program for hospitals in Medicare. On May 6, 2011, CMS published a final rule on the value-based purchasing program.

Reduces Medicare payments that would otherwise be made to hospitals to account for excess (preventable) hospital readmissions.

Implementation: October 1, 2012

Begins phasing-in federal subsidies for brand-name prescriptions filled in the Medicare Part D coverage gap (reducing coinsurance from 100% in 2010 to 25% in 2020, in addition to the 50% manufacturer brand-name discount).

Implementation: January 1, 2013
Establishes a national Medicare pilot program to develop and evaluate making bundled payments for acute, inpatient hospital physician services, outpatient hospital services, and post-acute care services for an episode of care.

Implementation: January 1, 2013

Increases Medicaid payments for primary care services provided by primary care doctors to 100% of the Medicare payment rate for 2013 and 2014 (financed with 100% federal funding).

Implementation: January 1, 2013 through December 31. 2014

Increases the Medicare Part A (hospital insurance) tax rate on wages by 0.9% (from 1.45% to 2.35%) on earnings over $200,000 for individual taxpayers and $250,000 for married couples filing jointly and imposes a 3.8% assessment on unearned income for higher-income taxpayers.

Implementation: January 1, 2013

Requires Medicare Advantage plans to have medical loss ratios no lower than 85%.

Implementation: January 1, 2014
Establishes an Independent Advisory Board, comprised of 15 members, to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds a target growth rate.

Implementation: First recommendations due January 15, 2014 (Funding available October 1, 2011)

Reduces Medicare Disproportionate Share Hospital (DSH) payments initially by 75% and subsequently increases payments based on the percent of the population uninsured and the amount of uncompensated care provided.

Implementation: October 1, 2014

Reduces Medicare payments to certain hospitals for hospital-acquired conditions by 1%.

Implementation: Fiscal Year 2015

NOTE: 2011 Annual Election Period (AEP) ends early this year, on December 7, 2011.

Please visit us at MyHealthQuoter.com or call 1-866-577-3620. We are here to help you understand your options and get you into the very best Ohio individual health insurance plan for you.

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Navigating Health Reform (Part 5 of 7): Health Reform Resources

Staying on top of health reform is critical. Individual and business need to keep abreast of the many changes that have already occurred as well as be informed about those yet to be implemented. Nearly every week, I am invited to speak public about health reform, below is a very short list of resources I use to stay up to date. Give me a call if I can answer any questions specific to your situation, (614) 336-3636 x 7.

The Patient Protection and Affordable Care Act (PPACA) is organized in 2 separate bills: HR 3590, from the Senate and HR 4872 the reconciliation bill that was eventually passed by the President.
Department of Health and Human Services provide a list of their current areas of emphasis including: medical loss ratio, exchanges, grandfathered health plans, and the Patient’s Bill of Rights.
• The Kaiser Family Foundation has handy timelines of when the PPACA rules take effect. The “official” source for information about health care reform is at HealthCare.gov.
• Another very helpful blog is Chris Conover’s blog, U.S. Health Policy Gateway.”
• In 2014, many Americans will qualify for federal assistance to help pay for health insurance, the Kaiser Family Foundation has a Health Reform Subsidy Calculator that show the amount of the potential individual premium subsidy.
• Small business can earn up to 35% health premium subsidy through Small Business Health Care Tax Credit.
• The Incidental Economist blog is a fascinating reading that explains the economic forces that shape health reform.

This is part of a 7 part series called Navigating Health Reform, please review some of our past entries.

Part 1: http://www.ohioindividualhealthinsurance.net/?p=422
Part 2: http://www.ohioindividualhealthinsurance.net/?p=432
Part 3: http://www.ohioindividualhealthinsurance.net/?p=437
Part 4: http://www.ohioindividualhealthinsurance.net/?p=444
Part 5: http://www.ohioindividualhealthinsurance.net/?p=510
Part 6: http://www.ohioindividualhealthinsurance.net/?p=524
Part 7: http://www.ohioindividualhealthinsurance.net/?p=625

MyHealthQuoter.com is a comprehensive website for your individual and small group health insurance needs. We offer FREE instant online insurance quotes and applications from major health insurance carriers.

Listen to internet radio with spiralight on Blog Talk Radio

Health Reform Insider (February 8-12, 2010)

Health Reform Insider (February 8-12, 2010)

President Barack Obama brought health care reform back into the spotlight this week, meeting with both Democrats and Republicans and calling for a bipartisan Health Care Summit later this month. The President challenged Republicans to bring their best ideas to the negotiating table. In response, two Republican thought-leaders – former House Speaker Newt Gingrich and President and CEO of the National Center for Policy Analysis John Goodman – laid out ten GOP health care reform ideas in an editorial in Wednesday’s Wall Street Journal . The ideas included more equitable taxation of health insurance plans, an increase in insurance plan portability and elimination of junk medical lawsuits.

In a CBS News interview on Sunday, the President said that the meeting would allow “Republicans and Democrats to go through, systematically, all the best ideas that are out there and move [health care reform] forward.” In reaction to criticisms that the negotiations have not been adequately transparent,

White House officials announced that the meeting will be televised live, presumably on C-SPAN. The call for a health care summit came a day after President Obama met with Democrats at their Democratic National Committee meeting, where he indicated that he would not walk away from health care reform. The President stated, however, that the effort needs to be bipartisan and that Republicans must be drawn into public debate. Following a meeting with both parties on Tuesday, the President signaled that he would be open to meeting his critics “part way,” even if the bill does not include everything pursued in earlier versions.

In a nod to Republican concerns, he specifically mentioned reconsidering medical malpractice reform. Legislators from both parties applauded the Summit; however, both seem to be sticking to their positions, signaling that compromise may still be far from reach. Senate Republican leader Mitch McConnell (R-KY) and House Republican leader John Boehner (R-OH) both called for President Obama to scrap the current proposed bill and start over. In a letter sent late Monday to White House officials, House Republican leaders reiterated this point and asked if the President would forego a legislative process known as reconciliation that could bypass a Republican filibuster and allow Democrats to pass a bill with just 51 Senate votes. White House aides quickly corrected any misconceptions that the President would consider starting from scratch. New Approach Calls for New Timeline: As President Obama worked to reinvigorate a bipartisan health care reform effort, he indicated that the change of course may potentially extend debate into the spring . This new timeline directly conflicts with the most recent approach taken by Speaker of House Nancy Pelosi (D-CA) and Senate Majority Leader Harry Reid (D-NV), which focuses more on swift, closed-door, partisan talks. Congressional Democrats Point Fingers: After the collapse of the 2009 health care reform effort, Congressional Democrats are looking to place blame. Some hold White House Chief of Staff Rahm Emanuel accountable, pointing to his lack of Senate experience. Others, in particular Sen. Al Franken (D-MN), criticize White House senior advisor David Axelrod for the administration’s failure to provide clarity or direction on health care. Democratic Senators also express frustration that White House officials have not done more to win public support for the overhaul effort. Plus, they feel White House officials need to offer more guidance, particularly following Scott Brown’s win of the Massachusetts Senate seat. Additional Activities Virginia Moves Closer to Banning Individual Mandate: On Tuesday, Virginia state House Delegates gave preliminary approval of a measure that would exempt its citizens from a federal mandate to buy health insurance or pay a penalty – a central component of President Obama’s health care reform package currently being debated in Congress. The measure is expected to be signed into law soon by Republican Gov. Bob McDonnell. Congress Looks Into Rate Increases: On Tuesday, members of Congress announced that they will look into Anthem Blue Cross’s proposed rate increases in California. The decision came after a letter was sent by U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius to Anthem Blue Cross on Monday that asked the company to publicly justify the rate increase, considering the profits made by its parent company, WellPoint, Inc. In a response letter to Secretary Sebelius, WellPoint indicated that the rise in premiums is necessary for several reasons. Among other considerations, the rise in premiums are to meet growing underlying medical costs, and to compensate for the many who have chosen to forgo health insurance or opted for lower-cost insurance coverage because of the recession.

Public Opinion Poll Shows Americans Want Some Health Reform, but It’s Not Their Top Priority: Recent public polling suggests that Americans support the concept of health care reform, but they remain skeptical of the measures being debated in Congress and currently put top priority on the economy.

A new Harris Interactive/HealthDay poll released Thursday finds that: •Nearly half of Americans favor some kind of health care reform in the next two years; • Nearly 40 percent believe it would be good if the current Democratic reform package never passes; and • While health care reform is important, a strong majority (about 8 out of 10) cite job creation and reducing unemployment as the top priority.

Further, a national ABC News/Washington Post poll released Tuesday shows that about two-thirds (63 percent) of Americans want Congress to continue to work towards a comprehensive health care reform bill. Regarding the bipartisan nature of negotiations, 58 percent of Americans believe Republicans are not doing enough to compromise on key issues; whereas 44 percent believe that President Obama has not made enough of an effort to find common ground. Looking

Ahead As two large snow storms battered Washington D.C. this week and essentially brought the city to a halt, the House of Representatives postponed further legislative action until February 22 after a week-long recess for the President’s Day holiday. Members of the House had planned this week to vote on a measure that would repeal the antitrust exemption for health insurers, but that vote will now take place after the break.

[Source: Parts reproduced from This Week in Health Reform, Wellpoint,Inc]

MyHealthQuoter.com is an industry leader in providing online shopping and comparison services helping Ohioans find affordable Ohio individual health insurance.  For free advise, call (866) 577-3620 or to obtain a no obligation quote please visit http://www.MyHealthQuoter.com.