Why your health insurance sucks...to you

Getting a health insurance plan can be a breeze, the employer offers some plans to you, mark a few x’s and done. It is simple, almost too simple. You have a 50/50 shot in the dark chance that you have the right health insurance benefits in the case you must use it. And no one wants to be without proper coverage during an emergency for a certain procedure.

I also want to point out that all emergencies don't necessarily start in the emergency room. Some emergencies begin in your primary care physician's office. The main reason why your health insurance plan sucks to you is that you did not consider all your options before you needed to use your benefits. And the reason you didn’t consider those options is that:

1.??????You didn’t even know these options exist

2.??????You were aware of the options but didn’t know how they work

3.??????You figured you couldn’t afford it and blew the conversation away without a second glace

But before we even get to the good part, it would be helpful for you to know what health insurance is and how you can make it work for you. The idea is for you to get viable information that allows you to look at more of the puzzle, instead of looking at a single piece thinking it is the whole puzzle.

I desire to open as many minds as possible to the idea that you have more power in your hands than you believe. You just need a little push in the right direction so you can consider exactly what is in front of you. This does not just go for individual consumers either, if you are a business owner it would be ideal to understand exactly what you are offering your employees and some workarounds that will not only provide your employees with quality care but will help them recuperate quicker, but also doing so in a way that does not hit hard to your bottom line.

Let’s begin

Health insurance coverage pays for a portion of health and medical expenses like routine care, emergency care, and chronic illness treatment. It is a contract that requires the health insurance company you choose, to pay some or all of your health care cost in exchange for a health insurance premium, the amount you pay every month to your insurance carrier. When you signed on the dotted line for your health insurance, did you look at the summary of benefits? Did you know that this document even existed?

The Summary of Benefits is not what was shown to you when you signed up for your health insurance plan under an employer-sponsored health care plan. What you saw was an overview or rather highlights of what the plan offers. The Summary of Benefits is a more comprehensive snapshot of the entire health plan. Once you see it you will know the difference. It explains the health plan’s costs, benefits, covered health care services, exceptions, and important features consumers need to know. This is the reason that you get so much time during open enrollment to decide before the health insurance deadline for your company. The problem is that you need to know that it exists, and you need to have a realistic view of what you need in a health insurance plan.

You should have gotten a copy of this document before your plan went into effect. But if you have had your plan for a while and need a new copy you should be able to access a copy through your insurance carriers' website or call the number on your insurance card and they may email or snail-mail you a copy. Your best option, in this case, is to put in the call. It is the best way to ensure you get the right copy. FYI each plan has its own Summary of Benefits, the same way each plan has its own formulary, aka covered drug list.

What health insurance should I get?

Everything depends on how much freedom you want vs what extra perks you may get from having more restrictions. Let me explain. There are several types of plans that I am sure you are aware of but don’t know the nitty-gritty about.

·????????Health Maintenance Organization (HMO)- they have a network of doctors, hospitals, and other healthcare providers who have agreed to accept payment at a certain level for any services they provide. These plans affect two things cost and choice. An HMO can offer lower monthly premiums because of the agreed payment level between the HMO and providers. With an HMO you can’t go outside of the network unless in the case of an emergency, meaning your primary care physician choice may have to change if your current physician is not in-network. Also, you would need referrals to see a specialist. So, you would see your PCP first to get referred to an in-network specialist which would be your next stop (is needed). If you are someone that doesn’t need a lot of specialist care an HMO plan can save money.

·????????Preferred Provider Organization (PPO)- This is where you get the most freedom. But you may have higher premiums in exchange for flexibility to use providers both in and out of the network without a referral restriction. Because you can use out-of-network providers, your out-of-pocket costs may be a little higher as well, and visiting an out-of-network provider can have a separate deductible. The upside is that referrals are not required for any services you desire that are covered under the plan. In some cases, you will have to pay for services directly and then file a claim to get reimbursed. This is explained in the Summary of Benefits.

·????????Point of Service (POS)- This is a hybrid between an HMO and PPO plan to facilitate managed care. Your coverage varies, depending on whether you see a provider who is in or out-of-network and if you have received a referral (if required) by your plan. Participants designate a PCP, like in an HMO, but may go outside of the provider network for health care services. If you go out of network you will have to shoulder most of the cost, unless referred to an out-of-network provider by your primary care physician. In general, your level of coverage will be greater when staying in the network. When receiving in-network treatment and services, the paperwork is usually done for you.

·????????Exclusive Provider Organization (EPO)- An EPO is like an HMO in which it only covers in-network care, but your network is a little larger. May I dare say, “you will cast a larger net."?Premiums may be higher than an HMO, but you may not require referrals from your primary care physician, it all depends on your plan.

As you can see, some plans allow you to use almost any doctor or health care facility, while others have their limits but offer cost savings in return in most cases. This is a nutshell of information about different healthcare plans in general from an employer-sponsored health insurance plan. But you get a little more help when you choose a plan from the marketplace, you just need to know what the help is and how it can help you. When exploring plans in the marketplace there is something you need to know so that you won’t get the wrong ideas and choose a plan based on these ideas.

Plans that appear in the marketplace are divided into four categories, but the categories have nothing to do with the quality of care and everything to do with health care plan expenses. These categories are Bronze, Silver, Gold, and Platinum and thus are called metal categories or metal tiers.

·????????Bronze- Requires you to pay more out-of-pocket before the insurance starts paying for some of the medical expenses you incur, but generally have the lowest premium.

·????????Silver- you may pay a little less than bronze for out-of-pocket costs and your premium is more competitive.

·????????Gold- Your premium is more competitive with the platinum tier, which shows in the decrease in out-of-pocket cost compared to silver or bronze tiers.

·????????Platinum- Will usually have the highest premium, but the health plan may offer more health care services.

The true question is how much care you need, not necessarily which plan is the best. If you frequently visit specialists and physicians more than most, a platinum plan may be a better fit for you if the plan covers a particular service that may be hard to get elsewhere. But if you don’t need much attention health-wise then the bronze level may be best, because it offers lower premiums. It is important to truly consider your choices, especially if you have access to an employer-sponsored healthcare plan. Employer-sponsored healthcare plans may offer a greater comprehensive benefit with the lowest cost share because the rates are based on a group rate rather than you as an individual and are more convenient, as your premiums are paid on a per compensation basis i.e., weekly, bi-weekly, etc.

If your employer does not offer any coverage yet, this is where the marketplace comes into play. For more in-depth details about the marketplace and the plans offered, feel free to check out Healthcare.gov.

But I am not done yet, so let me keep my promise and you keep on reading. If you have made it this far you want to know why you believe that your current health insurance coverage sucks, right?

The reason is that there are more plans out there that give you what you need that you can not get in your healthcare coverage. A few of them you already may have, and you don’t know it. The most common ancillary plans or voluntary plans are dental, vision, employee life, and AD&D. You can get them all or pick and choose. But there are others that you may want to consider as well.

I am not telling you to sign up for every product I mentioned, but it is always good to know where you stand and if one of these beauties catches your eye. But if on the off chance you are interested in all that I mentioned, make sure you give me a call first, I would be very happy to help, I am a licensed insurance broker and able to sell health and life insurance in multiple states after all.

Without further ado, let me tell you about some fewer known options that may very well interest you:

·????????Life insurance- To get a really good idea about why I added this to the list read about it here. You will get a better understanding of why you need to think about extra coverage and how you can get it at a less expensive price.

·????????Cancer, Heart Attack, and Stroke: Provides a lump sum benefit to help pay for care. Some have no tobacco questions on the application. Speak to an insurance broker in your area. Some areas don’t have all three included so make sure you are enrolling in the right plan.

·????????Hospital Indemnity: Helps pay a range of hospital expenses due to accidents or covered illness. This is also helpful when covering the uncovered cost of hospital stays. Instead of being responsible for the first 6 days or so of a hospital stay before your health insurance starts paying, you can use a hospital indemnity plan to cover the difference. Leaving you with less worry about hospital bills, and more time to recuperate. This is different from an Accident policy.

·????????Accident Treatment: Help pay for a range of treatments and care when injured in a covered accident. If you have any high-risk activities that you participate in, those activities may not be covered in your plan. Make sure you read all plan documents that you receive from your insurance carrier.

·????????Cancer Treatment: Helps pay for a range of cancer treatments, care, and associated costs. If you are interested in this coverage your insurance agent will be happy to answer any questions you may have about what is covered.

These are some of the products out there that can make a difference in your health care and can ease your mind in the case of a life event that your healthcare plan doesn’t cover or fully cover. And you may be thinking that it is great and all but there is no way that I can or want to afford all this insurance. So, if the price is a concern, I have news for you.

Some of the ancillary plans that I mentioned before may have a rider version. So instead of purchasing a stand-alone plan, you can choose a rider. This will allow you to have extra coverage, with a more cost-effective premium. For instance, most hospital indemnity policies may offer a cancer treatment rider. It won’t have the same benefit amount, but it will have the same benefit structure and at a fraction of the cost of a stand-alone plan.

The truth is that ancillary products are what makes the difference between what you think is a terrible healthcare insurance plan and what makes a great one. Ancillary products are meant to provide members with a more comprehensive health insurance package, that gives members the freedom to include and exclude whatever they want without any obligation to stay in the product or have an enrollment deadline.

But do be warned, some of the products I just mentioned have waiting periods and some of these waiting periods can be extensive, one of the reasons you can enroll in them at any given time in the year. So think twice before you disenroll from one of these plans. It all depends on you and what you feel comfortable with. A few employers offer these plans, but most don’t. If you are interested in these products reach out to an insurance agent or broker and find out what is available in your area.

For small business owners and executives, these are the products that will keep you competitive in your ever-changing industry. By offering these products to employees you can build morale, and have a better retention rate and it won’t affect your bottom line unless you choose to contribute to certain plans.

Want to know why they don’t affect your bottom line?

The answer is simple, ancillary benefits can be fully paid by the employees that choose to enroll. Just like your offering of health insurance, by offering ancillary products to your employees they are allowed to enroll at a group rate. That makes it a win-win.

Make sure you do your homework and find out what is available in your area, and if your employer doesn’t offer ancillary products ask your employer for them. After all, if it will keep employees healthy, happy, productive, and doesn’t bother the bottom line, I doubt if they would put up much of a fight.

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