Health Insurance 101

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What Is Health Insurance?

Whether you are in San Antonio, Texas or Pensicola, Florida, many of us are familiar with health insurance. But what about its textbook definition? Well, health insurance is a mechanism in which you can manage your health care costs. Basically, you pay health care companies a premium (a set amount each month) and you get benefits to pay for your eligible health care expenses. Your plan could also have a deductible, which is a set amount that you have to pay for covered services, before your insurance plan foots the bill.

A co-payment or co-insurance, is a set amount that you pay for covered services, usually after a deductible is met. For instance, you may have a set co-pay of $200 for an emergency room visit or a 70/30 co-insurance for advanced imaging, where you cover 30% of the costs, and the other 70% is from your insurance carrier. In general, the more you pay per month (premium), the lower your deductibles and out-of-pocket costs. You will also notice your plan will have an out-of-pocket maximum, which means that after your total health care costs in a calendar year reach this amount, the health insurance carrier will now be footing the rest of the bills, until the new plan year starts.

You usually will also have prescription drug coverage built in to your plan, in which you may have to meet a deductible first, and then have set co-pays or co-insurances for each tier or level of drugs in your plan’s formulary. Keep in mind, generic drugs are usually going to be more inexpensive than brand-name drugs. For example, when at the local Walgreens here in San Antonio, Texas, you may notice that Crestor is more expensive than the generic version: Rosuvastatin. That is why we advise folks to price check all of their medications and use discounts when possible, such as with GoodRX. This is essentially how it works with prescription drugs.

What is The Affordable Care Act (Obamacare)?

The Affordable Care Act, also known as “Obamacare”, is a federal law that once required many folks to have health insurance, but this was amended on January 1, 2019. After this date, one can no longer get penalized or fined by the Internal Revenue Service (IRS) for not having health insurance. So how does someone get health insurance if they do want it? Well, this can be done in a multitude of ways, from obtaining coverage from an employer, buying directly from an insurance carrier, or signing up for coverage on the government-run exchange, known as the Health Insurance Marketplace. An important feature of this legislation, is that is does not allow insurers to deny coverage based on a health condition you had before getting on a plan, known as a “pre-existing condition”, and you can’t be charged more because of it. For more on the nitty gritty details on The Affordable Care Act, click here. Something to keep in mind is that plans under The Affordable Care Act, are not required to cover vision and dental insurance for adults, but if someone is under 18 years old wanting coverage, these could be offered.

If you are needing to get either dental or vision coverage, we are more than happy to assist you personally or you can self-enroll online here.

Why Should I Buy Health Insurance?

To be frank, everyone should buy health insurance because it is critical when the unexpected health emergency arises to have something in place. In fact, medical bills are a leading cause of consumer debt and related financial problems. As you will see below from CNBC in 2019, 137 million Americans (yes you read correctly) are struggling with medical debt, and having adequate health insurance is certainly one way to mitigate being at risk of financial ruin.

What If I Have A Family?

If you have children, it is quite likely that they may need to visit the doctor or urgent care more frequently than a relatively healthy adult, especially newborns. One thing you want to ensure, is that your deductibles, co-payments, and co-insurance are affordable for you. Keep in mind also that your plan may have a family deductible, in addition to individual deductibles for each family member. Individual deductibles are often times lower than a family deducible. Once someone reaches their individual deductible, their health insurance plan kicks in just for them. On the flip side, when a family deductible is met, health insurance will kick in for every member of the family, regardless of whether or not an individual has reached their deductible.

What If I Am A Student?

You can stay on your parents health plan until you are 26 years old, so no need to buy health insurance if your parents are willing to let you stay on their plan. A good option is also to check your local university for any health insurance plans they may offer, which in some cases, can be quite affordable. If you are in the San Antonio, Texas area, check out the University of Texas at San Antonio (UTSA) student health insurance option here, or Texas A&M- San Antonio’s (TAMU-SA) student health insurance option here.  Keep this in mind especially if you are attending a college or university out of state, as your parents plan network may not be usable in that state.

What If I Am Self-Employed?

If you just became self-employed after leaving a full-time (W2 job), an option would be to use COBRA to continue your previous employer’s coverage until you are able to find a new plan. Be prepared, the premium may be quite hefty! If we are outside the Open-Enrollment Period (11/1-12/15), you should also be able to qualify for a Special Enrollment Period to shop on the Health Exchange if your COBRA was fully exhausted or you recently lost employer-based coverage (past 2 months). Ensure that your premiums are affordable, as your monthly income may be variable in the year. Your health insurance premiums are also tax deductible, so keep that in mind around tax time. Additionally, if you travel frequently for work, you might want to consider a plan that allows you to see out of network providers, like a PPO if available in your area.

What If I Have A Low Income? 

If you have a low income or tight budget, your first action should be to see if you qualify for Medicaid from your state. See the video below on how to do so. Medicaid is a public health insurance plan available for low income individuals and families. If you get denied Medicaid because your income is too high or you know you won’t qualify, the next step for you is to see if you may qualify for a subsidy on the Health Exchange. This subsidy can make your health coverage more affordable. The most important thing to keep in mind is to have some sort of coverage in place. A serious health issue can turn into a financial disaster if you’re not careful. If you qualify, look into plans that cover doctor visits, urgent care, lab work and more at a set co-pay, rather than having to meet a deductible first.

What If I Am A Veteran?

If you are a veteran, you may qualify for health care through the U.S. Department of Veterans Affairs (VA). The Affordable Care Act does not change VA health benefits.If you have health insurance coverage thorough a private-sector employer, you can have and use both health insurance plans at the same time.

What If I Am Pregnant?

All health insurance plans that count as qualifying health insurance cover pregnancy and childbirth related services. Maternity care and childbirth are one of the ten essential benefits required on qualifying health plans under the ACA. These services are covered even if you became pregnant before your coverage starts. Having a child also counts as a qualifying event for a Special Enrollment Period in which you can enroll in a new plan or switch plans. Maternity care and childbirth are also covered by Medicaid and CHIP. If you qualify for Medicaid and CHIP and are pregnant, you can apply at any time during the year through your state agency or marketplace.

What If I Am A Senior Citizen?

If you are above the age of 65, you likely qualify for Medicare. Medicare is a federal program designed to help you cover healthcare costs into your old age. We at The Harrin Group here in San Antonio, Texas, recommend to the public that at least 3-6 months before your 65th birthday, you ensure that you start to line up Medicare Part’s A&B coverage, in order for you to be eligible for many options, including Medicare Supplements and Medicare Advantage plans. Check out the “Medicare 101” page on our site, for more comprehensive information on all things Medicare.

What If I Am Currently In The Military?

If you are an active duty service member, your healthcare (and your family’s health care) is covered by TRICARE. You do not need to purchase additional health insurance to comply with the ACA. To see some of the benefits that TRICARE covers, see the below short video.

What If Am Married But Do Not Have Kids? 

If you are married but don’t have kids, you don’t need to buy health insurance as a family. You can buy individual plans from separate companies, if that makes sense for you and your spouse. You can also purchase a family plan from the Health Exchange. One of you can also be dependent on the other’s employer-provided health insurance plan, if that’s available.

Which Type Of Health Insurance To Buy?

Generally, there are two types of health insurance: public health insurance (like Medicare, Medicaid, and CHIP) and private health insurance. Most people have some form of private health insurance, whether they purchase it through the Marketplace or get it from an employer. We will be looking at private options below.

On-Exchange Private Health Insurance:

On-exchange private health insurance policies are plans that are sold on government-run exchanges, such as, the Health Insurance Marketplace. On-exchange plans must cover ten essential benefits, plus any additional services that are mandated by your state government. Additionally, every insurer that wants to participate in a government-run exchange must offer a plan at every metal tier (Bronze, Silver, Gold). On-exchange plans are the only plans for which premium tax credits and cost-sharing reductions (government subsidies) are available. While this is the system currently in place here in the United States, keep in mind that it could be subject to change in the future, so we are constantly analyzing the decisions coming out of Washington and ensuring you (the consumer) is informed about all options.

Off-Exchange Private Health Insurance:

Off-exchange private health insurance policies are plans that are sold either directly by the health insurance company, through a third-party broker, or a privately run health insurance marketplace. These plans must also cover the ten essential benefits and other rules dictated by the ACA, The caveat with these types of plans is that they are not eligible for any government subsidies, to drive the cost down. So if you are eligible for a subsidy, you should probably stick to on-exchange plans if you don’t want to overpay for your health insurance.

Small-Group Health Insurance:

The Harrin Group offers both fully-insured and self-funded small-group health insurance, dependent on the number of employees. In general, we can work with groups with at least two employees. So what is the difference between the two plans you might ask?

Well, a fully-insured plan is where an insurance company will charge an employer a set rate, payed out in 12 installments over the course of a year. This rate is based on factors such as the demographic data of the company’s employee population, historical claims data, etc. This rate is adjusted year after year, depending on how the plan performs. One downfall on this type of coverage is the lack of a refund to the company (even if there are zero claims).

With a self-funded plan, the employer is the owner of the plan, will pay a fixed cost for plan administration, access to a plan network (ie. Cigna/Humana), and “stop-loss” coverage that will help the employer cover any unexpectedly large claims that arise in the year. The employer pays claims as they incur, with the possibility of a refund at the end of the year if claims are minimal. In addition, this product could offer tax relief for the small business, rates can be better negotiated than a fully-insured plan and customized to fit your employees needs, such as wanting lower copays for certain services (ie. lab work).

For more on small-group health plans, please watch the helpful video below from one of our preferred carriers: Humana.

If you are interested in getting a quote for your small group (more than 2 employees), please contact us to get started.

Short-Term Medical Insurance:

Short-term health insurance plans provide limited health coverage, for a temporary gap in coverage. What kind of gap you might say? Well, if someone needs a temporary solution in place until going on Medicare, or an employer-based health insurance plan, this could be a good fit. But there are times when someone may not qualify for a subsidy and can’t afford a private, off-exchange plan. Then these alternatives could be a good fit! In general, these types of plans are limited to a duration of up to 3 years of coverage at a time, and at that point, the applicant will have to apply again. Keep in mind that short-term medical plans do not count as qualifying health coverage, but these plans seem to be gaining popularity for people who missed the deadline to sign up for the Exchange, are in between jobs or want a lower premium. We want to stress that short-term medical plans will not cover any pre-existing conditions, and you do have to fall in certain health parameters to qualify, like height and weight limitations. We also have some options for people who may have ongoing health issues and could have a “guaranteed issue” from the insurer.

For more on short-term medical plans, please watch the helpful video below from one of our preferred carriers: UnitedHealthOne. 

If you are needing to get a short-term medical plan, we are more than happy to assist you personally or you can self-enroll online here.

Hospital Indemnity Insurance:

In short, this type of coverage will pay a set amount of money for different medical services utilized, such as a hospitalization or a doctor visit. These types of plans are aimed to fill gaps in coverage, just like the short-term medical plan we just looked at and will typically require medical underwriting as well. Here is a practical example of how a traditional policy might work:

Let’s say you have this kind of policy and need to go to the hospital. A traditional hospital-indemnity plan will give you a lump-sum benefit for each day such as $1,000 per day, helping you cover some of the medical costs. There is no deductible to meet and in many cases, you are free to choose where you receive care. Many plans have built-in coverage for office visits to a primary care doctor/specialist, lab work, and even preventative care. After your receive qualified care, you will usually submit a claim form, with copies of your medical receipts to the plan carrier, and then you will receive reimbursement for eligible expenses. Now, we recently partnered with a new company called “Sidecar Health”, which will allow you to choose a plan or create one customized to you and they will send you a Sidecar Health Visa card to use for eligible services, like a doctor visit. What makes them unique is the technology behind their product, such as continuous updates to local rates for services like lab work, based on member’s experiences. You will be able to see ahead of time what things cost locally, and what exactly Sidecar will cover as well. All done from an intuitive mobile app or on their website!

For more on hospital indemnity plans, please watch the helpful video below from one of our preferred carriers: Sidecar Health.

If you are needing to get a hospital indemnity plan, we are more than happy to assist you personally or you can self-enroll online here. 

*Note- We can also offer this coverage to small business owners as optional coverage for employees.

Telemedicine:

Ever wish you could see a doctor, without having to take time off work or sit in a bacteria-infected waiting room, with people coughing all around you? Well, you should check out a widely-popular health insurance product called telemedicine. With telemedicine, one can remotely “see” a doctor licensed in your state such as Texas for example, on your phone or computer. The doctor goes over your health issue, and if necessary, prescribes medication for the issue, to your nearest/preferred pharmacy. This is not a total replacement of health insurance but a great add-on benefit, or often coupled with a catastrophic-type plan, like short-term medical plans, to “mock” a regular health insurance plan like ACA coverage. Telemedicine is great for common illnesses like colds, flu’s, and even minor skin rashes. We partnered with a company called HealthiestYou by Teladoc, who allows you to actually see the doctor on your phone, if one has a front-facing camera. We actually use HealthiestYou ourselves, and it really is quite valuable to have, for just a few dollars a month.

For more on telemedicine plans, please watch the helpful video below from one of our preferred carriers: HealthiestYou 

If you are needing to get a telemedicine plan, we are more than happy to assist you personally or you can self-enroll online here.

*Note- We can also offer this coverage to small business owners as optional coverage for employees, that can be coupled with Best Doctors.

Types Of Networks:

Health Maintenance Organization (HMO)- The most restrictive type of plan when it comes to accessing your network of providers. With this plan, you will be asked to choose a primary care physician (PCP), that is in the network. Think of your primary care physician as the gatekeeper, who will coordinate your care and refer you to any specialists you may need, that are in the network. HMO’s will not cover any out of network costs.

Private Provider Organization (PPO)- These plans are the least restrictive when it comes to accessing your network of providers and getting care outside of your plans network. You typically will have the option to choose between an in network doctor, whom you can see at a lower cost, or the freedom to see an out of network doctor, at a higher cost. These plans do not require referrals from your primary care physician to see a specialist. You may also choose to have a primary care physician with these plans and keep in mind, these plan types are generally more expensive than an HMO.

Point of Service (POS)- These plan types are a hybrid of the HMO and PPO. You will have a primary care provider on an HMO-style network who will coordinate your care. The difference lies with the access to a PPO-style network with out of network options, at a higher cost. The HMO network will be more affordable and you will need to get a referral to see HMO specialists. POS plans typically have more expensive premiums than pure HMO’s but are less expensive than PPO’s.

Exclusive Provider Organization (EPO)- These plans are another mix between HMO and PPO plans. They give you the option of seeing a specialist without a referral. Keep in mind these plans do not cover out of network services, unless its an emergency. EPO plans typically have more expensive premiums than HMO’s, but less expensive than a PPO. These types of plans are very prominent now with the Healthcare Marketplace, as we have witnessed here in San Antonio, Texas and beyond.

Metal Tiers:

Bronze: In general, have the lowest monthly premiums, costs are split 40% consumer responsibility, 60% insurer.

Silver: More expensive than a bronze, but will typically have a wider network. Costs are 30% consumer responsibility, 70% insurer.

Gold: Gold plans are more expensive than a silver and have the insurer take on more of the costs, with a 20% consumer responsibility and 80% insurer.

Health Insurance Cost Factors:

1. Your age
2. Your location
3. Whether or not you use tobacco
4. Individual or family plan
5. Your plan category (bronze, silver, gold)

When To Sign Up?

The Open-Enrollment Period starts November 1st, 2020 and runs through December 15th, 2020. You may be able to sign up outside of this period with a Special Enrollment Period, which enables one with a qualifying life event (ie. having a baby, getting married, loss of job-based coverage) to sign up at any point throughout the year. Ancillary products like telemedicine or short-term medical plans can be enrolled in at any point in the year. 

How Do I Enroll Online?

To sign up at your leisure 24/7, visit our “Enroll Online” page to select the product(s) of your choice, and easily enroll in minutes. And here is the nice part. Even if you self-enroll, we will be your local insurance agency if you ever have an issue or concern. No 1-800 # here, no waiting for the next representative (30 min later…), just a simple call, text, email, or live-chat away!

More A Visual Learner? Here Is A Quick Recap:

Sources: GoodRX, Healthcare.gov, The Balance, CNBC, UTSA, Texas A&M-San Antonio, U.S. Department of Labor, Texas Medicaid, VA.gov, CHIP, Medicare.gov, TRICARE, Humana, UnitedHealthOne, Sidecar Health, HealthiestYou, Best Doctors, Maryland Health Connection