I have been a medical coverage representative for longer than ten years, and consistently I read increasingly more “repulsiveness” stories that are posted on the Internet for health care coverage organizations, not paying cases, declining to cover explicit sicknesses and doctors not getting repaid for clinical administrations. Shockingly, insurance agencies are driven by benefits, not individuals (yet they need individuals to make benefits). On the off chance that the insurance agency can locate an official explanation not to pay a case, odds are they will discover it, and you the buyer will endure. In any case, what the vast majority neglect to acknowledge is that there are not many “escape clauses” in a protection strategy that give the insurance agency an unjustifiable bit of leeway over the customer. Insurance agencies make a considerable effort to detail the restrictions of their inclusion by providing the approach holders 10-days (a 10-day free look period) to survey their arrangement. Shockingly, a great many people put their protection cards in their wallets and spot their agreement in a cabinet or file organizer during their 10-day free look. It usually isn’t until they get a “refusal” letter from the insurance agency that they take their strategy out to peruse it.
Most individuals, who purchase their medical coverage, depend vigorously on the protection operator offering the strategy to clarify the arrangement’s inclusion and advantages. This being the situation, numerous people who buy their medical coverage plan can reveal to you almost no about their method, other than what they pay in premiums and the amount they need to pay to fulfill their deductible.
For some customers, buying a medical coverage strategy all alone can be a huge endeavor. Purchasing a medical coverage approach isn’t care for purchasing a vehicle, in that, the purchaser realizes that the motor and transmission are standard, and that power windows are discretionary. A medical coverage plan is substantially more uncertain, and it is regularly tough for the customer to figure out what kind of inclusion is standard and what different advantages are discretionary. As I would like to think, this is the essential explanation that most policyholders don’t understand that they don’t have inclusion for a particular clinical treatment until they get a massive bill from the medical clinic expressing that “benefits were denied.”
Indeed, we as a whole grumble about insurance agencies; however, we do realize that they serve an “essential abhorrence.” And, even though buying medical coverage might be a baffling, overwhelming and tedious errand, there are sure things that you can do as a purchaser to guarantee that you are buying the kind of medical coverage inclusion you need at a reasonable cost.
Managing entrepreneurs and the independently employed market, I have understood that it is incredibly hard for individuals to recognize the sort of medical coverage inclusion that they “need” and the advantages they truly “need.” Recently, I have perused different remarks on various Blogs upholding wellbeing plans that offer 100% inclusion (no deductible and no-coinsurance) and, even though I concur that those kinds of projects have an extraordinary “control claim,” I can let you know from individual experience that these plans are not for everybody. Do 100% wellbeing plans offer the arrangement holder more prominent significant serenity? Likely. In any case, is a 100% medical coverage plan something that most customers need? Most likely, not! As I would like to think, when you buy a medical coverage plan, you should accomplish a harmony between four significant factors; needs, needs, hazard, and cost. Much the same as you would do on the off chance that you were buying alternatives for another vehicle, you need to gauge every one of these factors before you go through your cash. On the off chance that you are stable, take no meds and infrequently go to the specialist, do you need a 100% arrangement with a $5 co-installment for physician endorsed drugs if it costs you 300 dollars progressively a month?
Is it worth $200 increasingly a month to have a $250 deductible and a $20 brand name/$ ten regular Rx co-pay versus an 80/20 arrangement with a $2,500 deductible that additionally offers a $20 brand name/$10generic co-pay after you pay a once every year $100 Rx deductible? Wouldn’t the 80/20 arrangement despite everything offer you satisfactory inclusion? Wouldn’t you say it is smarter to put that extra $200 ($2,400 every year) in your financial balance, just if you may need to pay your $2,500 deductible or purchase a $12 Amoxicillin solution? Isn’t it more astute to keep your well-deserved cash instead of pay higher premiums to an insurance agency?
Yes, there are many ways you can keep more of the money that you would usually give to an insurance company in the form of higher monthly premiums. For example, the federal government encourages consumers to purchase H.S.A. (Health Savings Account) qualified H.D.H.P.’s (High Deductible Health Plans), so they have more control over how their health care dollars are spent. Consumers who purchase an H.S.A. Qualified H.D.H.P. can put extra money aside each year in an interest-bearing account so they can use that money to pay for out-of-pocket medical expenses. Even procedures that are not usually covered by insurance companies, like Lasik eye surgery, orthodontics, and alternative medicines, become 100% tax-deductible. If there are no claims that year the money that was deposited into the tax-deferred H.S.A. can be rolled over to the next year, earning an even higher rate of interest. If there are no significant claims for several years (as is often the case) the insured ends up building a sizeable account that enjoys similar tax benefits as a traditional I.R.A. Most H.S.A. administrators now offer thousands of no-load mutual funds to transfer your H.S.A. funds into so you can potentially earn an even higher rate of interest.
In my experience, I believe that individuals who purchase their health plan based on wants rather than needs feel the most defrauded or “ripped-off” by their insurance company and insurance agent. I hear almost identical comments from virtually every business owner that I speak to. Comments, such as, “I have to run my business, I don’t have time to be sick! “I think I have gone to the doctor two times in the last five years,” and “My insurance company keeps raising my rates, and I don’t even use my insurance!” As a business owner myself, I can understand their frustration. So, is there a simple formula that everyone can follow to make health insurance buying easier? Yes! Become an INFORMED consumer.
Every time I contact a prospective client or call one of my client referrals, I ask a handful of specific questions that directly relate to the policy that a particular individual currently has in their filing cabinet or dresser drawer. You know the system that they bought to protect them from having to file bankruptcy due to medical debt.
So what do you think happens almost 100% of the time when I ask these individuals “BASIC” questions about their health insurance policy? They do not know the answers! The following is a list of 10 items that I frequently ask a prospective health insurance client. Let’s see how many YOU can answer without looking at your policy.
- What Insurance Company are you insured with, and what is the name of your health insurance plan? (e.g., Blue Cross Blue Shield-“Basic Blue”)
- What is your calendar year deductible, and would you have to pay a separate deductible for each family member if everyone in your family became ill at the same time? (e.g., The majority of health plans have a per person yearly deductible, for example, $250, $500, $1,000, or $2,500. However, some programs will only require you to pay a two-person maximum deductible each year, even if everyone in your family needed extensive medical care.)
- What is your coinsurance percentage, and what dollar amount (stop loss) is based on? (e.g., A good plan with 80/20 coverage means you pay 20% of some dollar amount. This dollar amount is also known as a stop loss and can vary based on the type of policy you purchase. Stop losses can be as little as $5,000 or $10,000 or as much as $20,000, or there are some policies on the market that have NO stop loss dollar amount.)
- What is your maximum out of pocket expense per year? (e.g., All deductibles plus all coinsurance percentages plus all applicable access fees or other fees)
- What is the Lifetime maximum benefit the insurance company will pay if you become seriously ill, and does your plan have any “per illness” maximums or caps? (e.g., Some programs may have a $5 million lifetime maximum but may have a maximum benefit cap of $100,000 per illness. This means that you would have to develop many separate and unrelated life-threatening illnesses costing $100,000 or less to qualify for $5 million of lifetime coverage.)
- Is your plan a schedule plan, in that it only pays a certain amount for a specific list of procedures? (e.g., Mega Life & Health & Midwest National Life, endorsed by the National Association of the Self-Employed, N.A.S.E. is known for supporting schedule plans) 7. Does your project have doctor co-pays, and are you limited to a certain number of doctor co-pay visits per year? (e.g., Many projects have a limit of how many times you go to the doctor per year for a co-pay and, quite often, the limit is 2-4 visits.)
- Does your plan offer prescription drug coverage, and if it does, do you pay a co-pay for your prescriptions, or do you have to meet a separate drug deductible before you receive any benefits and do you just have a discount prescription card only? (e.g., Some plans offer you prescription benefits right away, other projects require that you pay a separate drug deductible before you can receive prescription medication for a co-pay. Today, many programs offer no co-pay options and only provide you with a discount prescription card that gives you a 10-20% discount on all prescription medications).
- Does your plan have any reduction in benefits for organ transplants, and if so, what is the maximum your policy will pay if you need an organ transplant? (e.g., Some plans only pay a $100,000 maximum benefit for organ transplants for a procedure that costs $350-$500K, and this $100,000 maximum may also include reimbursement for expensive anti-rejection medications that must be taken after an operation. If this is the case, you will often have to pay for all anti-rejection medications out of pocket).
- Do you have to pay a separate deductible or “access fee” for each hospital admission or each emergency room visit? (e.g., Some plans, like the Assurant Health’s “CoreMed” plan have a separate $750 hospital admission fee that you pay for the first three days you are in the hospital. This fee is in addition to your plan deductible. Also, many plans have benefit “caps” or “access fees” for outpatient services, such as physical therapy, speech therapy, chemotherapy, radiation therapy, etc. Benefit “caps” could be as little as $500 for each outpatient treatment, leaving you a bill for the remaining balance. Access fees are additional fees that you pay per treatment. For example, for each outpatient chemotherapy treatment, you may be required to pay a $250 “access fee” per treatment. So for 40 chemotherapy treatments, you would have to pay 40 x $250 = $10,000. Again, these fees would be charged in addition to your plan deductible).
- Now that you’ve read through the list of questions that I ask a prospective health insurance client ask yourself how many questions you were able to answer. If you couldn’t answer all ten questions, don’t be discouraged. That doesn’t mean that you are not a smart consumer. It may just say that you dealt with a “bad” insurance agent. So how could you tell if you dealt with a “bad” insurance agent? Because a “great” insurance agent would have taken the time to help you understand your insurance benefits. A “great” agent spends time asking YOU questions so s/he can understand your insurance needs. A “great” agent recommends health plans based on all four variables; wants, needs, risk, and price. A “great” agent gives you enough information to weigh all of your options so you can make an informed purchasing decision. And lastly, a “great” agent looks out for YOUR best interest and NOT the best interest of the insurance company.
- So how do you know if you have a “great” agent? Easy, if you were able to answer all ten questions without looking at your health insurance policy, you have a “great” agent. If you were able to answer the majority of items, you might have a “good” agent. However, if you were only able to answer a few questions, chances are you have a “bad” agent. Insurance agents are no different than any other professional. Some insurance agents care about the clients they work with, and other agents avoid answering questions and duck client phone calls when a message is left about unpaid claims or skyrocketing health insurance rates.
- Remember, your health insurance purchase is just as necessary as purchasing a house or a car, if not more important. So don’t be afraid to ask your insurance agent a lot of questions to make sure that you understand what your health plan does and does not cover. If you don’t feel comfortable with the type of coverage that your agent suggests or if you think the price is too high, ask your agent if s/he can select a comparable plan so you can make a side by side comparison before you purchase. And, most importantly, read all of the “fine print” in your health plan brochure and when you receive your policy, take the time to read through your policy during your 10-day free look period.
- If you can’t understand something or aren’t quite sure what the asterisk (*) next to the benefit description means in terms of your coverage, call your agent or contact the insurance company to ask for further clarification.
- Furthermore, take the time to perform your due diligence. For example, if you research MEGA Life and Health or the Midwest National Life insurance company endorsed by the National Association for the Self Employed (NASE), you will find that there have been 14 class-action lawsuits brought against these companies since 1995. So ask yourself, “Is this a company that I would trust to pay my health insurance claims?
- Additionally, find out if your agent is a “captive” agent or an insurance “broker.” “Captive” agents can only offer O.N.E. insurance company’s products.” Independent” agents or insurance “brokers” can provide you with a variety of different insurance plans from many different insurance companies. A “captive” agent may recommend a health plan that doesn’t precisely meet your needs because that is the only plan s/he can sell. An “independent” agent or insurance “broker” can usually offer you a variety of different insurance products from many quality carriers and can often customize a plan to meet your specific insurance needs and budget.
- Over the years, I have developed strong, trusting relationships with my clients because of my insurance expertise and the level of personal service that I provide. This is one of the primary reasons that I do not recommend buying health insurance on the Internet. In my opinion, there are too many variables that Internet insurance buyers do not often take into consideration. I am a firm believer that a health insurance purchase requires the level of expertise and personal attention that only an insurance professional can provide. And, since it does not cost a penny more to purchase your health insurance through an agent or broker, my advice would be to use eBay and Amazon for your less critical purchases and to use a knowledgeable, ethical and reputable independent agent or broker for one of the most important investments you will ever make….your health insurance policy.
- Lastly, if you have any concerns about an insurance company, contact your state’s Department of Insurance BEFORE you buy your policy. Your state’s Department of Insurance can tell you if the insurance company is registered in your country and can also tell you if there have been any complaints against that company that has been filed by policyholders. If you suspect that your agent is trying to sell you a fraudulent insurance policy, (e.g., you have to become a member of a union to qualify for coverage) or isn’t being honest with you, your state’s Department of Insurance can also check to see if your agent is licensed and whether or not there has ever been any disciplinary action previously taken against that agent.