As you begin looking for individual health insurance in the state of Texas, it is easy to become overwhelmed by the options that are available today. The market place has exploded with options after legislation changes in 2018 and that means you can now explore many options beyond the Affordable Care Act Exchange policies that have been available the last few years. The only downside to these options is understanding what each policy means and which one is best for you. Texans have been asking us recently what are the keys to choosing the right health insurance plan for them. So we thought we would share the items that really matter the most when comparing these sometimes very different policies.
The Seven Keys To Every Health Insurance Policy
- Utilization - On an average year, how many times you typically utilize your doctor, do lab tests, take prescriptions, visit an urgent care center, trips to the ER, or any sort of regular hospitalization? We always hear people say that they NEVER go to the doctor. If your that person who just doesn't go very often, you will likely not see benefit from a higher cost, cheaper copay type policy. It will be a large sunk monthly cost that will not yield much for you.
- Networks - If you have a specific doctor that you HAVE to use, you have to do one of two things. Either make sure that they are on the network of any policy that you are considering, or utilize a plan that doesn't have a need for a network because you are paying for routine care out of pocket.
- Included Benefits - This is a conversation that has changed recently with the advent of the Minimum Essential Components included in all Exchange policies. People now look for things like preventive care (wellness checks, certain diagnostic tests, immunizations, etc) to be included on their health insurance and are shocked when it is not listed. These coverage items can all be obtained via cash pay as well. Understanding what is and is not covered, how much each item might cost you and whether or not you will need some of them in the upcoming year can have a profound effect on premiums and out of pocket expenses. Make sure you know what is covered!
- Type Of Plan - Are you buying an HMO, EPO, PPO, Sharing or Indemnity plan? Each plan comes with certain benefits and restrictions. Do you want to have to get a referral from your Primary Care Physician to go to the ER? Are you worried about being in network if you are 1,500 miles from home? Do you have to pay cash first and get reimbursed later? All of these issues will be defined by the plan that you are on.
- Pre-Existing Conditions - Many individual health insurance policies come with restrictions of coverage for the dreaded pre-existing condition. Each policy plan will have some variation, as some are much more restrictive than others. It's important to know if the health insurance policy you are considering will even take you.
- Costs of Care - There are many ways that insurance policies expect you to pay for the care that you utilize. Do they use any of the following?
- Co-Pays - simple copay amounts for visits that do not count towards a deductible.
- Deductibles - your portion of any large bill that will be paid first dollar by you.
- Coinsurance - your portion of any remaining bills after the deductible is met.
- Back Billing - does the the insurance company settle the bill with the provider and then require payment of co-pay/deductible/coinsurance after the fact?
- Cash Pay - will you be paying cash out of your pocket for low level services rendered?
- Cash Pay With Reimbursement - are you expected to front the cost of care only to be reimbursed later?
- Monthly Premiums - This is generally the first thing that Texans look at when comparing policies. We put it last for a reason. The goal is to avoid frustration no matter how large or small the premiums.
- A small monthly premium that provides limited coverage inside an HMO can be a very frustrating experience.
- A large monthly premium that provides robust coverage inside a PPO network with a tiny network that greatly limits your ability to get care can also be a very frustrating experience.
- A medium monthly for great coverage in a great EPO network that you truly never use can feel like a waste of money.
So How Do I Choose Which Health Insurance Plan Is Best For Me?
This is where the word best becomes very subjective unfortunately. We will start from the position of if you have a pre-existing condition like cancer, stroke, heart issues, etc you need to be utilizing the Exchange policies. They were created specifically for you. That said, let's consider some scenarios to help you understand how to use these key points to determine your best.
Scenario 1: James - 25 years old, healthy, and does not qualify for exchange subsidies
James is your prototypical healthy mid 20's guy who loves adrenaline sports, travel, and doesn't really ever visit the doctor. He will like use an urgent care center like Care Now if he has the flu or some other winter sickness. He's more likely to wind up in the ER from a motorcross accident than he is to visit a primary care physician for a physical. So what kind of plan should he choose?
- Utilization will be low
- He needs a geographically diverse network due to travel
- Does need a lot of included benefits for primary care since he just doesn't go
- Will need accident type of coverage for those adrenaline sports
James is a prime candidate for a more traditional Catastrophic Health Insurance plan to cover himself financially in the event of an accident or major illness. But since those plans don't cover basic primary care and will have low monthly premiums, it makes a great fit for his lifestyle.
Scenario 2: April - 30 years old, healthy, and mother to a two month old
April is working hard and raising her young baby. She knows that she will need routine care of the kiddo along with immunizations. She lives in a metro area like Dallas-Ft Worth and really wants to make sure that she can use her favorite pediatrician. What kind of plan would work well?
- Utilization will be high as babies require many visits and vaccinations during their first two years of life
- She is seeking a network that includes her baby's doctor and access to good hospitals if her baby needs something done
- With regular visits, the copays become important as it will impact her cash flow beyond the premium payments
April will have multiple options available to her. A short term medical plan can absolutely provide what she is looking for since some of those plans now include co-pays for visits and immunization coverage. They also have riders that can also eliminate the deductible for a hospitalization in some cases.
Scenario 3: Chuck - 37 years old, has a family of four, mom manages high blood pressure
Chuck is your typical suburban dad who works hard at his small business. He provides great service to his customer and takes care of his family. His wife's high blood pressure requires regular visits to the primary care doctor and she manages it well with a generic prescription, diet, and regular exercise. The kids also require some routine care.
- Utilization will be elevated because of the regular doctor visits and prescriptions
- Chuck uses a direct primary care doctor who charges him a flat fee per month to take care of his family's regular needs
- He is worried about monthly cash flow due to owning a small business
- He is desperately concerned with a big event destroying his savings
Chuck is utilizing a great, predictable way to manage his ongoing care needs with a Direct Primary Care doctor. Those costs need to be factored into his insurance costs as well since it's part of the monthly spend. Chuck could utilize a high deductible Short Term Medical plan or a Catastrophic Health Insurance Policy. Either would work well.
Where Do I Go From Here?
If those scenarios and factors make sense, speaking with an independent insurance agent can allow you to evaluate your situation in a pragmatic manner. The goal of an independent insurance agent is to fit the best plan to the customer rather than forcing them into a single solution. The agents at Insurance For Texans have various solutions available to you so that you can match needs and wants to real solution for your family's health insurance needs. If you would like to speak with us just click the button below and we can get the process started.