Insurance Basics and Plans
Dental, Vision and Hearing, Telemedicine
We offer: Dental HMO, PPO, Indemnity, No Wait and Discount Plans
Vision HMO, PPO and Discount Plans
Hearing plans that are offered with Dental and Vision
Telemedicine with copays and without
Additional Ancillary Products
Term, Whole, Universal, Final Expense, Accidental Death & Dismemberment, Accident, Cancer, Child Life, Critical Illness, Credit Lock, Hospital Indemnity, Legal Shield, Long Term Care, Long Term Disability, Short Term Care, Short Term Disability, Short Term Medical (ages 64 and younger) and Travel Insurance
Individual Health 101
Individual vs Group
Individual health insurance is, quite simply, coverage that an individual purchases for himself and/or his family. The Affordable Care Act (ACA) has made significant changes to how individual insurance policies are rated and the benefits that these policies provide. Individual insurance policies and provisions are also regulated by the state where the policy is purchased.
Individual policies are often purchased with the advice of a professional insurance producer due to the complexity of coverage offerings and the premium cost. With the advent of the ACA, a professional insurance producer’s expertise may be even more critical since insurance policies have changed so dramatically.
Whether or not a person has a pre-existing medical condition is no longer a factor when purchasing individual coverage. Since a person’s medical condition is not a factor, individuals are limited to certain times when they can enroll in coverage. A person must enroll during an open enrollment period to gain coverage for the year. There are limited opportunities to purchase coverage at other times during the year as a result of a special enrollment right.
Individual insurance policies may be purchased through an exchange or “marketplace” or they may be purchased outside of the exchange. Irrespective of whether a policy is purchased inside or outside the exchange, polices must cover the same set of Essential Health Benefits. The richness of the benefits under the plan is defined by a metal tier. These tiers are based on the percentage the plan pays of the average overall cost of providing essential health benefits to members:
- Platinum plans are the most generous and more expensive. These are designed to pay as much as 90% of medical expenses
- Gold plans are designed to pay 80% of medical expenses
- Silver plans are expected to pay 70% of medical expenses
- Bronze plans are expected to pay 60% of medical expenses.
It’s important to note that the metal tiers reflect what the plans will pay on average. These percentages are not the same as coinsurance, which calls for an individual to pay a specific percentage of the cost of a specific service.
Another category of individual plan is the catastrophic plan. A catastrophic plan must meet all of the requirements applicable to other QHPs (qualified health plans), but benefits are very limited. The limited benefits include three (3) primary care visits per year before the deductible is met. Catastrophic plans are an option for individuals under the age of 30 or others who have received a “hardship exemption” from the exchange due to other health coverage being deemed unaffordable.
Since medical services can be quite costly, the insurance premium for individual coverage is small compared to the amount an insurer may have to pay for claims. For example, a comprehensive individual insurance policy may cost $4,000 for a 30-year-old male for a year (actual premium costs vary by geographic area, metal tier selected and other factors, this is an estimate for comparison purposes only). Treatment costs for a broken leg that needs surgery (lower leg fracture surgery) are estimated to cost a total of $20,622 by the Healthcare Blue Book.
How are premium rates determined?
Premium rates both on and off of the marketplace are determined by the age of each individual who will be covered by a plan. Other factors that affect the premium for coverage include where a person lives and the level of plan (metal tier) that they select.
Individuals may be eligible for government subsidies to help pay for premiums. Subsidies are available only for coverage purchased through the exchange. Subsidies are calculated based on the modified adjusted gross income for the year and the household size. Subsides may be available to individuals with incomes between 100% of the Federal Poverty Level (FPL) and 400% of the FPL. More information on qualifying for premium assistance can be found at https://www.healthcare.gov/will-i-qualify-to-save-on-monthly-premiums/.
Individuals may also qualify for savings on out-of-pocket costs when they obtain medical care. These savings are called "cost-sharing reductions." Cost-sharing reductions reduce the amount an individual pays for out-of-pocket costs such as deductibles, coinsurance and copayment. They are available for Silver plans purchased through the exchange for individuals with incomes no higher than 250% of the FPL.
Can I still buy individual insurance if I have a very serious pre-existing medical condition?
Beginning in 2014, insurers providing individual insurance are no longer able to, in most cases, exclude, limit or deny coverage for any American solely on the basis of a pre-existing condition. There may be some limited situations where a plan has maintained special “grandfathered” status where this limitation would not apply.
What benefits will an individual health policy cover?
Health insurance plans offered through the exchange or outside of the exchange will offer the same essential health benefits. Each plan or insurance company may add items or services to these minimum essential benefits and may vary the hospitals and doctors that are part of the network so it is important to compare plans.
The essential health benefits include:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse disorder services
- Prescription drugs
- Laboratory services
- Preventive and wellness services
- Pediatric services
- Rehabilitative and habilitative services and devices.
When can I enroll in an individual plan?
Because there are no longer any restrictions on coverage for pre-existing conditions, coverage is generally available for purchase only during open enrollment periods. The limitation to purchase coverage during open enrollment is a mechanism to avoid “adverse selection” and is needed to help keep health insurance premiums more affordable. Adverse selection occurs when someone can purchase insurance only after they know that they need it.
The open enrollment period for coverage to be effective is established each year. Here is the link to the most current open enrollment deadline.
Enrolling in coverage outside of the open enrollment period generally requires that someone have a qualifying life event that triggers a special enrollment right. A qualifying life event is typically marriage, divorce, birth or adoption of a child or a change in income, among others. It is not a voluntary loss of employer coverage.
Some states or some insurance companies may offer coverage at times other than the open enrollment period. You should check with your state Department of Insurance, the exchange marketplace in your state or an insurance producer licensed to sell insurance in your state to see if there are exceptions.
Where can I get more information?
An insurance producer licensed to sell insurance in your area is one of the best resources for information on coverage that meets your needs.
You may also find a helpful glossary of insurance terms and other marketplace information at www.healthcare.gov.
Learn How to Choose a Medical Plan
There are many things to consider when choosing a health insurance plan. You want a plan that will meet your needs for types of coverage, access and dependability at a reasonable cost. Ask yourself the following questions to help steer your decision:
Do I want basic or more comprehensive coverage?
Some insurance plans offer basic coverage that protects your finances in the event of an illness or injury resulting in a hospital stay. These types of plans typically have a lower monthly premium, but you are responsible for doctor visits.
Other health insurance plans offer more doctor visits to include healthcare, maternity benefits, prescription drug benefits, eye care and routine doctor visits. These types of plans tend to have a higher monthly premium and may be more appropriate for those who may use their insurance benefits on a regular basis.
Is my doctor or hospital covered by the plan?
You need to check the insurance plan's network provider directory to confirm that your doctor or hospital is included in the plan's network. If you use doctors that are in the plan's network, you will receive the highest level of benefits.
Does the health insurance plan cover me if I travel?
Some plans have provider networks that are based on where you live. If you travel outside of that area, you are typically not covered by your health insurance plan. Consider stand alone travel insurance; where you may be covered almost anywhere you travel to in the United States and in 200 countries around the world.
Does the health insurance plan cover services that are important to me?
You must decide what services are important to you, such as preventive care and maternity coverage. Some plans do not cover these types of services; therefore, you may want to consider plans that includes coverage for preventive services, as well as labor and delivery if you are planning a family.
Does the health insurance plan cover my family?
Make sure to purchase family coverage and not single-only coverage just for you if you need coverage for your family now or in the near future.
Does the plan work with a health savings account (HSA)?
Some high-deductible health insurance plans work with tax-favored health savings accounts that can be used to pay for certain qualified medical expenses. HSA's can be established in a financial institution to make sure that your catastrophic needs are covered while you build a financial cushion for your later medical needs.
Are prescription drugs covered under my health insurance plan?
Prescription medication coverage varies by plan. Some of our plans require that you pay a copayment depending on the type of drug purchased, and we will pay the rest of the cost. Other health plans require that you must first meet your deductible before anything is paid.
Most drugs have a formulary, or list of drugs, that the plan covers. Find out if your medication is covered before selecting a health plan.
Most everyone is looking for ways to cut down on costs whenever they can. There are ways to save on your healthcare expenses, too. Becoming familiar with your healthcare options may help keep you and your family healthier without breaking the bank.
- Choose the right level of careWhen you need care, knowing your options can help save you time and money. When you choose the right level of care for your situation, it helps keep healthcare costs down and affordable for everyone.Below are some costs options (from lowest to highest):
- No-cost -- Nurse advice line: Determine if your health insurance plan or doctor's office offers a nurse advice line. Some of these may even be available during nights and weekends.
- $ -- Doctor's office: Offers a wide variety of services, from routine checkups to the diagnosis of a health condition.
- $$ -- Urgent/after-hours center: These facilities handle many problems that can be treated in a doctor's office but are also available during non-business hours. They also offer some services not generally found in a doctor's office, such as X-rays and minor trauma rooms.
- $$$ -- Emergency room: This should only be used for the most serious, life-threatening conditions, as it is the most expensive type of care.
- Take advantage of resources to shop for care
The more you know about healthcare quality, safety, services and costs, the easier it is for you to choose wisely when it comes to the care that's right for you.
Higher costs don't necessarily mean higher quality. High value is what's important when looking at healthcare. You can find care that's high-quality and high-value using online tools and resources.
Below are some trusted sites that can help you understand you need when it comes to high-quality, high-value healthcare.
Hospital Compare*: This tool from Medicare provides information about a facility's quality of care based on patient surveys and allows you to view specific information and ratings based on certain medical conditions or surgical procedures.
The Leapfrog Group: This online source provides you with quality reports for many hospitals nationwide and helps you reap the benefits of making smart, informed healthcare decisions.
Blue Distinction Centers®: You can compare the quality, and cost where available, of specific facilities (primarily hospitals) for common medical procedures, such as childbirths, tonsil removal, hip replacement, knee surgery, MRIs and colonoscopies.
Other Helpful Tips for Saving on Healthcare Costs:
- Make healthier lifestyle choices. Exercise regularly, eat a balanced diet and keep stress to a minimum.
- Practice prevention. Get regular physical and dental check-ups, schedule recommended health screening tests and get your annual flu shot.
- Take an active role in your care. Choose a primary care doctor to coordinate your care, and take time to build a good relationship with your doctor.
- Keep the word "emergency" in emergency room. Seek help at an emergency room for deep wounds, chest pain, severe burns or serious trauma. If possible, visit an after-hours clinic or wait to see your own doctor.
- Don't insist on an office visit or antibiotic prescription for a common cold.
- Ask why tests and treatments are being done, if they are really necessary and what your options are.
- Carefully review your doctor and hospital bills. Be on the lookout for duplicate billings, inaccurate dates and charges for supplies, medications or tests that you didn't receive.
- Discuss prescription medications with your doctor. Ask if a generic drug or over-the-counter medication is appropriate for your condition.
- Request samples when trying a new medication.
- Avoid overuse of antibiotics. The Centers for Disease Control estimates that one third of the 150 million outpatient prescriptions for antibiotics written each year in the United States are unnecessary.
- Take your medication as directed. Keep taking it and finish the prescription even if you feel better.
In considering what plan is appropriate for you, spend some time reviewing medical care you have received for the past few years. Use this amount to "estimate" your total costs for the year under the new plan. Add up your premium, anticipated deductible payments, coinsurance, copayments and other out-of-pocket expenses to make sure you can afford these costs.
You'll also want to think about the other services provided by the health insurance plan and the total value of the plan.
Would you like more information on plan details, have questions or would like to enroll?
Click here or give us a call (918) 973.3304 for Oklahoma or (954) 378.8881 for Florida.
For additional quotes on Individual Medical, Short Term Medical and Ministry Share Plans, click here.
Ancillary Links and Brochures
My Benefit Comparison. Compare, get quotes for multiple products and enroll online.
Spirit Vision. Click here for details, pricing and online enrollment.
Ameritas Security Life Dental and Vision. Click here for more information on plans, pricing and to enroll.
Denali Dental and Vision. Click here for more information on plans, pricing and to enroll.
Dental Plans. Click here for more information on plans and discounts for Dental, Vision and Alternative Medicine discounts.
Magnum Dental and Vision. Click here for more plan information, pricing and to enroll online.
Ally Health Telemedicine. Click here for plan pricing, details and online enrollment.
Starmount ADD. Click here for plan pricing and online enrollment.
Starmount Accidental Death. Click here for plan pricing and online enrollment.
Ministry Health Share Plan. Click here for plan pricing, coverage and enrollment.
Healthcare Blue Book. Look up reasonable and customary charges for medical procedures.