Mega Life & Health & Midwest National Life Finally Get What They Deserve!
This is a great day in the health insurance industry! Rarely is an insurance company held liable for improper conduct. The majority of the time the "Big Guy" takes advantage of the "Little Guy" and sadly the "Little Guy" has no recourse. But this is not the case today! After many years of repeated violations of insurance conduct laws the NAIC- (National Association of Insurance Commissioners) has levied one of the largest market conduct fines in insurance history against Mega Life & Health insurance company, Midwest National Life insurance company, a.k.a. Health Markets, a.ka. NASE - National Association for Affordable Services, formerly known as U.I.C.I. The fine is 20 Million Dollars and in my informed opinion, it is not nearly enough and it has come much to late!
Health Markets has been slinging their garbage for many years across the country to many thousands of innocent consumers who had no idea the extreme limitations included with the so called insurance coverage provided by Mega & Midwest. They have consistently offered "schedule plans" which pay out an average of only $100,000 per illness (even though the policy is sold as a plan that covers you to One Million or Two Million lifetime). Their coverage traditionally also has no "stop loss number". This has lead to many innocent consumers suffering catastrophic financial losses.
The lack of a "stop loss number" is a very dangerous policy design. To further explain. The term 80/20 is often used when describing how a health insurance policy works. The typical major medical health insurance policy has an 80/20 of $10,000 "co-insurance" percentage split. This quite simply means that after you have satisfied your calendar year deductible the insurance company will pay 80% ($8,000) and the insured will pay 20% ($2,000) of the first $10,000 in medical bills that you incur. This first $10,000 is known as the "stop loss number". After this brief sharing arrangement is over the insurance company pays 100% up to $5 Million per insured for the rest of that calendar year for in network treatment. Everything starts over again on the first of each subsequent year. This greatly reduces the risk to the insured and it is a standard policy design feature included with most legitimate health insurance policies.
In stark contrast, in the case of the "schedule plans" offered through the two aforementioned companies, the terms "co-insurance" and "stop loss" are very rarely if ever discussed with a prospective insured. This is because they have a direct effect on how much the insured will pay in the event of a worse case scenario. Worse yet, Mega & Midwest have traditionally been offering their policies with No Stop Loss Number. This means that if the bill is One Million Dollars, the consumer would pay 20% of that amount ($200,000) before the insurance company would pay 100%. However, with the $100,000 maximum pay out per illness clause included with their insurance contract, Mega & Midwest would still only be responsible for $100,000 regardless of the size of the bill! What a sweet deal for Mega & Midwest. Arguably the worse part about the coverage they offer is the fact that it costs the same or more than a major medical policy without all of the dangerous limitations included with their schedule plans.
Would you buy a policy like that if it was fully explained to you? Most definately not, and the NAIC apparently agrees. This is the primary reason why after a 3 year 29 state investigation, Health Markets has finally had to face up to all the fraud they have been responsible for. On May 29th, 2008 they were hit with a $20 Million fine. Furthermore, a scathing "Market Conduct" report has been written as well. To read all about it visit: http://www.insurance.wa.gov/oicfiles/marketconduct/2007mc/RSA05292008Final.pdf
Market Conduct Report: http://www.insurance.wa.gov/oicfiles/marketconduct/2007mc/MegaReportFinal.pdf
If you or a loved one have fallen victim to this organization and have purchased one of their "insurance products" please do not hesitate to contact me via the contact us page of our web site @ www.smallbusinessinsuranceservices.com for a complete review of your situation and an immediate replacement of your coverage. The risk to you and your loved ones is much to great if you remain "insured" by any of the policies offered by this organization. You can also contact me directly toll free @(866) 724 7123 or via email: steve@sbisvcs.com or click on the "LIVE HELP" button on any page of our web site here: www.sbisvcs.com
What are H.S.A's and H.D.H.P.'s and how can they save you money and boost your retirement?
The acronym "H.S.A" is being tossed around quite a bit nowadays especially since the tax advantages of owning an H.S.A. and a corresponding qualified H.D.H.P (High Deductible Health Plan) have been significantly increased under the Bush administration. Effective December 20, 2006 President George W. Bush signed the Health Opportunity Patient Empowerment Act of 2006, enhancing Americans' access to tax-advantaged health care savings. The law, part of the Tax Relief and Health Care Act of 2006, provides new opportunities for health savings account (HSA) participants' to build their funds. To read about the new adjustments in H.S.A. law for the year 2007 please Click here: http://www.treas.gov/press/releases/hp209.htm
H.S.A. stands for Health Savings Account. Health Savings Accounts are a unique way to attractively manage your health insurance costs. They were originally named M.S.A's or Medical Savings Accounts designed by Senator Bill Archer (R) of Texas. Bill's project was to find a way to reduce the cost of health insurance for the self employed without sacrificing quality coverage for a major medical illness. Bill's brilliant idea was to eliminate the parts of a traditional health insurance plan that cost the consumer the most money. These expensive benefits include outpatient doctor "co pays" and outpatient prescription "co pays". Bill approached Congress with a proposal that stated in essence that if you remove those two features and keep the major medical coverage in place you could conceivably cut the cost of your health insurance premium considerably. He was absolutely right!
To illustrate how Bill's idea works in the real world. We will use a real world example. Tony & his wife are currently paying $1,134 a month for Cobra continuation coverage from a previous group plan. In comparison, the monthly premium for an H.S.A. qualified H.D.H.P. (High Deductible Health Plan) which covers each insured family member up to $5 million dollars is less than half of the premium that they are paying now ($481.64 monthly to be exact). This is a yearly savings of $7,828.32 or a monthly savings of $652.36. This is a significant difference, however the insured has to give up all of their outpatient co pays. Is this worth it? This was the question posed to Senator Bill Archer when he approached Congress back in the 1990's. His answer to Congress was quite simply "make it worth it". In other words, he asked Congress to make it worth it to the insured. Their response was two fold. And it is these two primary reasons that make H.S.A.'s a "no-brainer" for every self employed prospective insured and for their corresponding employees.
The first thing Congress did was to state that if a policy holder buys a major medical health insurance policy (H.D.H.P.) with a yearly family deductible between $2,200 per family (not per person) or as high as $5,650 per family we will call that an H.S.A. qualified health insurance plan (H.D.H.P.) They further said that in order to make giving up outpatient co pays more attractive to the insured we will allow anyone who has an H.S.A. qualified health insurance plan (H.D.H.P.) the option to open a tax favored H.S.A. (Health Savings Account) with their local bank or financial brokerage house. Since the insured is saving a considerable amount of money each month by giving up their out patient co pays, we will allow them to take that extra premium that they would have normally given the insurance company for the "privilege" of a co pay and put it into a 100% tax deductible account that will grow tax deferred at an interest rate adjusted by the Fed.
In addition to depositing the amount you save in insurance premiums, you may also deposit in your H.S.A. an amount equal to the size of your chosen plan deductible. So if a family chooses an H.D.H.P. with a $5,650 yearly family deductible then that family can deposit an amount equal to that number each year and an additional $800 a year (in 2007) for each insured who is over the age of 55 (more on the age 55 allowance below). This means that the total amount that Tony and his wife (in our example above) can deposit per calendar year is $6,450 and they can take a 100% tax deduction for that contribution similar to an I.R.A.
Furthermore, if they do incur medical expenses that arise throughout the course of the year that are subject to the deductible (i.e. prescriptions, doctor's office visit charges, etc.) the I.R.S. will allow them to pull out that money that they put into their optional tax deductible, tax deferred H.S.A. savings account to pay for those expenses. When they use their H.S.A. money to pay for those expenses the I.R.S. will allow them to write those expenses off at a 100% tax deduction. The list that the I.R.S. allows them to spend their H.S.A. money on is very liberal and includes things like dental, orthodontics, eyeglasses, radiokeratonomy (Lasik corrective eye surgery), alternative medicines etc. Click the hyperlink to see the list of allowable expenses and disallowed expenses on the H.S.A. section of the I.R.S. web site here: http://www.irs.gov/publications/p502/index.html
Arguably the most attractive tax advantage to owning an H.S.A. is the fact that the money left over in the H.S.A. account that was not used on medical expenses at the end of the year is "rolled over" into the next year and awarded a higher rate of tax deferred interest. The insured also has the option to roll those unused funds into no load mutual funds, thereby building an extra tax deferred retirement account with money they would have normally given to the insurance company each and every year whether or not they had any claims that year! To learn more about H.S.A.'s and the recent federal legislation that has made them even more attractive to people over the age of 55 click here: http://www.treas.gov/offices/public-affairs/hsa/about.shtml to read all about them on the Federal Governments H.S.A. educational web site.
If you are an employer and are considering H.S.A. qualified plans for your employees consider this. An individual's employer can make contributions that are not taxed to either the employer or the employee. The combined income and payroll tax deductibility leads to discounts for health insurance of over 40 percent in some cases relative to other forms of insurance. For more details about the advantages to the employer please click here: Click here: U.S. Treasury - HSA Frequently Asked Questions
Please "Contact Us" with questions about H.S.A.'s. If you have a C.P.A. or tax advisor please feel free to ask he or she about the advantages of owning an H.S.A. as well. You can run your own quotes and learn even more about H.S.A. qualified H.D.H.P.'s via our web site here: Click here: Small Business Insurance Services-What are H.S.A.'s and H.D.H.P.'s and how can they save you money
If you are a business owner, self-employed or an employee of a company that is not offering medical coverage though your employer, you may have to undertake the frustrating, daunting and time consuming task of purchasing health insurance on your own. If this is the case, there are certain things that you can do as a consumer to ensure that you are purchasing the type of health insurance coverage you really need at a price you can afford.
When you purchase a health insurance plan, you must achieve a balance between four important variables; wants, needs, risk and cost, before you spend your money. Although you may “want” a health plan that offers you 100% coverage and a $5 co-pay for prescription medications, you may not “need” this type of health plan if you are healthy, take no medications and do not have any significant health related “risk” factors. Since a 100% health plan may “cost” significantly more than a health plan with 80/20 coverage, it may not be in your best interest to pay higher monthly premiums for coverage that you are not likely to use.
In addition to weighing the aforementioned key variables, it is also critical that you understand the limitations of your coverage. The following is a list of 10 key questions that you should ask your insurance agent, before making a decision to purchase a health insurance policy.
1. What insurance company do you represent and are you a “captive” agent, “independent” agent or insurance “broker?” (e.g. A “captive” agent usually represents ONE insurance company and can usually only sell that company’s insurance products. An “independent” agent or insurance “broker” usually represents many insurance carriers and can sell a variety of insurance products.)
2. What is the plan’s calendar year deductible and would I have to pay a separate deductible for each family member if everyone in my family became ill at the same time? (e.g. The majority of health plans have a per person calendar year deductible, for example, $250, $500, $1,000, or $2,500. However, some plans will only require you to pay a 2 person maximum deductible each calendar year, even if everyone in your family needed extensive medical care.)
3. What is the plan’s coinsurance percentage and what dollar amount (stop loss) it this percentage based on? (e.g. A 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. It is also important to note that some policies have NO stop loss.)
4. What is the plan’s maximum out of pocket expenses per year? (e.g. This expense is a total of all deductibles plus all coinsurance percentages plus all applicable “access fees” or other fees.)
5. What is the plan’s lifetime maximum benefit if I become seriously ill and does the plan have any “per illness” maximums or caps? (e.g. Some plans may have a $5 million lifetime maximum, but the policy many stipulate that there is 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.)
6. Is the 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. agents are known for selling schedule plans.)
7. Does the plan have unlimited doctor co-pays or is there a limited number of doctor co-pay visits per year? (e.g. Many plans have a limit of how many times you can go to the doctor per year for a co-pay and, quite often, the limit is 2-4 visits.)
8. Does the plan offer prescription drug coverage and if it does what type of coverage? (e.g. Some plans offer prescription benefits right away, other plans will require you to pay a separate drug deductible before you can receive prescription medication for a co-pay. Today, many plans offer no outpatient prescription drug co-pay options and only provide you with a discount prescription card that gives you a 10-20% discount on all prescription medications.)
9. Does the plan have any reduction in benefits for organ transplants and if so, what is the maximum the plan will pay out for an organ transplant? (e.g. Some plans only pay a $100,000 maximum benefit for organ transplants for a procedure that actually costs $350-$500K and this $100,000 maximum may also include reimbursement for expensive anti-rejection medications that must be taken after a transplant. If this is the case, you may be required to pay for anti-rejection medication out of pocket.)
10. Does the plan have any separate deductible or “access fee” for each hospital admission or for each emergency room visit? (e.g. Some plans, like the Assurant Health’s “CoreMed” plan have a separate $750 hospital admission fee or “Access Fee” that you pay for the first 3 days of a hospital admission. “Access Fees” are in addition to your plan deductible. Also, many plans have benefit “caps” or “access fees” for out-patient services, such as, physical therapy, speech therapy, chemotherapy, radiation therapy, etc. Benefit “caps” could be as little as $500 for each out-patient 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.
Remember, your health insurance purchase is just as important 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. 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.
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 state and can also tell you if there have been any complaints against that company that have been filed by policy holders. 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.
In today's fast paced world, business owners don't often have the time to thoroughly check out the companies they rely on to provide goods and services. In many cases, a determination of product/service quality can be made at the time goods are delivered or services are rendered. If goods or services do not meet expectations, there is often an immediate remedy available. For example, poor quality goods can be shipped back to the supplier and/or payment for services can be withheld until services are satisfactorily rendered.
Unfortunately, business owners do not always purchase items that are tangible items, in the sense that they can immediately determine the quality of the goods and/or services at the time of purchase. One example of such a purchase is health insurance. Since health insurance is not usually used immediately after purchase, the quality of care or the legitimacy of the policy may not even come into play until the business owner, or a family member, actually needs to have medical treatment. This is one of the primary reasons that many companies, often appearing legitimate, can get away with selling bogus health insurance coverage to unsuspecting business owners.
In most cases, fraudulent health insurance policies are sold to business owners by telemarketers or "agents" through bogus Associations and Unions. In that, the buyer must join a professional and/or trade association or become a union member to qualify for health insurance. In fact, in a study published by the U.S. General Accountability Office (GAO) in 2004, the GAO found that association schemes ranked at the top of the marketing methods followed by bogus health insurers. According to the report, "Employers and Individuals Are Vulnerable to Unauthorized or Bogus Entities Selling Coverage, between 2000 and 2002, the U.S. Department of Labor and state insurance regulators identified 144 unauthorized entities selling health insurance unlawfully. These entities defrauded 15,000 employers and more than 200,000 policyholders out of $252 million."
However, it is important to mention that many individual and group health insurance products are endorsed by reputable Associations, such as the ARRP and the American Bar Association and, many reputable Unions, such as the AFLCIO and the Teamsters. These organizations have long been recognized for bringing a common class of professionals or citizens together for other purposes that have very little to do with health insurance. Membership commonly includes a wide range of other benefits in addition to discounted health insurance. Typically, the organizations have a governing organization, a constitution and bylaws, a set of officers, voting rights, regular membership meetings and a professional code of conduct.
Unfortunately, most individuals do not find out that they were making hefty monthly payments or premiums to fraudulent Associations or Unions until they have a severe condition that requires medical treatment. Usually, it isn't until after they receive treatment that they receive notice from their medical provider that the claim that was submitted to the insurance company was denied and that all the medical charges that were incurred are now their responsibility.
Often, the scheme starts when business owners are contacted by telephone or approached by someone who claims to represent a certain, official sounding, Association or . The business owner is then informed that if s/he becomes a member of the Association or joins the , s/he could qualify for a low cost group or individual health insurance plan. Typically the Association or is promoted to represent self-employed individuals and small business owners. The low cost health insurance is usually presented as one of the many "perks" that the business owner can qualify for, in addition to many other "member" benefits, like discounts on other services, such as dental, eyeglasses, office supplies, hotels, rental cars, etc.
In many instances, these bogus companies involve licensed health insurance agents to sell their fraudulent health insurance products. Sometimes the "agents" know the products are fraudulent, other times, the "agent" also falls prey to the scheme.
Often, the schemes prey upon consumers who have been previously declined insurance coverage or suffer from a pre-existing condition. Since these consumers have very limited options to purchase private health insurance coverage, the benefits of an Association or Union membership that offers health insurance coverage for a "membership fee" or "union due" is enticing. To the unsuspecting consumer that has a pre-existing medical condition or is paying high premiums for coverage, the "membership fee" or "union due" is a small price to pay for what they believe will be a quality health plan that provides "guaranteed" coverage with no "pre-existing condition exclusions" and no "waiting periods."
In many circumstances, the print materials that are left with the consumer are very well designed, however, the majority of the time, the language in the "health plan brochure," if there is one, is very unclear. The literature may name the entity that is authorized to act as the health plan administrator of the plan, but neglect to name the actual insurance company that is providing the health insurance coverage. Unfortunately, it is often difficult for the consumer to separate the illegitimate companies selling official sounding health plans from the legitimate ones. Typically fraudulent health plans have many commonalities.
Here are 10 "Red Flags" that may indicate health insurance fraud:
- The "agent" is not a licensed insurance agent but an "enrollment" or "membership" coordinator.
- The term "discount plan" is written in the product literature, but the term health plan, health insurance or policy is frequently used by the plan promoter. Discount plans often provide nothing more than a discount for medical services, such as prescription medications, eyeglasses, dental, etc. These plans are not designed to offer major medical health insurance coverage.
- The official sounding "Association or " is one that you have never heard of before.
- The plan is referred to as an ERISA plan. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that allows employers to set up employee benefit plans for employees and their dependents. ERISA plans are not subject to state regulation and are not regulated by the state insurance commissioner. ERISA plans are normally not sold as health insurance, but are instead, established by employers, unions or groups acting on behalf of employers. Therefore, unsuspecting buyers believe these plans actually offer health insurance coverage, when if fact, they do not.
- The buyer is told that the "membership fee or union dues" includes the health insurance premium, but there is no mention of the word "premium" in any of the plan literature.
- The plan offers "guaranteed" insurance coverage with no exclusions for "pre-existing conditions" and no "waiting periods."
- The plan is significantly cheaper in price than other health insurance plans.
- The term "reinsured" is used in regards to the plan. Reinsurance is something insurance companies buy to protect themselves against their own risks. It is insurance for insurance companies. Licensed insurers rarely have their agents mention any of their reinsurance arrangements during a sales presentation.
- If the Association or Union is comprised of members from all walks of life and/or requires its members to state that they belong to a certain trade, class or group of professionals that they have no affiliation with, for example, the Association or Union is said to be comprised of "Food and Beverage" workers, but "Florists" and "Machinists" are allowed to enroll as members.
- If the Association or Union is said to have a special arrangement with a health insurance company, a plan administrator or another third party that has designed the plan using a legal "loophole" that allows members to purchase health insurance at a discounted rate or to purchase a individual or group health insurance policy.
So how can you protect yourself from falling victim to a fraudulent insurance scam? Make sure you contact your state's department of Insurance to determine if the health insurance company and the third-party administrator are licensed to do business in your state and make sure that the "agent" selling the plan is a "licensed health insurance agent." Additionally, make sure that the health insurance company has been approved to sell the particular policy that is being offered. Since it may be difficult to tell if fraud is involved, always put off buying your insurance policy until you have had the opportunity to perform your own due diligence.
If you are one of the 46.6 million Americans that have joined the ranks of the uninsured, what you may not know is that you may have to pay more for your medical treatment than your privately insured counterparts. If those without insurance get sick, they usually have to pay much more for the same medical services, since insurance companies can negotiate discounts with doctors, hospitals, pharmacies, and others health care providers. This means that the average uninsured working man or woman who suffers a mild heart attack can be stuck with a hospital bill that is in excess of $30,000 compared to the $10,000, negotiated rate, which is charged to an insured patient’s private insurance carrier. In many cases, uninsured individuals are charged 3-4 times more for the exact same medical treatment that is administered to patients with private insurance. Additionally, uninsured patient with huge medical bills are usually aggressively pursued by collection agencies and new bankruptcy laws make it extremely difficult to discharge medical debt. If you don’t have health insurance coverage, you have a 25% greater chance of developing a life-threatening disease or condition than those with health insurance. Here are some startling statistics from the National Institute of Medicine (IOM) – an arm of the National Academy of Sciences: Today, there are more uninsured Americans than any point in history. According to the U.S. Census Bureau, approximately 15.9 percent of Americans are walking around without health insurance coverage and paying for medical expenses out of pocket. Although treatment for a sore throat or broken ankle can be a manageable medical expense for some families, more expensive treatments like surgery or chemotherapy can be financially devastating. If you are the type of person that wouldn’t risk driving your vehicle without car insurance, consider the fact that there is a statistically greater chance that you will suffer from an illness or injury than an auto accident.
I have been a health insurance broker for over a decade and every day I read more and more “horror” stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. Unfortunately, insurance companies are driven by profits, not people (albeit they need people to make profits). If the insurance company can find a legal reason not to pay a claim, chances are they will find it, and you the consumer will suffer. However, what most people fail to realize is that there are very few “loopholes” in an insurance policy that give the insurance company an unfair advantage over the consumer. In fact, insurance companies go to great lengths to detail the limitations of their coverage by giving the policy holders 10-days (a 10-day free look period) to review their policy. Unfortunately, most people put their insurance cards in their wallet and place their policy in a drawer or filing cabinet during their 10-day free look and it usually isn’t until they receive a “denial” letter from the insurance company that they take their policy out to really read through it.
The majority of people, who buy their own health insurance, rely heavily on the insurance agent selling the policy to explain the plan’s coverage and benefits. This being the case, many individuals who purchase their own health insurance plan can tell you very little about their plan, other than, what they pay in premiums and how much they have to pay to satisfy their deductible.
For many consumers, purchasing a health insurance policy on their own can be an enormous undertaking. Purchasing a health insurance policy is not like buying a car, in that, the buyer knows that the engine and transmission are standard, and that power windows are optional. A health insurance plan is much more ambiguous, and it is often very difficult for the consumer to determine what type of coverage is standard and what other benefits are optional. In my opinion, this is the primary reason that most policy holders don’t realize that they do not have coverage for a specific medical treatment until they receive a large bill from the hospital stating that “benefits were denied.”
Sure, we all complain about insurance companies, but we do know that they serve a “necessary evil.” And, even though purchasing health insurance may be a frustrating, daunting and time consuming task, there are certain things that you can do as a consumer to ensure that you are purchasing the type of health insurance coverage you really need at a fair price.
Dealing with small business owners and the self-employed market, I have come to the realization that it is extremely difficult for people to distinguish between the type of health insurance coverage that they “want” and the benefits they really “need.” Recently, I have read various comments on different Blogs advocating health plans that offer 100% coverage (no deductible and no-coinsurance) and, although I agree that those types of plans have a great “curb appeal,” I can tell you from personal experience that these plans are not for everyone. Do 100% health plans offer the policy holder greater peace of mind? Probably. But is a 100% health insurance plan something that most consumers really need? Probably not!
In my professional opinion, when you purchase a health insurance plan, you must achieve a balance between four important variables; wants, needs, risk and price. Just like you would do if you were purchasing options for a new car, you have to weigh all these variables before you spend your money. If you are healthy, take no medications and rarely go to the doctor, do you really need a 100% plan with a $5 co-payment for prescription drugs if it costs you $300 dollars more a month?
Is it worth $200 more a month to have a $250 deductible and a $20 brand name/$10 generic Rx co-pay versus an 80/20 plan with a $2,500 deductible that also offers a $20 brand name/$10generic co-pay after you pay a once a year $100 Rx deductible? Wouldn’t the 80/20 plan still offer you adequate coverage? Don’t you think it would be better to put that extra $200 ($2,400 per year) in your bank account, just in case you may have to pay your $2,500 deductible or buy a $12 Amoxicillin prescription? Isn’t it wiser to keep your hard-earned money rather than pay higher premiums to an insurance company?
Yes, there are many ways you can keep more of the money that you would normally 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 HSA 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 normally 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/or insurance agent. In fact, I hear almost identical comments from almost 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 2 times in the last 5 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 particular individual currently has in their filing cabinet or dresser drawer. You know the policy that they bought to protect them from having to file bankruptcy due to medical debt. That policy they purchased to cover that $500,000 life-saving organ transplant or those 40 chemotherapy treatments that they may have to undergo if they are diagnosed with cancer.
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 questions that I frequently ask a prospective health insurance client. Let’s see how many YOU can answer without looking at your policy.
1. 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.”)
2. 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 plans will only require you to pay a 2 person maximum deductible each year, even if everyone in your family needed extensive medical care.)
3. What is your coinsurance percentage and what dollar amount (stop loss) it 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.)
4. 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.)
5. 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 plans 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.)
6. 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 & National Life, endorsed by the National Association of the Self-Employed, N.A.S.E. is known for endorsing schedule plans.)
7. Does your plan have doctor co-pays and are you limited to a certain number of doctor co-pay visits per year? (e.g. Many plans 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.)
8. 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/or do you just have a discount prescription card only? (e.g. Some plans offer you prescription benefits right away, other plans require that you pay a separate drug deductible before you can receive prescription medication for a co-pay. Today, many plans 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.)
9. Does your plan have any reduction in benefits for organ transplants and if so, what is the maximum your plan 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 actually costs $350-$500K and this $100,000 maximum may also include reimbursement for expensive anti-rejection medications that must be taken after a transplant. If this is the case, you will often have to pay for all anti-rejection medications out of pocket.)
10. Do you have to pay a separate deductible or “access fee” for each hospital admission or for 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 3 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 out-patient services, such as, physical therapy, speech therapy, chemotherapy, radiation therapy, etc. Benefit “caps” could be as little as $500 for each out-patient 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 mean 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 really 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 10 questions without looking at your health insurance policy, you have a "great" agent. If you were able to answer the majority of questions, you may 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. There are some insurance agents that really care about the clients they work with, and there are other agents that 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 important 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 really 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 own 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 ONE insurance company’s products.” Independent” agents or insurance “brokers” can offer you a variety of different insurance plans from many different insurance companies. A “captive” agent may recommend a health plan that doesn’t exactly 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 when they make health plan comparisons. 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 important purchases and to use a knowledgeable, ethical and reputable independent agent or broker for one of the most important purchases 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 state and can also tell you if there have been any complaints against that company that have been filed by policy holders. 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.
In closing, I hope I have given you enough information so you can become an INFORMED insurance consumer. However, I remain convinced that the following words of wisdom still go along way: “If it sounds too good to be true, it probably is!" and "If you only buy on price, you get what you pay for!"