Individual/Family Health Insurance

ACA Plans are the Best Option for Most People!

The Affordable Care Act (ACA or Obamacare) is not new anymore but there is still substantial confusion regarding the plans, network, pricing and coverage. The ACA changed how health insurance companies were able to offer insurance. In order for their plans to be complaint with the ACA and considered “Major Medical” or “Qualified Health Plans”, they have to meet certain requirements in regard to coverage, network and pricing.

It does not matter if you purchase these plans on the Healthcare.gov website, directly from the insurance carrier or our preferred solution, a direct enrollment system like Health Sherpa, all Major Medical health insurance plans are subject to the ACA rules.

Ten Defining Characteristics of a Qualified Major Medical Health Plan under the ACA:

1. Prescription drugs must be covered.
2. Emergency coverage at the closest hospital that can help you.
3. Surgery, overnight stays and other services much be covered at hospitals.
4. Pregnancy, maternity and newborn care is included.
5. Ambulatory patient services (outpatient care you get without being admitted to a hospital) are covered.
6. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills).
7. Bloodwork and laboratory services included.
8. Preventative and wellness services and chronic disease management included for members.
9. Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits).
10. Mental health and substance use disorder services, including behavioral health treatment (includes counseling and psychotherapy).

Source: https://www.healthcare.gov/coverage/what-marketplace-plans-cover/

These plans can only be purchased during the “Open Enrollment” period of the year. Generally, this period is from November 1^st to December 15^th, however the past few years have seen special periods and extensions of “Open Enrollment”.

As the ACA market matures there are more and more carriers coming into Tennessee. This is great for the consumer as more options means more competition. This generally results in better pricing and better benefits. However, it is very important to work with an agent like us that can explain the pros and cons of each plan and make sure that you are getting the right plan. Our services are free to you, and we spend all our working hours learning about health insurance! Let us help you!

Pros:

• Prices can be lower than ACA plans if you do not qualify for an ACA subsidy.
• Bigger networks than most individual plans.
• These plans are underwritten so that can help control costs.
• Generally, you can enroll any time of year.

Cons:

• You can be declined based on your health conditions.
• Pre-Existing conditions are NOT covered.
• Does not cover most preventive healthcare or normal doctor visits.
• Pre-existing condition starts over with each new application!

Emergency Insurance Coverage

It is important to remember that Short Term plans are much more limited than Major Medical (ACA) plans. They are limited in time frame, coverage and availability. They are not comparable to ACA plans in terms of what is covered. One of the most important things to remember about Short Term plans is that they do not normally cover preventative care OR your primary care or specialist visits.

Another issue with Short Term plans is that they do not cover preexisting conditions from a certain time period before you enrolled. And when you renew your plan you may have to restart your preexisting condition lookback period! However there are longer lasting plans that do offer some protection against lookback periods. These plans work best for people without many preexisting conditions and who are looking for protection against large, unexpected expenses.

In the past Short-Term Medical plans were used most often when someone was between major medical coverage at their job. But due to the ACA restrictions dictating when you can apply for a major medical plan and the high cost of those plans for some people, short term plans are being used more option.

There are good uses for these plans, but you need to be very careful about what you are purchasing. If you understand the plan, you can make an educated decision about if this type of plan is right for your situation.

Josiah Lee can help with that so give him a call @ (615) 528-1227

Read about our suggested Short Term Plans HERE!!

Pros:

• You can save you 40-60% compared to ACA plans.
• They reimburses you a pre-set amount for services you receive.
• You can customize these plans to fit you desires.
• These plan have large, PPO networks.

Cons:

• You must go through underwriting and can be rejected based on health conditions.
• Pre-Existing conditions are not covered initially.
• Plans are more complex and do not protect you against massive costs.
• Claims to file to save the most money.

Fee-For-Service

An Indemnity plan is often referred to as fee-for-service plan. These types of plans pay a set amount for different healthcare services. They do NOT operate like modern day, major medical insurance plans. Their coverage is limited to a set dollar amount even if your costs far exceed what the plan covers.

Some indemnity plans do give you access to a network of providers, usually a large PPO network. Or sometimes you can submit your bills for reimbursement to the insurance carrier and they will send cash directly back to you. Some plans reimburse on the Medicare Fee Schedule. They allow you to buy one, two or even three times the Medicare reimbursement rate. That way you can customize your plan. I do want to clarify that this type of plan is NOT an ACA qualified health plan and they do not cover pre-existing conditions.

To learn more about this option call Tennessee Health Insurance @ (615) 528-1227.

Pros:

• This innovative healthcare model allowing better Dr/Patient care than insurance allows.
• Provides high-quality, 24/7 access to your personal Primary Care Physician
  • Dr. available in office, by phone, secure message text, or video
• Low cost for labs, imaging, medications and specialty consultations.
• Membership costs are around $100 per person per month.
• Can be used with Medicare or any insurance product for the more expensive items.

Cons:

• The area that these type of plans are available is limited.
• They can be very expensive if you do not use the doctor often.
• You still need other insurance to cover major services.

A Better Healthcare Delivery Model

Most doctors are in the healthcare business to help people. Unfortunately many doctors are stuck worrying more about insurance than practicing healthcare. They do not get to spend all of their time and energy on their patients as they are incentivized by insurance to see as many patients as possible!

The direct primary care model is still in its early stages but it has the potential to offer a more personal, historic style of healthcare. Imaging being able to contact your doctors anytime without having to pay a fee! They can also provide many services for a low cost that would typically cost multiple different payments inside of traditional insurance.

Contact us to learn more!

A Biblical Approach to Healthcare

These are NOT insurance products. They work by members sharing in each other’s medical expenses. These memberships can be joined at any time of the year but are not for everyone as they are lifestyle based. However, they are growing quite large due to their popularity since the start of the Affordable Care Act.

And some of them use a very large network of providers. I had a doctor in charge of the insurance for a very large physician’s practice in Atlanta tell me he would rather have his patients in a sharing ministry than some of the ACA plans available now. He said, “at least with these plans we know we will get paid”.

To learn more about these options call Terri Potter @ 615-528-1227.

Questions? Send us an email!