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Healthcare Is Making Me Sick | Author Hour Podcast

I had a great conversation recently with Nikki Van Noy on her Author Hour podcast. We talked through the book and my background, but more importantly I walked her through the same actionable, plain-spoken tips that anyone can use to better empower themselves when dealing with the healthcare system.

All of us can make better choices in selecting our healthcare insurance plans, how we can maximize our coverage, how we can lower costs for treatment and prescriptions, and how we can generally make better choices that render better health results.

Listen below to hear the conversation.

The Difference Between Healthcare and Insurance

Healthcare and health insurance are the same thing, right?

Actually, they’re completely different—and the difference is important. It can be easy to get the two confused, and if you have in the past, you’re not alone. Most people don’t choose to become consumers of healthcare, but we have to become consumers because we participate in the system whether we like it or not. 

Unfortunately, most of American’s only think about healthcare when they’re sick, which leaves them woefully unprepared and vulnerable to those sky-high costs you read about in the news.

Roughly 289 million people in America have some kind of health plan. Most of us get it from the following sources: 

  • we enroll in our employer-offered plans
  • we directly purchase from insurance carriers ourselves
  • we qualify for and enroll in Medicaid
  • we turn sixty-five and enroll in Medicare
  • or we are employed through a government entity and receive one of their offerings. 

And for many that’s where it starts and stops. Which begs the question, what is the difference? 

What is healthcare?

Healthcare refers to the system of doctors, specialists, nurses, hospitals and every other kind of profession in the health industry that’s responsible for caring for someone’s mental or physical wellbeing and treating illnesses. Every time you see your family doctor, get an X-Ray or get treatment for a chronic condition you are using the healthcare system.

Why is that important?

The important thing to remember is that the healthcare system is designed to care for you. The healthcare’s primary responsibility is not to look after your financial well-being. Doctors, nurses, surgeons and everyone else who treats an illness wants to serve their patient by making them better.

That makes our healthcare system very inviting and accommodating when it comes to providing care. However, as consumers of healthcare, we need to understand that we have the power and the responsibility to engage that care responsibly and in a way that best suits our health and financial needs.

What is health insurance?

Health insurance on the other hand refers to the financial tool that individual use to protect themselves against times when they need the medical system. It is a way to transfer the risk of paying for care from you as the individual to the insurance carrier. 

Health insurance helps protect you against the unexpected costs that arise when you have a sudden healthcare need or an ongoing chronic condition. 

Why is that important?

If you have a health insurance plan these days, one way or the other, you are paying more than you would have a decade or two ago. You then have the “privilege” to pay more when you actually incur a health expense—i.e., you see a doctor. 

We all know that health insurance doesn’t give you a free pass to use the healthcare system whenever you want for free. Which means that it’s critical that you shop for the insurance that’s right for you. 

Costs that are predictable and affordable, you do not want to insure otherwise you will be overpaying. By the same token, you want to make sure you’re not under insuring and that you’re prepared for the unexpected. 

Why is the difference so important?

Because health insurance isn’t an endless pool of resources – but many of us act like it is. 

Behind the scenes, Th confusion between the two can create a vicious cycle going on. The more people use healthcare, the more premiums go up next year when their health insurance policy renews. That’s because the insurance company sees the extra usage and assess that there is more risk than they expected.

Insurance companies are big businesses after all, and as businesses they’re trying to turn a profit.

The “Doctor Mystique”

Another piece that plays into this misconception is an affect we call the “doctor mystique.” People have grown to expect a cure for whatever they have and to revere their medical professionals. This behavior is in part because we think that we pay premiums for our health insurance which means we should be using it.  

As a result, when your insurance plan finally begins to cover all expenses at 100 percent or you’ve reached your out of pocket maximum, you mentally check out. You think, “I don’t care what the services cost, how many are performed, if they are necessary, or if services not provided are on the bill.”

What does that mean for me as a healthcare consumer?

Whether you agree with how the system works or you hate it, the fact is that it’s the system we have right now. Understanding the difference between healthcare and health insurance is one of the first steps you if you’re going to take back control.

The most important thing we want you to learn from this guide is that what you decide matters the most in this equation. It means we need to be smart when shopping for insurance and also wise when it comes to expecting the healthcare system to immediately cure any ailment.

This is what we must do if we are going to collectively flip the script on the system and propel a healthcare consumer revolution. 

How Much Should You Pay For Health Insurance?

When it comes to health insurance, one of the most common questions I hear is, “Who pays for that?” At the risk of sounding like a smart aleck, the simple answer is: you do.

When it comes to health insurance, one of the most common questions I hear is, “Who pays for that?” At the risk of sounding like a smart aleck, the simple answer is: you do.

But that does not necessarily mean you’re responsible for 100% of the cost of health insurance. There are three basic categories of health insurance sources: employers, individuals buying health insurance, and government programs. In this article, we’ll examine each category in greater detail to more fully answer the question, “Who pays for that?”

Coverage Through Your Employer

Employer coverage is pretty straightforward: you work for somebody, they offer coverage, they pay for a majority of the premium, and you enroll. Employers with over fifty employees are required by the ACA to offer healthcare coverage to their full-time employees (those working over thirty hours per week) or pay a $2,000 penalty for each full-time employee every year. Most elect to offer the coverage.

They must offer at least one plan that complies with all ACA guidelines, including the essential coverage, the minimum plan design, and maximum employee monthly contribution of 9.86 percent of household monthly income for 2019 single coverage. Employers with fewer than fifty employees have the option to offer coverage or not; it depends on their financial situation. If you work for an employer who does not offer coverage, you will need to investigate options: purchasing directly or, depending on your financial situation, looking into government-sponsored plans.

Plan Options

Most employers offer multiple options for their employees. The range of options addresses plan designs that impact how much is covered and what you’ll have to spend if and when you use the healthcare system. Your premium cost impacts how much of your paycheck is paid monthly for your selected coverage. The options you are presented will be from the coverages we discussed PPO (Preferred Provider Organization), HMO (Health Maintenance Organization), or High Deductible Health Plan, usually with a Health Savings Account. Many offer tax-deferred savings vehicles to help offset the cost of healthcare.

Individuals Buying Directly

Buying health insurance directly under Obamacare has been like trading one nightmare for another. Before Obamacare, people with existing conditions were denied coverage. With Obamacare, those people can now buy coverage, but more and more often they can’t afford the monthly health insurance premiums or even find coverage.

Many of the national health insurance companies (Anthem, Cigna, Aetna, United Healthcare) have reduced the number of states to which they offer individual health insurance to the point that a number of counties had only one health insurance carrier option in 2019. And increasingly, the options offered have smaller provider networks.

Bottom line: if you are buying directly, you will probably need to consider increasing your deductibles and out-of-pocket costs to offset premium increases.

The Kaiser Family Foundation, www.kff.org, does an excellent job of tracking health insurance carriers offering coverage by state and the premium rate increases or decreases filed by health plans in each state. They are already compiling 2019 health insurance carrier offerings by carrier by state. Please review their site for updates under the heading Tracking Premium Changes on ACA Exchanges.

Doesn’t Obamacare provide premium subsidies for non-government health insurance to offset the cost? Yes, it does. Obamacare provides premium tax credits and cost sharing subsidies. A portion of the monthly health premiums may be offset for individuals earning less than 400 percent of the federal poverty level (FPL).

Interestingly, 84 percent of the people who signed up for individual health insurance since 2014 received subsidies. Luckily, because of inflation protection in the ACA subsidies, inflation increases are not passed on to those with subsidies. Their subsidies increased as the premium increased, keeping them whole. The people who bore the brunt of the increases were those without subsidies, and not all of them are rich.

The most efficient way to find out what plans, pricing, and subsidies are available to you is to access healthcare.gov or your state-sponsored healthcare exchange. The federal government’s website covers thirty-seven states and the District of Columbia, and will direct you to state-sponsored exchanges. They will start the session by asking basic financial questions that will determine whether you qualify for a subsidy.

In 2019, persons earning up to $48,560 may qualify for an individual’s health insurance subsidy while individuals earning up to $83,120 may qualify for a family health insurance subsidy. The dollar amounts are adjusted annually.

An alternative is Healthsherpa.com, which covers all states and all available health plans. They are a private company whose mission statement is “to help every American feel the comfort and security of having health coverage. [They] use design, technology, and customer service by real people to make insurance easier to understand, faster to sign up, and simpler to use.” The major differences are an easier and faster system, and real-time help. They provide counselors via chat rooms who walk through your enrollment and continue the chat room assistance throughout the year.

Government Programs

Note that the following information is true as I write this article, but—as we all know—nothing stays the same, especially in the government and in the world of healthcare. Visit www.healthcare.gov for the most up-to-date information about the status of the healthcare system in the US and what it means to you.

Medicaid

Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program, makes up the single largest source of health coverage in the United States. Its goal is to provide low-income individuals, families, and children health insurance with little or no premiums, and little or no out-of-pocket medical expenses.

The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under age sixty-five. Eligibility for children was extended to at least 133 percent of the federal poverty level (FPL) in every state (most states cover children to higher income levels), and states were given the option to extend eligibility to adults with income at or below 133 percent of the FPL.

The majority of states have chosen to expand coverage to adults, and those that have not yet expanded may choose to do so at any time. Eighteen states have not expanded coverage as of 2019. They are Alabama, Florida, Georgia, Idaho, Kansas, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

The 2019 federal poverty level (FPL) income numbers are used to calculate eligibility for Medicaid and the Children’s Health Insurance Program (CHIP).

Medicaid Benefits

States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. Federal law requires states to provide certain mandatory benefits and allows states the choice of covering other optional benefits. Mandatory benefits include services like inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Optional benefits include services like prescription drugs, case management, physical therapy, and occupational therapy.

You can enroll through healthcare.gov. Additional state-by-state information is on medicaid.gov. Or, you can try the American Council on Aging’s Medicaid Assistance site at medicaidplanningassistance.org/state-medicaid-resources. They provide state-by-state names and contact info, and free planning advisor services.

Children’s Health Insurance Program (CHIP)

Children’s Health Insurance Program (CHIP) is a federal/state health program managed by the states. It provides medical coverage for individuals under age nineteen whose parents earn too much income to qualify for Medicaid, but not enough to pay for private coverage. Program coverage varies from state to state, but all states’ CHIP plans cover routine checkups, immunizations, doctor visits, prescriptions, dental care, vision care, hospital care, laboratory services, x-rays, and emergency services. Some states also cover parents and pregnant women. Its goal, like Medicaid, is to provide health insurance with inexpensive or no premiums or out-of-pocket medical expenses.

It’s cumbersome to get coverage through CHIP, but it could be a huge winner for your family if you qualify. If you make up to $40,000 for, say, a family of three, you can still get Medicaid coverage. CHIP, on the other hand, is for people who make more than that but still have a tough time affording coverage. We run into plenty of people who keep their employer’s coverage for themselves but carve off their kids and put them on CHIP. To sign up, you can call 1-800-318-2596, or you can begin the process by completing an insurance application on healthcare.gov. The application will determine if you qualify for the program and will notify your state agency. Your state agency will contact you about enrollment. My advice is to do both and follow up.

Medicare

Medicare is the guaranteed-issue, government health insurance program for individuals over sixty-five, certain younger people with disabilities, and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). It does not have income requirements to join. Its goal is similar to Medicaid in providing affordable healthcare insurance to seniors. All four components of Medicare (Parts A, B, C, and D) require monthly premiums, deductibles, and out-of-pocket costs for services.

Different parts of Medicare help cover specific services:

Part A: Hospital Insurance. It covers inpatient hospital stays, some home healthcare, stays in skilled nursing facilities, and hospice care.

Part B: Medical Insurance. It covers outpatient care, preventive services, medical supplies, and some doctors’ services.

Part C: Medicare Advantage Plans. Offered by private companies that contract with Medicare. They provide Part A and Part B coverage, and most cover Part D benefits.

Part D: Prescription Drug Coverage. This is provided by private insurance companies and adds drug coverage to the other parts of Medicare.

Additional information is available at medicare.gov, or for supplemental assistance and supplemental policies, consult the American Association of Retired Persons (AARP).

But that does not necessarily mean you pay 100 percent of the cost. There are three basic categories of health insurance sources: employers, individuals buying health insurance, and government programs. In this article, we’ll examine each category in greater detail to more fully answer the question, “Who pays for that?”

Coverage Through Your Employer

Employer coverage is pretty straightforward: you work for somebody, they offer coverage, they pay for a majority of the premium, and you enroll. Employers with over fifty employees are required by the ACA to offer healthcare coverage to their full-time employees (those working over thirty hours per week) or pay a $2,000 penalty for each full-time employee every year. Most elect to offer the coverage.

They must offer at least one plan that complies with all ACA guidelines, including the essential coverage, the minimum plan design, and maximum employee monthly contribution of 9.86 percent of household monthly income for 2019 single coverage. Employers with fewer than fifty employees have the option to offer coverage or not; it depends on their financial situation. If you work for an employer who does not offer coverage, you will need to investigate options: purchasing directly or, depending on your financial situation, looking into government-sponsored plans.

Plan Options

Most employers offer multiple options for their employees. The range of options addresses plan designs that impact how much is covered and what you’ll have to spend if and when you use the healthcare system. Your premium contributions impact how much of your paycheck is paid monthly for your selected coverage. The options you are presented will be from the coverages we discussed (PPO, HMO, HDHP/ HSA). Many offer tax-deferred savings vehicles to help offset the cost of healthcare.

Individuals Buying Directly

Buying health insurance directly under Obamacare has been like trading one nightmare for another. Before Obamacare, people with existing conditions were denied coverage. With Obamacare, those people can now buy coverage, but more and more often they can’t pay for the insurance coverage or find coverage.

Many of the national health carriers (Anthem, Cigna, Aetna, United Healthcare) have reduced the number of states to which they offer individual health insurance to the point that a number of counties had only one health insurance carrier option in 2019. And increasingly, the options offered have smaller provider networks.

Bottom line: if you are buying directly, you will probably need to consider increasing your deductibles and out-of-pocket costs to offset premium increases.

The Kaiser Family Foundation, www.kff.org, does an excellent job of tracking health insurance carriers offering coverage by state and the premium rate increases or decreases filed by health plans in each state. They are already compiling 2019 health insurance carrier offerings by carrier by state. Please review their site for updates under the heading Tracking Premium Changes on ACA Exchanges.

Doesn’t Obamacare provide premium subsidies for non-government health insurance to offset the cost? Yes, it does. Obamacare provides premium tax credits and cost sharing subsidies. A portion of the monthly health premiums may be offset for individuals earning less than 400 percent of the federal poverty level (FPL).

Interestingly, 84 percent of the people who signed up for individual health insurance since 2014 received subsidies. Luckily, because of inflation protection in the ACA subsidies, inflation increases are not passed on to those with subsidies. Their subsidies increased as the premium increased, keeping them whole. The people who bore the brunt of the increases were those without subsidies, and not all of them are rich.

The most efficient way to find out what plans, pricing, and subsidies are available to you is to access healthcare.gov or your state-sponsored healthcare exchange. The federal government’s website covers thirty-seven states and the District of Columbia, and will direct you to state-sponsored exchanges. They will start the session by asking basic financial questions that will determine whether you qualify for a subsidy.

In 2019, persons earning up to $48,560 may qualify for an individual’s health insurance subsidy while individuals earning up to $83,120 may qualify for a family health insurance subsidy. The dollar amounts are adjusted annually.

An alternative is Healthsherpa.com, which covers all states and all available health plans. They are a private company whose mission statement is “to help every American feel the comfort and security of having health coverage. [They] use design, technology, and customer service by real people to make insurance easier to understand, faster to sign up, and simpler to use.” The major differences are an easier and faster system, and real-time help. They provide counselors via chat rooms who walk through your enrollment and continue the chat room assistance throughout the year.

Government Programs

Note that the following information is true as I write this article, but—as we all know—nothing stays the same, especially in the government and in the world of healthcare. Visit www.healthcare.gov for the most up-to-date information about the status of the healthcare system in the US and what it means to you.

Medicaid

Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program, makes up the single largest source of health coverage in the United States. Its goal is to provide low-income individuals, families, and children health insurance with little or no premiums, and little or no out-of-pocket medical expenses.

The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under age sixty-five. Eligibility for children was extended to at least 133 percent of the federal poverty level (FPL) in every state (most states cover children to higher income levels), and states were given the option to extend eligibility to adults with income at or below 133 percent of the FPL.

The majority of states have chosen to expand coverage to adults, and those that have not yet expanded may choose to do so at any time. Eighteen states have not expanded coverage as of 2019. They are Alabama, Florida, Georgia, Idaho, Kansas, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

The 2019 federal poverty level (FPL) income numbers are used to calculate eligibility for Medicaid and the Children’s Health Insurance Program (CHIP).

Medicaid Benefits

States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. Federal law requires states to provide certain mandatory benefits and allows states the choice of covering other optional benefits. Mandatory benefits include services like inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Optional benefits include services like prescription drugs, case management, physical therapy, and occupational therapy.

You can enroll through healthcare.gov. Additional state-by-state information is on medicaid.gov. Or, you can try the American Council on Aging’s Medicaid Assistance site at medicaidplanningassistance.org/state-medicaid-resources. They provide state-by-state names and contact info, and free planning advisor services.

Children’s Health Insurance Program (CHIP)

Children’s Health Insurance Program (CHIP) is a federal/state health program managed by the states. It provides medical coverage for individuals under age nineteen whose parents earn too much income to qualify for Medicaid, but not enough to pay for private coverage. Program coverage varies from state to state, but all states’ CHIP plans cover routine checkups, immunizations, doctor visits, prescriptions, dental care, vision care, hospital care, laboratory services, x-rays, and emergency services. Some states also cover parents and pregnant women. Its goal, like Medicaid, is to provide health insurance with inexpensive or no premiums or out-of-pocket medical expenses.

It’s cumbersome to get coverage through CHIP, but it could be a huge winner for your family if you qualify. If you make up to $40,000 for, say, a family of three, you can still get Medicaid coverage. CHIP, on the other hand, is for people who make more than that but still have a tough time affording coverage. We run into plenty of people who keep their employer’s coverage for themselves but carve off their kids and put them on CHIP. To sign up, you can call 1-800-318-2596, or you can begin the process by completing an insurance application on healthcare.gov. The application will determine if you qualify for the program and will notify your state agency. Your state agency will contact you about enrollment. My advice is to do both and follow up.

Medicare

Medicare is the guaranteed-issue, government health insurance program for individuals over sixty-five, certain younger people with disabilities, and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). It does not have income requirements to join. Its goal is similar to Medicaid in providing affordable healthcare insurance to seniors. All four components of Medicare (Parts A, B, C, and D) require monthly premiums, deductibles, and out-of-pocket costs for services.

Different parts of Medicare help cover specific services:

Part A: Hospital Insurance. It covers inpatient hospital stays, some home healthcare, stays in skilled nursing facilities, and hospice care.

Part B: Medical Insurance. It covers outpatient care, preventive services, medical supplies, and some doctors’ services.

Part C: Medicare Advantage Plans. Offered by private companies that contract with Medicare. They provide Part A and Part B coverage, and most cover Part D benefits.

Part D: Prescription Drug Coverage. This is provided by private insurance companies and adds drug coverage to the other parts of Medicare.

Additional information is available at medicare.gov, or for supplemental assistance and supplemental policies, consult the American Association of Retired Persons (AARP).

Why You Must Demand Transparency with Your Healthcare Costs

I wrote Healthcare Is Making Me Sick to help people learn the rules of healthcare so they can regain control of how they experience the system. A friend of mine asked me: What made me feel that I had to write it?

The answer is two-pronged—partly from the financial side, and partly from the quality of life side. The common denominator between them, though, is that it comes down to maximizing your coverage and experience when it comes to insurance.

Allow me to explain both sides of this equation in more detail.

Medical Providers Are in Business

Let’s start with finances: if you get service from a doctor and don’t inquire about the course of treatment, the appropriateness of the treatment, and the cost, you’ll more than likely have a less than optimal experience. Physicians and hospitals are in BUSINESS. One of their goals is to grow their business as profitably as they can. If you’re a passive healthcare consumer, the number of tests, where the tests are performed, and who performs them will affect the financial outcome of your treatment—it’ll cost you more!

Now, consider if everyone else with that same policy takes the same approach; they simply keep paying whatever the bill says and, while they may grumble, they don’t give it a second thought. What, then, are those expenses going to do? They’ll go up.

If those expenses go up, the insurance company’s expenses go up. What is the insurance company (that’s in business like the hospitals and physicians) going to do to your premiums? They are going to go up, too. And this dynamic does not change if you’re on your employer’s sponsored health plan, buying from the public exchange, or buying insurance directly. There’s no incentive for providers or insurance companies to change if they’re not challenged. They both make more money as the costs go up and are, in effect, negotiating with each other over their goals versus yours. I know learning the ins and outs of the industry is time consuming, but the benefits are long term.

Do the Work to Find the Best Doctor

The other side of the equation is life quality. It seems obvious that you’d want the best doctors, right? Why wouldn’t you? Yet, in our society, we haven’t adopted the mentality that we should scrutinize doctors the way we would other service providers, as they’re all not created equal. After all, the last to graduate medical school is still a doctor.

To overcome this hurdle, we must start insisting on transparency by any means available to us, and that includes referrals. Referrals can come from anybody close to us, such as friends, other doctors, and even the carriers themselves. Use any tool at your disposal in order to find the best doctor for you. If you do, you’ll have a better outcome, which means you save money long-term and have a better quality of life.

By allowing the status quo to continue—which means not questioning our doctors and paying whatever they tell us to—we are all complicit. At the end of the day, when my friend asks me why I wrote my book, I tell him it’s because I can make a difference—and so can you. You can change the definition of an industry, even if it’s something as big as healthcare. Doing the same thing over and over and expecting a different outcome hasn’t worked, so why not try something new? That question begs another: How do you tackle two giant industries representing one-sixth of the economy?

Information is Key to Transparency

Information! Information will lead to knowledge, and as Sir Francis Bacon stated, “Knowledge is power.” One piece of information you need to know is the mark ups on common medical services versus the cost and the range of prices for that service.

A quick look at information out there on hospital markups provides some staggering numbers. According to a report from John Hopkins University, on average, hospitals mark up their cost 4.32 times and, in some cases, over six times.

That’s right—for a service that costs them $100, they are charging you between $432–$600. The study also found that “certain types of hospitals had higher markups. In government-run hospitals, the ratio was 3.47; in nonprofit hospitals, 3.79; and in for-profit hospitals, 6.31. System-affiliated hospitals had an average ratio of 4.76, versus 3.54 for independent hospitals, and hospitals with regional market power had an average ratio of 4.56, versus 4.16 for hospitals that lacked such clout—supporting the researchers’ finding that hospitals that can mark up prices will do so.”

This can also be found in medicines within hospitals. Hospitals mark up medicines an average 500 percent of their cost—and have a markup of 250 percent even after negotiations with insurance carriers. The confusion does not stop there. HCCI’s 2015 report, “National Chartbook on Health Care Prices” found there’s a wide range of prices for the same services at different hospitals. Prices vary by state and within states too.

Transparency Tools You Can Use

So, what are you to do? Healthcare prices are crazy! Fortunately, the world is changing. There are a growing number of transparency tools for every healthcare industry sector (doctors, hospitals, and drugs) that you can access. This will help you pull the curtain back on the Great Wizard of Oz of healthcare.

There are categories of transparency sites. The first is what I call qualitative sites. They provide useful information such as: areas of specialty, college education, hospital affiliation, ease of scheduling, staff responsiveness, patient level of trust, and amount of time spent with patient. These sites are useful in helping determine the type of relationship you might have with your doctor. Here are some popular options:

The second set of sites focus more on the quantitative, or outcome-based, aspects of the doctor’s care. For example, they examine items such as costs and how the doctor ranks against his/her peer set for a procedure. Does the doctor you’re reviewing perform more or fewer procedures than their peers? This is important. Remember Malcolm Gladwell’s position that the more you practice the better you are.

The following websites provide you access to healthcare transparency.

For Hospitals

  • Leapfroggroup.org: Leapfrog Hospital Safety Grade
  • Hospital Patient Price List Information: (Look up each hospital’s published pricing list. Your pricing will vary based on your insurance.)

For Doctors

For Prescriptions

The Transparency Genie is Out of the Bottle

I haven’t found one single resource that has provided every answer or covered every area of the country yet, but these resources are growing, becoming more robust, and currently providing us more access to the real costs than we have ever had before. USE them. When comparing costs, look outside your area and see if your situation turns out like the knee replacement from Sacramento to Tucson or if your hospital has substandard records on the services you need covered.

If you’re on your employer’s health plan, ask to see if the health insurance carrier provides a price calculator and quality evaluation tool. If not, ask your employer to investigate offering one. Companies like Castlight, Amino Health, or Grand Rounds can be added, offering access to transparency. Remember, if you save yourself money, you save your employer money, too. They will direct you to the most cost-effective provider based on that carrier’s network and negotiated discounts.

When it comes to transparency, the genie is out of the bottle. If we seek it, demand it, and use it, there’s no way they (the industry) can put it back in.

The First Step to Retaking Your Health is Figuring Out Who You Are

I read an Aetna success story about a man named John who was two steps from a heart attack. In 2010, he took a Health Risk Assessment through his employer. His cholesterol and blood pressure were both off the charts. The news of his high cholesterol was particularly alarming, since he’d been on medication for it the previous two years. He couldn’t argue with the facts: he was forty-seven years old, 300 pounds, and had already had two knee surgeries because of his weight.

Armed with the results from the Health Risk Assessment, he knew he needed to change. He got a health coach who helped him create a game plan to lose some weight. Eventually, he lost 125 pounds. He’s even off cholesterol medicine now.

In short, he changed his life. John’s story is not unique.

There are many stories out there of people like John—people who see a health problem in their life and take steps to fix it. The percentage who actually follow through, though, is small—in my experience, it’s about 6 percent. You need something personal to motivate you. There has to be a catalyst that kicks you in the rear end. For John, he should’ve realized something was wrong when he had those two knee surgeries because of his weight. He knew he wasn’t feeling his best. It wasn’t until the report told him, “Be ready. You’re a walking heart attack,” that something clicked in him.

Don’t wait for a report to tell you you’re dying to take control of your health. Start your healthcare journey earlier than you think you should. It will be uncomfortable, and you’ll encounter a lot of questions. For example, you know you need health insurance, but how much should you get and why? What will it cost? What should it cover? When selecting a doctor or hospital, which ones are experts in the areas I need addressed? How much do they charge? What are their patient outcomes after treatment?

In order to answer those questions, you must know who you are first. You do this by taking a look at what your needs are, what your resources are, then going to the market and seeing who matches them. In this article, I’ll help you figure out your needs.

A Health Risk Assessment is the First Step

Knowing your needs as a healthcare consumer comes down to defining who you are, identifying your risks, and identifying your costs. You start with defining who you are because without that understanding, you won’t know what to buy. You could over-buy or under-buy insurance, and both of those are outcomes you want to avoid.

The first step to becoming familiar with who you are as a healthcare consumer is taking a Health Risk Assessment. What John did by taking that Health Risk Assessment was smart, even if he waited too long to do it. This assessment has a standard set of questions that helps develop your health profile. It assesses your health status, estimates your level of health risk, and provides feedback to guide your behaviors.

Information collected includes your demographic information (age and sex), lifestyle information (alcohol intake, exercise habits, whether or not you smoke, etc.), personal and family medical history, physiological data (weight, height, blood pressure, etc.), and your attitudes and willingness to change your behavior in order to improve your health.

The HRA analyzes your information and produces your health risk profile, which ranks your health in seven key health areas: heart, cancer, diabetes, obesity, nutrition, fitness, and mental and emotional health through color-coding, graphs, icons, and a number based scoring system that tells you if you are doing well, need to be cautious, or need to take immediate action. It recommends key ways to improve your scores and health.

How to Take a Health Risk Assessment

How can you get your own health risk profile? About 33 percent of employers offer these HRAs (Health Risk Assessments) through their employee health plan. For companies with over 200 employees, that number goes up to 51 percent. Many of them even have an app you can use to securely give and receive information for your health risk profile. Medicare and Medicaid both offer HRAs as well, as do some hospitals. Check with your local hospital to see if they have one.

Not too long ago, you had to do these HRAs on paper. Now, you can complete them on your phone through an app or on your computer through a website. It’s so easy that there’s no excuse not to do it, especially because much of the information required can be gathered at a basic physical (which is totally covered if you have an ACA plan.)

Be sure the information is taken within a six-month window, especially for test results. Why is this so important? Understanding your basic health status is the first step in identifying what your objectives need to be. Your objectives clarify and direct you to which tools and options are right for you. A health risk profile is a perfect way to discover what type of insurance and providers you should be pursuing.

Compiling Your Health Record

After completing an HRA, you need to compile all your medical history to complete your total health profile. At first, it will feel laborious. It’s like setting up Quicken, the personal budgeting software, for the first time, or transferring all of your files to a new computer—not a joyous experience, but you’ve got to do it! It entails gathering all of your health records, including documentation of conditions, biometrics, physicals, immunizations, surgeries, imaging, diagnostic test results, and medications.

It should include a thorough understanding of family conditions. Interview your parents about your family health history. If you discover a family history of a genetic condition, after consulting with your doctor, you want to weigh the pros and cons of genetic testing to determine if you are at risk of developing the condition. For example, certain types of tests may be useful in identifying your risk of certain types of colorectal cancer.

So, how do you access your information? With the exception of your family history, all of your data is moving to electronic data interchange (EDI) and storage, so you can call your hospital, doctor, or specialist and ask to download your records (lab work, diagnostic imaging, doctor’s notes). If you are unable to pursue the electronic route, paper records are just as effective. At the very least, keep a list of doctors or hospitals where you have received or are receiving care, what conditions you have been or are being treated for, and what medications you are taking and for what purpose.

Now You’re Ready for the Next Steps

These records complete your in-depth health profile. Having full access to your records, electronically or via hard copy, will help you communicate effectively with your doctor in an efficient manner. That way, they can more accurately assess your conditions and prescribe effective courses of treatment. These records also set you up to find a health insurance option that’s right for you and select a doctor who best fits your needs.

Examining 3 Popular Options for Nontraditional Medical Care

The following is adapted from Healthcare is Making Me Sick: Learn the Rules to Regain Control and Fight for Your Healthcare.

Not everyone approaches healthcare the same way. Cost of care, higher out-of-pocket costs, technology, and transparency are all causing the medical field to evolve.

The evolution is producing nontraditional provider options. So, instead of visiting a traditional primary care provider, millions of people are opting to pursue a different path when it comes to the care they receive. Let’s look at three of the most popular options.

#1: Telemedicine

Telemedicine offers medical consultations over the phone, Skype, or FaceTime, and it’s a piece of the healthcare industry that is constantly growing. In fact, the global telehealth market is projected to reach 12.1 billion by 2023, with a compound annual growth rate of 23 percent between 2018 and 2023.

With fewer doctors able to give significant time to patients, telemedicine can serve as the front line of medicine. In addition, rural areas yearn for good medical care, so teledoctors are a great way to serve people who can’t easily get into a doctor.

One of the advancements in services that is propelling telemedicine is the ability to prescribe medicine through their service. Some services can refer to specialists and facilitate the scheduling of the specialist’s appointment.

Another plus: teledoctor visits are usually discounted compared to traditional in-office visits. If a doctor visit costs $100 on your plan, a telemedicine “visit” might only be $49. If your carrier doesn’t offer a telemedicine service, you can buy it directly from some hospitals such as the Cleveland Clinic and Premier Hospital in Dayton, Ohio, or from Teladoc. You don’t even have to be in their area to use the service.

In addition, Walgreens recently cut a deal with New York Presbyterian to provide telemedicine in the greater New York area. There’s a movement to give people quality, non-emergency healthcare through flexible, timesaving access to doctors.

Telemedicine is the private market responding to the market needs. Using technology, we are reinstating the doctor “house calls.” It’s worth considering twenty-four-hour care in your home with qualified practitioners at a fraction of the cost!

#2: Clinics

What do Wal-Mart, Safeway, Kroger, Target, Walgreens, and CVS all have in common?

They all offer health clinics within their select stores.

More and more, traditional retailers are bringing their retail expertise to medicine to provide easier-access, lower-cost alternatives to healthcare.

The clinics provide services similar to a primary care doctor and are staffed by registered nurses (RNs), nurse practitioners (NPs), and physician assistants (PAs). Services include treating minor illnesses; screening for and monitoring minor injuries, handling skin conditions, conducting wellness exams and physicals, performing women’s services, and giving vaccinations and injections. They diagnose, treat, and prescribe medicines at a lower cost. Fees range from $49–$99 and are accepted by most insurance carriers. Check on their websites for locations that have a clinic and for insurance carriers that accept their services.

Here’s a tip: if prescribed medicine at one of the pharmacy companies’ clinics, make sure you are getting the best price on the prescription before filling it.

#3: Concierge Services

Most primary care practices are inundated with patients, ranging from 2,000 to 3,000 per physician. They typically see twenty to twenty-four patients a day—or about eight minutes with each patient (after you take into account paperwork, lunch, and breaks).

Does eight minutes seem like enough time to you? No, it doesn’t, and many physicians don’t think so either. As a result, they have been morphing their practices into concierge service providers; in fact, there were over 12,000 in 2014.

A concierge practice charges an annual retainer, generally $1,500 per year, waives your insurance copay or deductible for office visits, and submits claims for services to your carrier. Most concierge practices are primary care or general internist doctors.

They limit their practice to 400–600 patients per year, allowing them to extend their time with each patient. You may be wondering why you would want to spend an additional $1,500 per year on top of your insurance to see your doctor?

The answer is simple: enhanced service and access. Concierge practices offer immediate access to their doctors via cell phone, email, and same-day appointments.

Visits are, on average, thirty minutes, granting time to cover all issues. Additional attention is provided with referrals to specialists or hospitals, and some services offer home or hospital visits as well as access to top specialists. In short, they’re the clinical advocates they once were, but at an additional cost. Most practices are located in or near large cities and on the coasts. Two national practices are MDVIP and Pinnacle.

Nontraditional Care is Worth Consideration

Depending on your insurance plan, the care options available to you, and your medical needs, one of these three nontraditional options might work for you.

For more advice on nontraditional care options, you can find Healthcare is Making Me Sick on Amazon.

Scott Heiser has more than twenty years’ experience as a consultant for clients in the insurance and healthcare system. Scott was a partner and owner of a commercial insurance brokerage, in which he led and developed an employee benefit practice that managed more than half a billion dollars in health benefits. Scott is a strategic innovator who knows the ins and outs of what can feel like the overwhelming world of healthcare and insurance. Today, he is dedicated to sharing his knowledge to help educate and empower his readers. His goal is to improve your health outcomes while lowering your costs. To get started, visit www.UncoveredHC.com. 

How Tax-Savings Healthcare Plans Can Save You Serious Money

Health insurance and healthcare expenses can cost a fortune. If the IRS offers tax-incentivized plans, you need to take advantage of them. If not, it’s like throwing money away. In this article, we’ll look at three of the most popular tax-savings plans.

Employer-Offered Tax-Savings Plans

Your employer may elect to offer two additional tax-advantaged or pre-tax programs where you can deduct money from your paycheck before taxes, thus increasing your purchasing power and reducing your taxes. They are:

The premium-only plan (POP) that lets you pay for your monthly portion of the premiums pre-tax; and the Flexible Spending Account (FSA) that allows you to save money from your paycheck on a pre-tax basis toward medical expenses for the year.

You can consult tasconline.com, a company for employers providing flexible spending account administrative services, and search for eligible expenses for a complete list of eligible charges. Your employer will decide the amount you may save, up to a max of $2,650/year in 2018. Eligible expenses include your healthcare plan’s copays, deductibles, and coinsurance. Medications are covered as long as they are prescribed by your doctor. The catch with FSAs is that you have to either use the funds in the plan year or lose them to your employer. That sounds unfair, right? Well, maybe not.

The FSA rules allow you to access 100 percent of what you committed to save for the year at any time during the year, meaning you can access the full year before you have saved for it. Therefore, you need to accurately assess what your expenses will be to ensure you don’t waste your money. There has been a slight loosening of the “lose it” provision, and at this time, you can carry $500 forward into future years.

There is no reason for you not to take the POP plan and reduce your cost of the monthly premium. You should be aware, though, that if you elect to take the POP, you cannot drop the health coverage until the next open enrollment unless you have a qualifying life event (QLE). The FSA, likewise, is an excellent way to reduce your costs if you know which medical expenses you will be incurring in the coming year. Why pay more for the services or more to the government in taxes?

Employer/Individual Tax Incentive Plans—Health Savings Account

Health Savings Accounts (HSAs) are available in both the individual and employer markets if you have elected a High-Deductible Health Plan. High-deductible health plans with HSAs do have minimum deductible and maximum out-of-pocket expense requirements for individual-only and family coverage. The 2019 levels are as follows: $1,350 for individual coverage and $2,700 for family coverage, in terms of the minimum annual deductible. The maximum annual deductible and other out-of-pocket expense limits are $6,750 for individual coverage and $13,500 for family coverage.

The following are the benefits of an HSA:

You can claim a tax deduction for contributions you, or a party besides your employer, make to your HSA even if you don’t itemize deductions on a Schedule A (Form 1040).

Contributions to your HSA made by your employer (including contributions made through a cafeteria plan) may be excluded from your gross income.

The contributions remain in your account until you use them. The interest or other earnings on the assets in the account are tax free. You can save tax free and distributions may be tax free if used to pay qualified medical expenses.

An HSA is “portable.” It stays with you if you change employers or leave the workforce.

HSA Contribution Limits

For individuals buying insurance directly, HSA regulations allow you to legally reduce federal income tax up to $3,500 a year for individuals, or $7,000 for families, into a health savings account for tax year 2019, as long as you’re covered by an HSA-qualified HDHP. There’s no minimum deposit, but whatever you put into your account is an “above the line” tax deduction that reduces your adjusted gross income. Just like IRAs, HSA contributions can be made until April 15 of the following year.

Account holders who are fifty-five or older are allowed to deposit an additional $1,000 in catch-up contributions (this amount is not adjusted for inflation; it’s always $1,000).

For people with employer-sponsored HDHP/HSA accounts, they can deduct up to the same amounts from their payroll before taxes are taken out.

Using Your HSA Funds

You can use the tax-free savings in your HSA to pay for doctor visits, hospital costs, deductibles, copays, prescription drugs, or any other qualified medical expenses. Once the out-of-pocket maximum on your health insurance policy is met, your health insurance plan will pay for your remaining covered medical expenses.

If you switch to a health insurance policy that’s not HSA-qualified, you’ll no longer be able to contribute to your HSA, but you’ll still be able to take money out of your HSA at any time to pay for qualified medical expenses, with no taxes or penalties assessed.

If you don’t use the money for medical expenses and still have funds available after age sixty-five, you can withdraw them for non-medical purposes with no penalties, although income tax would be assessed at that point, with the HSA functioning much like a traditional IRA or 401(k). A list of qualified medical expenses is available on the IRS website, www.irs.gov, in IRS Publication 502, “Medical and Dental Expenses.”

Where Is My Account?

HSA bank accounts can be offered by your employer with easy payroll automatic deposit features, or you can set up an HSA account at one of the many participating banks throughout the country.

They are a great way to offset medical expenses on a pre-tax basis, and save tax-free for future medical or retirement expenses.

Individual Premium Tax Deduction

Additionally, if you’re not on an employer plan, you don’t qualify for subsidies under individual insurance and you itemize deductions on your tax returns, you can deduct qualified medical expenses that exceed 7.5 percent of your adjusted gross income for 2018. Beginning January 1, 2019, all taxpayers may deduct only the amount of the total unreimbursed allowable medical care expenses for the year that exceed 10 percent of their adjusted gross income. This includes health insurance premiums.

If you’re self-employed and have a net profit for the year, you may be eligible for the self-employed health insurance deduction. This is an adjustment to income, rather than an itemized deduction, for premiums you paid on a health insurance policy covering medical care, including a qualified long-term care insurance policy covering medical care for yourself, your spouse, and dependents.

In addition, you may be eligible for this deduction for your child who is under the age of twenty-seven at the end of 2017 even if the child wasn’t your dependent. See chapter 6 of Publication 535, Business Expenses, for eligibility information. If you don’t claim 100 percent of your paid premiums, you can include the remainder with your other medical expenses as an itemized deduction on Form 1040, Schedule A.pdf.

Remember, you need to get professional tax advice on your specific situation.

How To Get The Insurance That’s Right For You

How To Get The Insurance That’s Right For You

HMO, PPO, HSA. We’ve all heard these terms before but many people really don’t know the difference and why the difference is so important.

The health insurance industry is filled with confusing acronyms like these —we call it healthcare soup. The confusion around them makes it hard to understand what insurance plans really offer, but also they make it hard to determine which plan is right for you.

This guide is designed to clear up the confusion and give you the tools you need to make the insurance decision that’s right for you.

Choosing A Health insurance Plan—Start With A Health Risk Assessment

What’s a health risk assessment you ask? A health risk assessment is a tool that you should use before you make a decision on health insurance. It helps you understand your needs as a healthcare consumer, helps you identify your risks and helps you understand your costs.

It all starts with defining who you are because without that understanding, you won’t know what to buy. You could over-buy or under-buy insurance, and both of those are bad decisions. 

This assessment has a standard set of questions that helps develop your health profile. It assesses your health status, estimates your level of health risk, and recommends ways to change your behavior to improve your health. 

What Information a Health Risk Assessment Collects

Information collected includes your demographic information (age and sex), lifestyle information (alcohol intake, exercise habits, whether or not you smoke, etc.), personal and family medical his- tory, physiological data (weight, height, blood pressure, etc.), and your attitudes and willingness to change your behavior in order to improve your health.

The HRA analyzes this information to produce a health risk profile, which ranks your health in seven key health areas: heart, cancer, diabetes, obesity, nutrition, fitness, and mental and emotional health through color-coding, graphs, icons, and a number based scoring system that tells you if you are doing well, need to be cautious, or need to take immediate action. It recommends key ways to improve your scores and health.

How to Take A Health Risk Assessment

How can you get your own health risk profile? About 33 percent of employers offer these HRAs (Health Risk Assessments) through their employee health plan. If your employer is one who gives you access to an HRA they will direct you on where and how to take it.

If your employer doesn’t offer a HRA, that doesn’t mean you’re out of luck. There are other online resources where you can access one.  

What’s Next? Compile Your Health Record

After completing an HRA, you need to compile all your medical history to complete your total health profile. At first, it feels like a lot of busy work, not a joyous experience, but it’s worth it. Use the checklist below to make sure you have everything you need

Health Record Checklist

  1. Documentation of conditions you have been diagnosed with
  2. Biometric data 
  3. Copies of your past physicals
  4. Immunization records
  5. Records of surgeries you’ve had
  6. Past X-Rays, MRI’s, CT scans or other imaging you’ve had
  7. Diagnostic test results 
  8. Your current medications
  9. Family history of genetic conditions

It’s a big list, but your health record will be much easier to maintain and update once you do it. If you can’t manage to collect everything or don’t have the time, something is always better than nothing. In that case what’s most important is to have documentation of your current conditions, medications, surgeries and family history. 

Now You’re Ready To Make The Right Decision

These records complete your in-depth health profile. Having full access to your records, electronically or via hard copy, will help you communicate effectively with your doctor in an efficient manner. That way, they can more accurately assess your conditions and prescribe effective courses of treatment. These records also set you up to find a health insurance option that’s right for you and select a doctor who best fits your needs.

Making The Right Insurance Decision

What Insurance Has To Cover

What does insurance have to cover? The Affordable Care Act (ACA), aka Obamacare, man- dated all individual or employer-sponsored health plans must cover these ten essential benefits without annual or lifetime spending caps. Note: annual deductibles, copays, and out-of-pocket requirements must still be met, but once met, the medical expense cannot be limited.

  • Ambulatory patient services (outpatient care without being admitted to the hospital)
  • Emergency services
  • Hospitalization(such as surgery and over night stays)
  • Pregnancy, maternity, and new born care (both before
  • and after birth)
  • Mental health and substance abuse disorder services
  • including behavioral health treatment
  • Prescription drugs
  • Rehabilitation and habilitative services (those that
  • help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision

Make Sure Your Plan Has Access To The Providers You Need

Different types of plans (HMO, PPO) and different insurance carriers (Blue Cross Blue Shield, Aetna, Cigna, United Healthcare, etc.) repre- sent different providers. Some plans have more doctors and hospitals available and others fewer. Some may be limited by geographic areas. 

You can find this information using your insurer’s provider directory. Below is a list of the major insurance carrier’s provider directories. However, you will need to log in to view the directory.

HSA vs. PPO vs. HMO – General Strategies To Choose Between Plans

Everything you’ve done up until this point is critical because it’s what allows you to make sure your insurance decision is right for your personal needs. However, there are some general strategies that you should have in mind when it comes to choosing between HSA’s, PPO’s, and HMO’s. 

When To Choose A PPO 

If you’re a family who uses the healthcare system but doesn’t have a ton of claims A PPO will provide you with the right amount of coverage, but you shouldn’t get to a point where you’re paying more than you would with another plan type.
If your personal cash flow isn’t great Your monthly premium will be slightly higher but co-pays will make prescriptions and trips to the doctor more affordable in the short term.

PPO’s have become the most common type of plan offered and almost every employer will offer a PPO plan. PPOs grant you the freedom of choice to see any provider but create a network of physicians and hospitals (“in-network”) that offer discounted pricing to plan members. The networks are generally broad but do not include all providers.

It’s really important to have an idea of how much you will use the healthcare system during the year. A PPO can be a great general solution, but if you start to rack up claims, an HSA can be cheaper in the long run because the plan will pay 100% after you’ve met the deductible. 

When To Choose A High Deductible Plan With An HSA

If you’re young and healthy You should be using the healthcare system rarely so an HSA will offer the cheapest monthly premiums and provide protection against any catastrophic health condition.
If you have a chronic condition or are battling a serious illness An HSA will be more effective than an alternative plan in the long run because you are essentially hacking the system to have your plan pay 100% of your health costs once your deductible is met. If you anticipate easily exceeding your deductible during the year you will actually end up saving money vs. a co-pay plan. 
If you don’t have enough cash up front to meet your deductible, set up payment plans with your providers to take the weight off financially. 

A High-Deductible Health Plan follows all the features of a basic PPO with one exception: it cannot offer any copays for any level of service. The plans do not pay until deductibles are met; that includes physician office visits and prescription drugs (see example plan). Deductibles must be at least $1,350 for an individual and $2,700 for a family. 

When To Choose An HMO 

If you have minor health needs, your current doctors are in-network and you don’t expect your health to change An HMO will provide the cheapest protection to you if you’re a moderate user of healthcare and you don’t expect to need care from a provider out of network.

HMOs offer a contracted network of physicians and medical providers that you may choose. There is no coverage for non-networked providers (except in emergencies). 

The major drawback of an HMO is the lack of choice. Before selecting an HMO as your health plan you need to make sure that you are satisfied with the doctors, pharmacies and hospitals that are in network because you will be locked in to those providers. 

Another thing to consider before selecting an HMO is whether or not you anticipate that your health situation will change. If you suddenly have a new need arise in the middle of the year, an HMO might not be the best plan option.

Using Alternative Health Insurance Options To Cover Gaps

Any health insurance plan can have gaps when it comes to what it protects. This can be true for all health plans but is especially true for high deductible plans with an HSA. In those situations you have options when it comes to closing the gaps. 

  • Critical illness plans
  • Accident plans
  • Christian coverage
  • Credit cards

Finding The Plan That’s Right For You

The most important thing to keep in mind when you’re shopping for health insurance is to make sure the plan fits your needs. 

What Does Insurance Cover

 “Does my insurance cover that?”

 “Does my insurance cover that?”

It’s a question I’ve heard asked many times, and it’s probably a question you’ve asked before. The healthcare landscape—especially insurance—can be a confusing mess. Trying to understand it is like untangling a mess of Christmas lights. You might get there eventually, but it’s not going to be easy and you will question your sanity at points.

I wrote this article to simplify things by answering: What do health insurance plans cover?

Essential Benefits Covered Under ACA

The Affordable Care Act (ACA), aka Obamacare, mandated all individual or employer sponsored health plans must cover these ten essential benefits without spending caps of any kind (annual or lifetime). Note: annual deductibles, copays, and out-of-pocket requirements must still be met, but once met, the medical expense cannot be limited.

Ambulatory patient services (outpatient care without being admitted to the hospital)

  1. Emergency services
  2. Hospitalization and hospital stays (such as surgery and overnight stays)
  3. Pregnancy, maternity, and newborn care (both before and after birth)
  4. Mental health and substance abuse disorder services
  5. Prescription drugs
  6. Rehabilitation and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  7. Laboratory services
  8. Preventive and wellness services and chronic disease management
  9. Pediatric services, including oral and vision

In addition, a set of preventive services for men, women, and children are covered at 100 percent under the plans without charging copays, deductibles, or out-of-pocket costs. These include annual physicals, female contraceptives, and immunizations.

For a list of all fully covered services go to healthcare.gov. If you have coverage through your employer, ask for and review your employer’s Summary Plan Description (SPD).

Remember: The most efficient way to determine if your item is covered is to ask for the health insurance policy’s “not covered” or “exclusion” section.

What Does Minimum Coverage Cover?

Plans must cover the ten essential required benefits at an actuarial value of no less than 60 percent. Plans offered through healthcare.gov simplified the selection process by branding all plans that comply with the minimum actuarial value as bronze plans.

This is not to say that all healthcare insurance plans only cover the 60/40 percent split. There are 90/10 (platinum), 80/20 (gold), 70/30 (silver), and even some 50/50 (bronze as well) plans that comply with minimum actuarial value. Deductibles, copays, maximum out-of-pocket expenses and the amount you pay will vary by plan offering.

Note: What are medically necessary charges? Medicare’s definition of medically necessary charges is “health-related services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms, and that meet accepted standards of medicine.” In general terms, it excludes experimental unapproved procedures, and cosmetic procedures.

What Physicians and Hospitals Are Covered?

So far, we have highlighted what procedures are covered. You must also consider which providers are covered. Whatever plan or plans you are presented with and are considering, make sure they offer the doctors or hospitals or facilities that you use.

Different types of plans (HMO, PPO) and different insurance carriers (Blue Cross Blue Shield, Aetna, Cigna, United Healthcare, etc.) represent different providers. Some plans have more doctors and hospitals available and others fewer. Some are limited by area.

How do you find out if your providers are available? Ask for the provider directory. Each insurance carrier’s plan has its own unique list or directory. All are available online.

You are given the option to review the provider directories when you are applying for the insurance. Health insurance companies, employer plans, and government-sponsored plans offer multiple types of plans each with their own unique provider directory. When looking for your provider(s) in the carrier’s directory, make sure you are looking at the correct health plan. Different plans within the same carrier will have different lists of providers.

One Final Tip

If you don’t have a doctor relationship established, you need to ask how many doctors in the plan you are choosing are accepting new patients. Doctors on the list may not be taking new patients. Ask the insurance company or pick a doctor and call them to ask if they are taking new patients under the plan you are looking to select.

It’s a question I’ve heard asked many times, and it’s probably a question you’ve asked before. The healthcare landscape—especially insurance—can be a confusing mess. Trying to understand it is like untangling a mess of Christmas lights. You might get there eventually, but it’s not going to be easy and you will question your sanity at points.

I wrote this article to simplify things by answering: What do insurance plans cover?

Essential Benefits Covered Under ACA

The Affordable Care Act (ACA), aka Obamacare, mandated all individual or employer sponsored health plans must cover these ten essential benefits without spending caps of any kind (annual or lifetime). Note: annual deductibles, copays, and out-of-pocket requirements must still be met, but once met, the medical expense cannot be limited.

Ambulatory patient services (outpatient care without being admitted to the hospital)

  1. Emergency services
  2. Hospitalization (such as surgery and overnight stays)
  3. Pregnancy, maternity, and newborn care (both before and after birth)
  4. Mental health and substance abuse disorder services
  5. Prescription drugs
  6. Rehabilitation and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  7. Laboratory services
  8. Preventive and wellness services and chronic disease management
  9. Pediatric services, including oral and vision

In addition, a set of preventive services for men, women, and children are covered at 100 percent under the plans without charging copays, deductibles, or out-of-pocket costs. These include annual physicals, female contraceptives, and immunizations.

For a list of all fully covered services go to healthcare.gov. If you have coverage through your employer, ask for and review your employer’s Summary Plan Description (SPD).

Remember: The most efficient way to determine if your item is covered is to ask for the health insurance policy’s “not covered” or “exclusion” section.

What Does Minimum Coverage Cover?

Plans must cover the ten essential required benefits at an actuarial value of no less than 60 percent. Plans offered through healthcare.gov simplified the selection process by branding all plans that comply with the minimum actuarial value as bronze plans.

This is not to say that all healthcare insurance plans only cover the 60/40 percent split. There are 90/10 (platinum), 80/20 (gold), 70/30 (silver), and even some 50/50 (bronze as well) plans that comply with minimum actuarial value. Deductibles, copays, and maximum out-of-pocket expenses will vary by plan offering.

Note: What are medically necessary charges? Medicare’s definition of medically necessary charges is “health-related services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms, and that meet accepted standards of medicine.” In general terms, it excludes experimental unapproved procedures, and cosmetic procedures.

What Physicians and Hospitals Are Covered?

So far, we have highlighted what procedures are covered. You must also consider which providers are covered. Whatever plan or plans you are presented with and are considering, make sure they offer the doctors or hospitals or facilities that you use.

Different types of plans (HMO, PPO) and different insurance carriers (Blue Cross Blue Shield, Aetna, Cigna, United Healthcare, etc.) represent different providers. Some plans have more doctors and hospitals available and others fewer. Some are limited by area.

How do you find out if your providers are available? Ask for the provider directory. Each insurance carrier’s plan has its own unique list or directory. All are available online.

You are given the option to review the provider directories when you are applying for the insurance. Health insurance carriers, employer plans, and government-sponsored plans offer multiple types of plans each with their own unique provider directory. When looking for your provider(s) in the carrier’s directory, make sure you are looking at the correct health plan. Different plans within the same carrier will have different lists of providers.

One Final Tip

If you don’t have a doctor relationship established, you need to ask how many doctors in the plan you are choosing are accepting new patients. Doctors on the list may not be taking new patients. Ask the insurance company or pick a doctor and call them to ask if they are taking new patients under the plan you are looking to select.

What You Need to Know About Supplemental Health Plans

The following is adapted from Healthcare is Making Me Sick: Learn the Rules to Regain Control and Fight for Your Healthcare.

You’ve just purchased a health policy and had to increase the deductibles and out-of-pocket costs to afford the monthly premium. You’re not sure where you’re going to come up with the money, but you felt like you had no alternative based on the costs of the lower-deductible plans. Sure, your insurance will kick in after you meet that deductible, but what do you do if you can’t meet your deductible in the first place?

When shopping for insurance, it’s easy to overlook that deductibles represent real money out of your pocket. Your grocery bills, mortgages, and car payments don’t stop just because you have a medical expense you need to cover. In this article, we’ll talk about filling in those gaps in coverage with supplemental policies.

Why Consider a Supplemental Policy?

These are not healthcare policies and should not be considered as a replacement for one. They may make sense, depending on your budget and health concerns, to offset the effects of a catastrophic illness on your finances. You’ll wonder, “Where do I get the money to cover the deductibles and out-of-pocket costs of my insurance plan caused by medical expenses? If I’m not working because I’m sick, how do I cover those costs?”

Supplemental policies offer you direct cash payment in the event you have a critical illness, hospital stay, or accident. They can be purchased directly from the insurance carriers or agents and are often offered through your employer.

Programs can be designed to meet your specific needs and affordability, and they can provide peace of mind. They are not reduced or coordinated with other health insurance you own and are generally extremely affordable—usually under $50 a month.

Supplemental policies have become increasingly popular due to the escalating premium costs that have driven most of us to higher-deductible plans.

Different Types of Coverage

If you have a lower out-of-pocket healthcare plan, you likely don’t need a supplemental plan. In other words, if your deductible is $500, why buy a $5,000 cancer policy?

The direct payments can be purchased at different levels, allowing you to fit them to your specific needs. Underwriting requirements are nominal for basic levels of coverage. Pre-existing exclusions do apply to individuals with an existing condition. There are basically three types of coverage: critical illness, accident and hospital, and medical indemnity plans. Let’s look at each type of coverage in more detail.

Critical Illness

Critical illness covers expenses resulting from specific diseases. The benefit amount is paid in a lump-sum payment when you are diagnosed with that named disease. The most common illnesses covered in this category are as follows:

  • Heart Attack
  • Cancer
  • Stroke
  • Organ Transplant
  • Heart Transplant
  • Kidney Failure
  • Coronary Bypass Surgery
  • Paralysis
  • And more

You can purchase coverage as low as $5,000 per disease up to $50,000 by answering basic health questions. Amounts over $50,000 require full medical underwriting. Costs range from $50 to $150/month depending on your age and the coverage amount.

Accident Coverage

Accident and health coverage simply means plans that pay covered expenses related to accidents. They’re paid in a lump-sum payment to you to use as you deem appropriate and are not limited to, or coordinated with, other medical coverage you have. Covered conditions can include the following as long as they are due to an accident:

  • Fractures
  • Dislocations
  • Concussions
  • Lacerations
  • Second- and Third-Degree Burns
  • Ruptured Discs
  • Torn Knee Cartilage
  • And more

Hospital Indemnity

Hospital indemnity covers expenses for hospital admissions, allowing a daily rate up to a maximum number of days and dollars. You can purchase daily benefits of $100–$1,000 per day for a period of up to 180 consecutive days.

Coverage for the following is included under this type of plan:

  • Intensive Care Units
  • Emergency Room Visits
  • Qualifying Outpatient Visits
  • And more

Major Players in the Supplemental Market

Plans like those I’ve described are becoming more popular as deductibles and out-of-pocket costs rise. So, more insurance companies are now offering those plans. Newcomers in the field are the major health carriers—Aetna, Cigna, Humana, Blue Cross Blue Shield, and United Healthcare—which are now offering the coverages in addition to their comprehensive, ACA-compliant health insurance offerings.

The following companies, alternately, have been offering these coverages for decades: Aflac, Mutual of Omaha, Colonial Life Insurance Company, Principal Financial Group, Assurity Life Insurance, Co-American Fidelity, Assurance, Guardian Life Insurance Company of America, Assurant Health Company, Combined Insurance, and AIG.

Critical illness, accident and hospital, and medical indemnity coverages should be considered when creating your total healthcare insurance package. You may be able to select a higher-deductible health plan at a lower premium and purchase one of these programs for less than the cost of buying a lower-deductible health plan.

Don’t Overinsure Yourself

Only buy the amount of coverage that covers your deductible and out-of-pocket expenses before your health insurance plan pays 100 percent. Only purchase the plan if one of these plans and your health insurance plan combined is less than a lower-deductible health insurance plan. Otherwise, you are overinsured.

For more advice on supplemental policies, you can find Healthcare is Making Me Sick on Amazon.

Scott Heiser has more than twenty years’ experience as a consultant for clients in the insurance and healthcare system. Scott was a partner and owner of a commercial insurance brokerage, in which he led and developed an employee benefit practice that managed more than half a billion dollars in health benefits. Scott is a strategic innovator who knows the ins and outs of what can feel like the overwhelming world of healthcare and insurance. Today, he is dedicated to sharing his knowledge to help educate and empower his readers. His goal is to improve your health outcomes while lowering your costs. To get started, visit www.UncoveredHC.com. 

Is Christian Healthcare Right for You? Here’s What You Should Know.

With the reduced carrier selections, increasing and sometimes unattainable premiums, and increased deductibles and coinsurance, people are aggressively looking for alternatives to traditional health insurance. Some are turning to nonprofit, religious-based plans, known as Christian healthcare plans, due to their significant reduction in premium costs and their exclusion from ACA penalties and requirements.

These plans have seen tremendous growth over the past three years, paying close to two-thirds of a billion dollars in medical expenses and covering over 600,000 members in 2016. Their explosive growth is eliciting greater interest and greater scrutiny.

Both are warranted. Who are they? What do they offer? What don’t they offer? What are their costs? Are they legitimate? Are they regulated? Let’s take a closer look at Christian healthcare plans to see if they might be right for your needs.

What is Christian Healthcare?

Christian health plans are healthcare-sharing ministries oriented toward practicing Christians. They are aligned with biblical teachings that believers have a responsibility to assist each other’s needs. They have been in existence for over twenty years and are growing rapidly due to their philosophy and low initial costs for healthcare solutions.

They are not insurance companies. They are excluded from ACA mandates like pre-existing coverage exclusion, underwriting, and unlimited payments, due to their religious conviction. Members literally share in certain expenses covering one another’s costs. Interestingly, this is the basic definition of insurance to aggregate expenses.

What Are the Requirements?

The major membership qualifications require: Christian testimony (live by biblical standards, bear one another’s burdens, and regularly attend a fellowship of believers); healthy lifestyle (no smoking or illegal drugs); application review (underwriting—you can be denied for pre-existing conditions); and health partners (be willing to participate with health coaches to work toward a healthier lifestyle).

Interestingly again, this shared commitment to health produces solid aspects of the program that work in improving the members’ lives and keeping health costs in control, thereby leading to better quality of life for the individual.

How Does Payment Work? What’s Covered?

Some Christian health plans have PPO network providers, and some don’t. All encourage you to negotiate fees with providers and have provider counselors to assist with negotiations if providers refuse. By paying cash, the members are generally successfully receiving significant discounts off of the published provider charges.

The programs have annual contributions that grant you “sharing” amounts per qualified illness. Each illness will require a deductible from you before the illness is submitted for sharing. Non-qualified or preexisting condition bills can be submitted as financial prayer requests that may or may not be met by the membership. Each individual is assessed on the annual contribution level and then will also receive financial prayer requests from others throughout the year. Entry-level plans usually don’t cover prescription drugs.

When considering these plans, or any other plan for that matter, do not just read the covered procedures. Find the exclusion section, generally in the appendix of their coverage guide, and scrutinize those features. Make sure your health profile, which includes your family health history, does not include those features. Common exclusions with these plans are pre-existing illnesses, prescription medicine, chiropractic treatments, diagnostic services, birth control, and illegal drug-related services.

Who Are the Biggest Players?

The healthcare-sharing ministry landscape is dominated by five major players with the largest memberships and highest revenue spread across the country and across Christian denominations. Samaritan Ministries (Illinois), Christian Healthcare Ministries (Ohio), and Medishare (Florida) are the three large evangelical operations.

Dozens of similar ministries exist across the country, mostly smaller and more localized. Ohio’s Liberty HealthShare is Mennonite, a denomination traditionally committed to pacifism and dialogue. Solidarity HealthShare, founded in 2015, is Catholic, and partnered with another Mennonite aid group in Ohio to be grandfathered into the ACA exemption for sharing ministries, which required that they exist before 1999. There is also a Jewish-based health plan found at unitedrefuahhs.org.

Who Should I Talk to?

If you’re interested in one of these plans, analyze the plan designs, rules, and regulations. Seek out current participants who have had large claims. Find out what worked for them and what didn’t, and go from there. 

How to Develop a Winning Relationship with Your Healthcare Provider

Once you’ve gathered referrals, done your research, and scheduled an appointment with a new primary care physician, how do you get the most out of this relationship? Remember, your doctor is the clinician who should know you best and holistically.

They make the primary diagnosis. They are the ones who will cut through the healthcare system clutter and ease your way into the best appropriate specialties and hospitals. They will even help you save money. Developing a good, solid relationship with this person is the best start or foundation of your healthcare experience.

Your doctor is your teammate and advocate. And no, this isn’t a fantasy; it can be a reality, and one you can achieve without bribing your physician with candy, flowers, or a bottle of Maker’s Mark. If you’re educating yourself, being proactive about your health, and providing the right information, you can establish the kind of relationship that is healthy for you both physically and financially.

The process is like any other valuable relationship: simple if you approach it with the right mindset and effort, but not necessarily what we’ve typically done with healthcare professionals. The keys to success are preparation, clear two-way communication, and clear goals. On average, you’ve got eight minutes per visit with the doctor. Your goal is to efficiently communicate your ailments and expectations. Let’s review some tips on how to maximize that experience and develop a relationship with your doctor.

How to Prepare for an Appointment

Be organized. Studies have shown that patients who filled out a detailed checklist asked more questions during their doctor visit and got more satisfaction with the visit. The checklist should include accurate information, dates, times, and circumstances about your symptoms, your health record (including any and all medications you are taking), and a list of questions you wish to cover. Prioritize the questions by their importance.

Use SBAR to Communicate Confidently

Read this sentence twice to truly get it in your head: it’s your responsibility to communicate effectively with your doctor. You have to be organized when it comes to your own health. Stephen Covey wrote that to effectively communicate, both parties have to “seek first to understand and then to be understood.” Understanding the doctor’s environment sets you up to further prepare your discussion with them.

What better way to prepare is there than understanding how they are trained to communicate with themselves? Many physician practices and hospitals use a technique called SBAR (Situation Background Assessment Recommendation). It was developed by the Navy for use in nuclear submarines to enhance efficient communication. Staff and physicians use SBAR to share patient information in a clear, complete, concise, and structured format and to improve communication, efficiency, and accuracy.

Here’s the framework and how it relates to you:

  • Situation: Take ten seconds to explain (your reason for the appointment)
  • Background: Provide context and data (your medical health record)
  • Assessment: Describe the specific problem/situation (doctor’s diagnosis)
  • Recommendation: Explain what you want to do and when (course of treatment)

Try not to get emotional or engage in non-essential stories. Stick with the facts! Also, don’t withhold information on embarrassing symptoms, issues, or cost concerns that are causing fear. Without that information, the doctor can’t help you.

By being prepared and fact-based, the two of you will have more time to focus on your issues and questions. You have to be concise, organized, objective, and precise.

Here’s a tip: take an advocate with you to the appointment who can make sure you cover your situation and key questions. They can also be another set of ears to listen to the doctor’s diagnosis and course of treatment. Take notes during the appointment and ask for a summary of the appointment from your doctor outlining their diagnosis and treatment plan. This can often be accessed online as well.

Good Questions to Ask

Looking for some assistance in developing good questions to ask your doctor? The US Agency for Healthcare Research and Quality (AHRQ), a division of the Department of Health and Human Services, has included on its website a “tips and tools” section on what to do before during and after your appointment. Sample questions are:

  • What is the test for?
  • How many times have you done this procedure?
  • When will I get the results?
  • Why do I need this treatment?
  • Are there any alternatives?
  • What are the possible complications?
  • Which hospital is best for my needs?
  • How do you spell the name of that drug?
  • Are there any side effects?
  • Will this medicine interact with medicines that I’m already taking?
  • What is my diagnosis?
  • What are my treatment options?
  • What are the benefits of each option? What are the side effects?
  • Will I need a test? What is the test for? What will the results tell me?
  • What will the medicine you are prescribing do? How do I take it?
  • Are there any side effects to this medication?
  • Why do I need surgery? Are there other ways to treat my condition?
  • How often do you perform this surgery?
  • Do I need to change my daily routine?

The Bottom Line

Your healthcare is not a game. Instead of approaching visits with a chip on your shoulder or with confusion, go in confident and prepared. Build a mutually respectful relationship with them, one in which you communicate openly and concisely.

And don’t just get to know your doctor; establish relationships with their nurses and their administrative staff, too, because they’re the gatekeepers.