PPO, HMO, EPO

Obamacare 2016

Today more than ever, people need help when buying insurance.  Some say they want Obamacare, some say they don’t want Obamacare.  Here is the skinny on Obamacare.

Plan Benefits

Obamacare is not an actual plan.  Obama made the laws and it has been coined “Obamacare”, but you still get the insurance directly from the insurance companies, however if you buy it ON EXCHANGE through healthcare.gov then you may qualify for a subsidy or a reduced premium.  In addition, when you buy on the exchange you have a longer time to pay your premiums than if you buy OFF EXCHANGE.  Therefore, THAT is why a lot of the doctors are not taking Obamacare/ON EXCHANGE plans because in theory, you could use the 3 month grace period to pay your premiums and still get care during that time.  The doctors could get stuck with treating you and never getting paid by the insurance company, or getting paid 3 mos later.  THAT is why they don’t want to take it.  Problem is, most of the companies sell the same plans ON and OFF EXCHANGE so the doctors have no idea if the person has 3 mos extra to pay or not — so they are all saying we won’t take any insurance!!!  Can you see what is going on now?

The benefits of the plans are still great, the problem this year is who will take the insurance you buy.  So make sure you look up your doctor to see if they are in network or not.

Networks

This year the networks are the key to everything.  Instead of shopping benefits, you are essentially shopping networks of providers.  A lot of companies have done away with offering PPOs entirely and are only offering EPOs and HMOs.  Again, there is nothing wrong with the benefits of either of these plans, in fact the benefits of an HMO are typically better than a PPO, however you are restricted to a certain network of doctors and those doctors are not the doctors you have seen for 20+ years.  The reason for that is, on an HMO the doctors in essence get paid less each time they see a patient than if they were to file the claim through a PPO.  In addition, there is a whole lot more paperwork to keep up with when filing a claim on an HMO too.  So a lot of the doctors who have been in business for a long time, don’t want to change how they do things (with good reason).  Therefore, the result is, you have newer “hungrier” doctors on the HMO networks.  The doctors possibly fresh out of medical school or the ones still trying to build their practice.  This doesn’t make them bad doctors, again, just not the doctors you have seen for 20+ years.

Changes

So because of all the changes within the Affordable Care Act, ACA for short, a lot of doctors are getting out of the practice.  This year, you will probably have to change doctors and will have to pay more for your insurance so be prepared.  If you decide to go without insurance entirely, there is a penalty, and it did increase for 2016.  Be aware of all of your options, and it is still FREE to have an agent help you.  They are still the most knowledgeable resources available.

What is a PPO HMO POS EPO

Is it an acronym city or the abbreviations you put behind your name! Health insurance plans are categorized by a few main ways: PPO, HMO, POS, and EPO.

Depending on which plan you buy, depends on if your care is covered when you see a network provider or any doctor. In addition, you may have larger deductible or coinsurance, and/or you may have to get a referral if you want to see a provider out of network

PPO (Preferred Provider Organizations)

PPOs give you the choice of seeing providers in network or out-of-network. You pay less if you use in network providers. You’ll pay more if you want to go out of network for doctors, providers, and hospitals. You may have higher out-of-pocket costs too. If you have a PPO plan, you can visit any doctor without a referral.

POS (Point-of-Service)

POS plans let you go to both in-network and out-of-network providers. With a POS plan, you will have to choose a PCP or primary care doctor from a list of participating providers in network. Your PCP will refer you to other in network providers as needed. If you choose to go to an out-of-network provider, you’ll need a referral and you may pay higher out-of-pocket costs.

HMO (Health Maintenance Organizations)

HMO plans usually require you to seek care from in network providers who work for or contract with the HMO. An HMO generally doesn’t cover or has limited coverage if you go out-of-network except in an emergency. If you choose to see a doctor or facility that isn’t in the HMO network, you may have to pay the full cost. Like the POS plans, HMO members usually have a PCP and must get a referral to see a specialist.

EPO (Exclusive Provider Organizations)

EPOs are much like the HMO in that they generally have coverage only if you see a provider in the EPO network (except in an emergency). Health plans generally can’t require higher copayments or coinsurance if you get emergency care from an out-of-network hospital, no matter what type of plan you have. However, providers may bill you for some additional costs.

Plan F Plan G

Medicare Supplement Plan F or Plan G

“That is the real question, which Medicare Supplement Plan do I go with?” Bob said. “Plan F or Plan G? They both look the same.” “Good question.” I told him. Then I began to explain as I do to all the folks I talk to who ask this same question. It’s funny how in the end, they always seem to agree and make the same decision because it just makes $ense.

Here is the deal. Plan F has been the most popular plan in the Medicare Supplement Market for years. Mainly because it is simple to understand; most people have almost no out of pocket costs other than what they pay each month for the plan. If Medicare pays, then the Medicare Supplement pays. Some people even say the “F” stands for “Full coverage”. However, “Full coverage” as we all know, comes at a price, and sometimes it isn’t the best “bang for your buck”.

Plan F and Plan G are identical, the ONLY difference is, on Plan G you have to pay for the Medicare Part B deductible. Therefore, Plan G is becoming more and more popular, mainly because of the cost. If you look at the graph below, the Part B deductible has not changed in the past 3 years.

PART B DEDUCTIBLE HISTORY

In 2010 Part B deductible was $155
In 2011 Part B deductible was $162
In 2012 Part B deductible was $140
In 2013 Part B deductible was $147
In 2014 Part B deductible was $147
In 2015 Part B deductible was $147

Even though the Part B deductible hasn’t changed much in the past 5 years (in fact it’s lower than it was in 2011), Plan F prices have steadily been increasing every year. Basically, for 4 years people with Plan F have been paying more for a benefit that hasn’t changed.

When you look at the actual numbers, the Medicare Part B deductible breaks down to around $12 per month ($147 / 12 months). So if a Plan F costs $12 more than a Plan G per month for you, then you are paying too much!!! Make $ense??

In some areas, we see a Plan F for a customer and a Plan G be as much as $40 difference! So tell me, if Progressive or Geico told you that you could save $480 per year in premium and only add $147 in your deductible, would you be willing to make that change? Of course you would, because it makes $ense.

So after quoting Bob Plan F @ $187.39 per month and Plan G @ $157.35 per month … I said to Bob … “I always give folks the choice by showing them the price difference and let them make the decision … which plan do YOU think you should go with?” Without hesitation Bob blurted “Well I would be dumb to not go with Plan G!” Bob is a smart man. Over 90% of our customers go with Plan G, however if you are willing to give an insurance company $200-$400 in trade for $147, then we won’t mind helping you do that.

medicare open enrollment

2016 Medicare Open Enrollment

Most people don’t realize that the 2016 Medicare Open Enrollment Dates only apply to people who are wanting to make changes to their Medicare Advantage (Part C of Medicare) and prescription drug plan (Part D of Medicare). Each year, open enrollment runs from October 15 to December 7. Therefore in 2016 it will begin on October 15, 2015. That is the time for you to shop around for a new Medicare Advantage Plan (Part C of Medicare) or a new Prescription Drug plan (Part D of Medicare).

So first of, to be clear, as far as enrolling in Medicare, you can do that as soon as you are eligible … no matter what month it is. Most people become eligible when they turn 65, and begin enrolling in Part B up to 3 months before their 65th birthday month.

It is only during open enrollment that you can switch from original Medicare to Medicare Advantage (Part C of Medicare), or vice versa. Also, if you find that another Medicare Advantage plan (Part C of Medicare) will fit your needs, or has a broader network, you can switch from one Medicare Advantage plan (Part C of Medicare) to another. Same with a prescription drug plan (Medicare Part D), you can switch from one plan to another during open enrollment or drop your prescription drug plan (Medicare Part D) coverage altogether. However, you may incur penalties later on if you go without a prescription drug plan (Part D of Medicare) – we would not advise this. Especially since you can get prescription drug plans (Part D of Medicare) for generally under $20 a month.

Now for people who are on a Medicare Advantage plan (Part C of Medicare), who miss the open enrollment but who just want to go back to original Medicare, there is also a Medicare Advantage disenrollment period (MADP) that runs from January 1 to February 14 each year. At that time, you could opt to switch back to original Medicare and then sign up for a prescription only plan (Medicare Part D). Most people will do this if they are going from a Medicare Advantage Plan (Part C of Medicare) to a Medicare Supplement Plan.

For 2015 coverage, open enrollment is over for Medicare. Medicare Advantage (Part C of Medicare) and prescription drug plans (Medicare Part D) ended on December 7, 2014, and the Medicare Advantage disenrollment period ended on February 14, 2015. Remember, you can enroll year-round in Medicare if you are newly-eligible.

For more information or to shop plans, visit us at www.emedigap411.com  call 877-740-8683 or email.

special enrollment

Life events can change insurance

Some of our biggest life events that trigger special enrollments and change our healthcare coverage too.

Under the Affordable Care Act, many life events, such as losing a job, having a baby, moving, divorcing and getting married, allow people to sign up for health insurance throughout the year, outside of the annual open enrollment period.

Obamacare enrollment runs from Nov. 1 through Jan. 31 for 2016 coverage.

Young adults are more likely than any other age group to experience a life event that qualifies them for special enrollment

Once people understand that getting married, having a kid or moving can be an opportunity to enroll in affordable care, people are interested in hearing about their options. Especially if they picked a plan they are not so happy with.

One thing to remember though, there is only a limited period of time to get a new health policy when these life events happen.

As a general rule, you have to enroll within 60 days of a qualifying event. It’s not an open window.

Not all big life events can alter your insurance coverage — at least not immediately.

Pregnancy

Having a baby, triggers an opportunity to switch health plans, but most people are suprised to find out that pregnancy does not trigger an opportunity. Pregnancy doesn’t allow you to switch plans, it only allows you to add the child to the plan.

Here are some common reasons people qualify for a special enrollment period under Obamacare:

Losing insurance

The reasons for losing insurance are varied – The loss of a job-based plan, aging out of a parent’s coverage at the age of 26, losing coverage through divorce, or losing eligibility for Medicaid or the state’s insurance program for people with low incomes, trigger a special enrollment period.

Most people feel COBRA is their only option. They aren’t aware that after leaving or losing their job they can sign up for a plan and even apply for a tax credit to lower their insurance costs.

Once you elect COBRA, you can’t just drop it. If you continue your current job-based health plan through COBRA, you’ll have to keep it until it ends or the next annual open enrollment comes around when you can sign up for a new plan. Canceling COBRA before it expires does not count as a qualifying event triggering a special enrollment period.

In fact, losing insurance because of something you do yourself — say, stopping payment because you believe that your plan is too pricey — won’t qualify you for a special enrollment period.

Moving

Most health plans operate within a specific geographic area. If you permanently move to a new city or ZIP Code, you may qualify for a special enrollment period and have the chance to pick a new plan.

If you move to a ZIP Code where another plan is now offered or a plan that was offered is no longer available, that’s a qualifying life event.

Marriage – Divorce – Adoption

You can add someone to your health plan if you get married, or if you have or adopt a child. Losing insurance coverage because of divorce also qualifies you to buy a new policy during a special enrollment period.

There are a few other special events that may trigger a special enrollment opportunity. To learn if you qualify for special enrollment email us directly or call 877-740-8683 and we will be happy to assist.