Private Health Insurance Plans

Private Health Insurance ( Off- Exchange/ACA)

When it comes to finding the highest level of health insurance for you, your family, or your employees it comes down to 2 pathways: a marketplace plan either on/off the exchange or a private health plan. As you are doing your research and choosing a plan, you may hear a wide-range of names given creating more confusion to the you, the consumer. Agents may call these plans other names such as: private health plans, PPO plans, off-exchange, non-marketplace/Obama-care plans, or various other names.

Private health insurance plans can be purchased directly from insurance companies or through individual brokers like myself! These plans differ slightly from those offered through the marketplace in several ways and it's important to have an understanding of some of these differences:

Plans are not eligible for financial assistance/subsidies, income is irrelevant and has no impact on the monthly premium.
Plans may be structured similar to those on the marketplace. Some may even meet ACA mandates by providing essential health benefits.
Plans can be purchased online, through and insurance broker or directly from the insurers. Note: brokers should not charge for their services as commissions are paid by the carrier upon the sale and will not increase your final cost.
Networks may be slightly larger, because the insurer avoids additional administrative fees tied to marketplace plans.

Off-exchange health plans include "short-term" health plans, defined benefit plans, healthshare plans or additional supplemental coverage that can be added to your coverage: cancer plans, critical illness, accident protection, etc. While these do not qualify as "ACA-compliant" health coverage, they generally will offer lower premiums and may suit an individual's needs better as a more affordable alternative.

Short-term medical plans, can provide a temporary solution that helps you get the benefits you want, for the time you need. Short-term medical plans offer a lot of upside, especially if you are in need of coverage ASAP and looking for an option that requires little time to complete and process an application, wide network of providers, and affordable premiums. Depending on your state these plans may have a duration of 1 - 90 days, with a 1 month extension option.

Short-term insurance may be the right choice for you if you’re:

Waiting for open enrollment to apply for an Affordable Care Act (ACA) plan
Not experiencing a situation that’s a qualifying life event and you don’t qualify for a Special Enrollment Period (SEP) to apply for an ACA plan
Waiting for ACA coverage to start

Looking for coverage to bridge you to Medicare
Turning 26 and are coming off your parent's insurance
Between jobs or waiting for benefits to begin at your new job
Healthy and under 65

In most cases, short term health insurance plans are medically underwritten, which means they will look back and review your healthcare history to determine if you qualify and/or have any pre-existing healthcare conditions. Many short-term plans do not cover pre-existing conditions or have a waiting period until that condition is covered. Depending on your state’s definition and the insurance carrier's policy, a pre-existing condition is a condition that was diagnosed or treated within the last 1 to 2 years.If you are in this situation, you may want to explore other options or see if you can extend your current insurance plan.

Short-Term
Medical Plans

A defined benefit health plan offers transparency that pays a set, predetermined amount of money for listed services as opposed to a cost share after the deductible. It's also known as a defined benefit or "fee for service" insurance. Defined benefit plans are a great option for people who are self-employed, not offered employer coverage, or want more flexibility in their plan or how they approach healthcare, especially if you are young or your overall health is good.

Deductibles can be a killer financially for many, especially if your plan has a high deductible. 92% of insured Americans will not meet their deductible in a calendar year. That means any healthcare needs will be paid by the consumer (including copays, out-of-network costs, and services not covered before the deductible is met.

An indemnity plan will not generally have a deductible, or will only require a deductible when admitted to a hospital for > 24 hours.

No insurance plan pays for everything, however, indemnity plans do offer more flexibility within the network utilizing a PPO network with coverage for out-of-network services. Indemnity plans also reward consumers for "smart healthcare management". With the flexibility to see any provider, anywhere, anytime. Often time, approaching services as a "cash payer" can lower out-of-pocket costs vs. using their insurance. Indemnities allow you to benefit as a "cash payer" and as a customer by paying you the full, listed benefit for that service if cash paying.

For Example: Elaine likes to think she is “never” sick, so when she began to feel under the weather it took several days before she seeked help. She doesn’t have a regular doctor, so opted to visit a nearby Urgent Care facility. The doctor ran multiple tests before determining she had strep throat. She was prescribed an antibiotic, which was filled at a nearby pharmacy. Elaine did not pay anything for her visit, and because her indemnity benefit exceeded the billed amount, she received over $300.00 back!

BELOW IS A COPY OF "ELAINE'S SUMMARY OF BENEFITS AND THE CHECK SHE RECEIVED FOR EXCESS BENEFITS.

Needless to say in this scenario, Elaine was happy with her her coverage. Had she used a major medical plan she would have been responsible for her copay and any additional services not covered prior to her deductible.

Similar to the Short-term plans, many of these plans require medically underwriting and will have a list of limitations and/or exclusions. Be sure you have reviewed your plan documents thoroughly. In most cases, your agent will review those details before select a plan. These plans may be the most affordable option. They can be kept as long as needed and do not require an open enrollment period to sign up.

Defined Benefit
Health Plans

Healthcare sharing plans are provided by organizations whose members “share” medical costs. As part of a healthcare sharing plan, you are responsible for paying in a certain share amount each month (like a premium) as well as an “annual unshared amount” for your own expenses (like a deductible) that your medical expenses must exceed before the plan shares your expenses. Beyond that, all medical expenses are shared among members of the organization.

Healthcare sharing can be great for people who:

Are generally in good health
Are not eligible for a tax credit based on income
Lack access to insurance through an employer or government program
Aren’t able to get coverage from missing open enrollment
Only want/need catastrophic coverage
Can’t afford current health insurance premiums

Health sharing organizations are mostly religious-based. That doesn’t always mean you have to declare your faith to any particular religion to participate or join, but they do ask that you agree to live by a moral and healthy lifestyle—like not using tobacco or abusing drugs or alcohol.

Healthcare sharing is not insurance, which means they are not overseen or governed by each states Department of Insurance (DOI), but plans count as insurance under the Affordable Care Act (ACA). That means more affordable healthcare benefits while avoiding the tax penalty for going uninsured. Health care sharing plans aren’t required to cover pre-existing conditions, such as cancer, diabetes, or lifestyle-related conditions like smoking. Those who have them may be declined membership or won’t have the conditions fully covered for a year or more.Health care sharing also doesn’t typically cover the essential health benefits like wellness exams or mental health counseling.

Health Share Plans

"Invest in health insurance today for a worry-free financial tomorrow."

Hercules Health Solutions has the solution to solve your health insurance problems!

Regardless of the problem you're trying to solve, Hercules Health Solutions has a wide variety of private health insurance solutions. That means you only have to know one phone number, one name, one agent to call. No matter the problem you're trying to solve, we will work with you to provide a solution that meets the needs of your individual situation.

Let us help. Let us make your health insurance buying process easier and less confusing. Click the link below to request at free, customized quote or call our office directly: 956.246.4123

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