These days health insurance is a top concern for many people. It’s expensive, and the options can be overwhelming. Especially if you’re facing a significant life change such as divorce or retirement, or are about to leave a company job to start your own business. My guest today is Isabel Gonzalez-Lawson. She is the owner of Core Benefits, a company that helps people find the best health insurance options. Today, she will answer some of our questions on this topic.
What is your experience in the world of health insurance?
What are the basic options people have today regarding health insurance?
What other options are there when one does not have employer-sponsored health insurance?
What distinguishes a group policy from an individual policy?
Would visiting a doctor with no provider lead to payment of out-of-network benefits?
While dealing with PPOs, are deductibles paid before insurance comes into effect?
Does co-pay count against your deductible?
Do people need to pay up until their deductibles?
Under group policy insurance, is preventative care covered?
How is an HMO (Health Maintenance Organization) different from a PPO?
Would a change in location to where one’s HMO is not operating require searching for another health insurance?
Can group policy cover sole proprietorship businesses at all?
Under group policy, are there any other types of interest apart from HMOs, PPOs and EPOs?
Does the pricing of a group policy depend on the health of the members of the group?
Can one decide whether or not to be in a group with no health risk assessment?
Is the self-funded plan actually self-funded?
What are the options available to an unemployed person unable to get health insurance through their spouse as a result of divorce?
What benefits are covered on an individual Obamacare plan versus on a fully insured group plan?
What income level will stop you from getting any of the subsidies or benefits from the lower deductibles?
In the absence of a lot of subsidies, how expensive is it?
Have the providers offering those services and plans also been shrinking?
Are there any options that has benefits for special diagnosis like cancer?
What does healthcare look like for the retired person?
Does Medicare cover nursing home care in case you need one?
Do you help people to navigate and make choices from the various options that are available in Medicare?
How do you get paid?
What Is Your Experience In the Health Insurance Business?
I have been in the health insurance business for 26 years, and it’s been an amazing journey. I love it, and I take it as an educational process for all my clients. Today, healthcare is extremely expensive, and there are a lot of options out there for everyone needing healthcare. It’s just knowing what your needs are exactly and really tailoring the plan to your specific needs.
It can be really overwhelming to see the expenses increasing while the benefits keep getting smaller. Unlike car insurance policies or others, health insurance is not something you can shop around, go to different insurance companies, and sign up for. Historically, it seems like the access to health insurance was more through employer-sponsored programs.
What Options Are Available Today Regarding Health Insurance?
There are group options, and this depends on the size of the group. For instance, if you’re going through a divorce and are employed in a company with 20 employees or more, you have access to COBRA benefits, which will last for 36 months. On the other hand, if you work for a company with under 20 employees here in Texas, you have state continuation, which will last for nine months.
So that works great if your spouse was employed?
For someone looking to get employed, one of the things such a person will probably be looking at is health insurance through the employer?
What Options Are There When One Does Not Have Employer-Sponsored Health Insurance?
For example, you and your husband own two separate small businesses, but you’ve always been on his insurance. Today, companies offer one-man group insurance. An LLC will enable you to get group insurance as one person.
Does that only apply to LLCs alone or other business entities as well?
It applies to LLCs, partnerships, and corporations, not sole proprietorships. Once you have some sort of business entity for your small business which contains just you, you can get a group policy.
What Distinguishes A Group Policy From An Individual Policy?
In today’s market, there are some distinctions. I would say the main distinction right now is the networks. With group policies, you have options for a Preferred Provider Organization (PPO), and then you have options for ‘in-network only’ where you have benefits that are only in-network but work as a PPO. And then you have the Health Maintenance Organization (HMO) option.
With the individual market, it depends on the company, but a lot of them are HMOs. You have some PPOs, but it’s less the amount of offering in that market.
PPO means Preferred Provider Organization. One can work with any of the providers in the organization without first having a referring doctor.
Exactly. PPO is usually a national network, so you can go anywhere in the nation and have out-of-network benefits. But with an Exclusive Provider Organization (EPO), you can go anywhere in the entire country, but it’s only in-network benefits.
With PPO, you have both in-network and out-of-network, but you have only in-network with EPO.
Would Visiting A Doctor With No Provider Lead To Payment Of Out-Of-Network Benefits?
Yes, the only exception would be an emergency. In an emergency situation, you will have in-network benefits. For example, visiting an orthopedic doctor in California to check your foot after a fall while under an EPO will require you to pay.
That is out-of-network. In the case of an operation for an appendicitis attack, that would be in-network.
While Dealing With PPOs, Are Deductibles Paid Before Insurance Comes Into Effect?
Not necessarily. The deductible will apply to major services. Under some plans, going to see the primary doctor or specialist for an office visit allows co-pay. Under some plans, seeing the chiropractor or physical therapist allows co-pay. The same goes for seeing a counselor, too, under some plans.
There are so many plans where some plans have these kinds of benefits and some plans don’t.
Co-pay could mean paying $25, $50, or $100 for that doctor’s visit while the insurance pays the rest.
Does Co-Pay Count Against Your Deductible?
It counts towards your out-of-pocket.
Do People Need To Pay Up Until Their Deductibles?
For an individual in today’s world, a low deductible is $1,500. The highest deductible is about $8,800. And that’s the highest out-of-pocket too.
When people ask for catastrophic insurance, I tell them that if their out-of-pocket is $8,800, then that is their maximum exposure in-network for the entire year. For example, suppose someone is diagnosed with cancer in the face of a divorce. Treating cancer with radiotherapy, chemotherapy, and surgery could have the $8800 consumed in two months. So for the rest of the year, the carrier would pay a hundred percent in network of those claims.
As a mom of young kids, I was always worried about broken arms in the kids or the emergency visit. Will those types of visits be paid out of pocket if you have a higher deductible?
Yes. So your deductible is part of your out-of-pocket today.
Those are all important things to look at when considering why an insurance option is so expensive. The individual could have a really low deductible, a low out-of-pocket, and a low co-pay, so that kind of policy will cost a lot more.
Yes. Basically, the norm is the lower your deductible, the sooner the care will pay your claims. And the higher the deductible, the more you will pay your claims until you reach your out-of-pocket.
Under Group Policy Insurance, Is Preventative Care Covered?
Under the preventative, it’s very clear and delineated, but again, it’s healthcare. Firstly, maximum out-of-pocket refers to the maximum out-of-pocket of approved claims as some might not get approved, leading to trouble.
Under preventative for women, examples are annual physicals, mammograms, and pap smears, and all covered a hundred percent. There are no co-pays for that. And for men under a certain age, we have a colonoscopy. Some of the carriers will cover that, and some will not. It just depends on the carrier, but that’s considered preventative too.
How Is An HMO (Health Maintenance Organization) Different From A PPO?
It is quite different as an HMO has significantly fewer positions specifically on the specialist side as opposed to the entire carrier’s network on a PPO basis nationwide.
So if an individual is in an HMO, such an individual will only go to HMO hospitals, be working within that system, and have no option to shop around.
Exactly. The most important part is that the HMO will have a primary care doctor who will know you very well. He will select a specialist for you in case you need to see one. You can research your HMO and tell your physician that you would like to see a doctor in the HMO. It can be difficult to get there, but the healthcare is not bad; it could just be restrained and restrictive.
One has to get comfortable working with their PCP (Primary Care Physician), and feel that they are really taking good care of you. That’s very key.
Would A Change In Location To Where One’s HMO Is Not Operating Require Searching For Another Health Insurance?
Yes. But if you move from Dallas to Houston, your HMO will still be operating since it’s your health policy in Texas.
What if I moved to California?
Your health policy would only hold for different areas in Texas. And so, if you moved to California, you would apply for their insurance since you have moved out of the realm your HMO operates in.
Can Group Policy Cover Sole Proprietorship Businesses At All?
It can cover a sole proprietorship, but at least two people have to be there.
Under Group Policy, Are There Any Other Types Of Insurance Apart From HMOs, PPOs, And EPOs?
Those are the types we have. There are PPOs, which have in and out of network and are nationwide. There are EPOs, which have only in-network and are nationwide. There are HMOs, which are regional. And there’s another plan created by one of the carriers. It’s very similar to an HMO and very regional, but I think it has more specialists than HMO. It’s always evolving and changing.
Does The Pricing Of A Group Policy Depend On The Health Of The Members Of The Group?
Considering Obamacare, one of its main goals is to remove pre-existing conditions. A company that has between one and 50 employees would have a fully insured plan where your first name, last name, and personal information are written, and no single health question is asked. Due to this, those plans will be more expensive as the insurance cannot assess the untold risks.
Can One Decide Whether Or Not To Be In A Group With No Health Risk Assessment?
There are two different options. The second one is when a company is fully insured, and the health history of the people in the group is assessed. A self-funded policy usually has to go back to five years past health history. But for the self-funded plans, you have to have at least five people.
For an individual with no health issues, choosing a group plan where the health history is assessed would be a great way to get health insurance, right?
Yes, the individual person will be put on the fully insured policy. There’s no other option for an individual.
Is The Self-Funded Plan Actually Self-Funded?
It’s interesting. It’s called level self-funded because your health risk will be assessed with about 20 questions, and rates will be given based on that. The lower your risk, the lower your rates. If your risk is too high, your offer for insurance will be declined. That’s at the self-funded level, and for such an individual to be fully insured will be the only option.
What Options Are Available To An Unemployed Person Unable To Get Health Insurance Through Their Spouse As A Result Of Divorce?
Such a person can then tap the individual market. The primary individual market is Obamacare, the healthcare created under Barack Obama in 2013. Its main benefit is subsidies that are based on an individual’s income. Presently, the subsidies are quite high.
For instance, I have a couple where the husband is a retired pilot, and the wife also worked with air traffic control. They just live off of their investments, and they earn a hundred thousand dollars off of it, which is good money for two people. These people can qualify for a subsidy.
So there is the chart that has eight different categories with how many people you have in your household and what ages. It can be very complex, but quite a bit of subsidy is offered in today’s world.
So the great advantage is that if you qualify based on income, you’ll have to pay much less for insurance.
What Benefits Are Covered On An Individual Obamacare Plan Versus On A Fully Insured Group Plan?
Basically, the same benefits. The beauty of Obamacare is that they wanted to make the plans affordable. But if the plan has a high deductible, then the plan is not really accessible to me. It depends on where you fall, your deductible and out-of-pocket can decrease, and your co-pay can be zero.
What Income Level Will Stop You From Getting Subsidies Or Benefits From The Lower Deductibles?
It depends on the chart, which is very complex.
Someone making more than $178,000 is probably not going to get a lot of subsidies.
In The Absence Of A Lot Of Subsidies, How Expensive Is It?
It varies on the product you buy and how many people the plan covers. For instance, in the case of a divorce, who will carry the insurance? Is it the husband that’s going to be carrying the insurance from now until the child turns 18 or 24 based on the divorce decree, or are the parents going to alternate the insurance on a yearly basis?
Unfortunately, healthcare will continue to go up. The other thing that is important to address is that the variables change, the out-of-pockets change, and the deductibles and copays can go higher.
Have The Providers Offering Those Services And Plans Also Been Shrinking?
It depends. Right now, we have much fewer networks and carriers than we had back in 2010. This is because the small players in the market at that time couldn’t assess the risk while they offered insurance to between one to fifty people; hence, they thought they could be out of business and sold their businesses to the bigger carriers.
Are There Any Options That Have Benefits For A Special Diagnosis Like Cancer?
There are some other options. For example, there are short-term policies and long-term policies. So with these, they underwrite you and ask you a few questions. Some carriers can offer them for up to three years, but if something happens within those three years, you still continue to pay your premiums, and you can’t get canceled. But if you want to, you can buy it for a specific amount of time.
It is very important to know about those products and what is really covered, so you don’t have any surprises. They’re good plans. Then we have what is called supplemental plans. This could be a little more tricky and complex to understand because different policies are put together. So you can have like three different policies where every policy has a different contract.
I’ve learned that not knowing what’s going to be covered can cause a lot of anxiety since you do not know what decisions to make or not to make when health issues arise. Our health is one of the most valuable things that we have.
It’s true. As I would say, ‘your health is your wealth.’ Without your health, one can’t work to make money, which is used to make payments.
What Does Healthcare Look Like For The Retired Person?
Actually, it’s very good healthcare, speaking in the context of Medicare. Basically, if someone has worked 10 years or more, then they’ve already paid enough for their Part A, which is the ability to access any hospital in the entire country. Part B is where you are able to see a doctor or get therapy. It entails in-office visits, not hospital settings. Part B depends, varies, and costs on how much you make.
And you have to opt into Part B or subscribe to that?
Yes, before one turns 65. Many people may send you all kinds of information, which can be very mind-boggling since you don’t know which way to go. The benefits are very good. Medicare works by covering 80% of the expenses, while you cover 20%.
That’s why it’s important to put something over that will cover that 20%. You can do that with a supplement, or you can do it with a Medicare advantage. The options will be selected depending on your needs. But in today’s market, the benefits are amazing for the cost.
Does Medicare Cover Nursing Home Care In Case You Need One?
It will only cover a hundred days.
All right. The great policy covers many things, but there are some limitations?
Yes. It won’t cover long-term care. And basically, a hundred days is what’s covered under the policy. For example, if you have a knee surgery done at the hospital, and then you are put in a rehabilitation facility because you can’t walk yet, the healthcare will cover that.
Do You Help People Navigate And Make Choices From The Various Options Available In Medicare?
Absolutely, because every day, 11,000 people or more are turning 65.
How Do You Get Paid?
The carriers will pay me my commission directly.
Can people consult with you and get their questions answered? And you’re happy to work with them to pick the best plans.
Yes, and if for some reason, I don’t have that product, I will direct them to a person I know that can offer that product.
I know that your heart is really in your work and you are committed to helping people find the right or best solution. I know this from people that I’ve sent to you, as you may not get any business off of them.
Absolutely. It’s about helping someone today, and you might help them again in the future, or they’ll send you a referral. It’s just my mission to educate people on all their options and really guide them to what’s best for them.
Right. Especially when there are so many options to navigate in healthcare, only a few of which we have touched on today.
It has been great having Isabel here today. We hope you will reach out to contact Isabel Gonzalez-Lawson to learn more about her practice and the guidance she has to offer. Thank you.