Insurance Talk – Affordable Healthcare Act Part 2

Insurance Talk – Affordable Healthcare Act Part 2

Rex and Cheri have the answers. Listen here.

Insurance Talk — Learn About the Affordable Healthcare Act Part 2

Cheri Martinen – You are listening to Insurance Talk with Cheri Martinen and Rex Lesueur. We’re the father-daughter team from Bancorp Insurance located in beautiful Central Oregon. Our family-run insurance agency is here to help you with all of your insurance needs — home, auto, commercial as well as your Medicare and health insurance needs. You should call us.

Rex – If you’re talking about health insurance and you’re confused and if you’re not confused, you’re hired. If you’re not confused and you have a health insurance license, give us a call. We’ll get you set up really fast.

CM – We’re talking about health insurance. This is actually our second show about health insurance, so if you missed the first one, you can find it on our website at www.bancorpinsurance.com. It’s underneath our blog tab and we have all of our podcasts and all the radio shows we do there. Yeah. So yeah, you can listen to it and you can listen to anytime.

Rex – We’re going to do two possibly three shows on health insurance.

CM- It’s a big topic and it seems very simple, but once you get into it, it’s like an onion.

RL- You know, you peel off the one layer and then you see another layer, and then you peel off that layer and there’s another layer, and then you closer to the middle of this and it makes you want to cry.

Searching for Health Insurance on Healthcare.gov

CM – So we were kind of talking about the different levels of the plans and how the deductibles and maximum out-of-pockets work and the copays. And we went through more of the bronze and the silver plans. And we talked a little bit about the ACA or the affordable healthcare act and how it changed really the entire way we consume or buy health insurance, even how we compare them, right?

RL – Yeah, we do it online, we no longer have Cover Oregon. CM – So one of the things that I always like to bring up for our customers is that they might see a really, really great price on healthcare.gov. So we’ve gone into healthcare.gov we’ve put in some of the rating criteria that we’re going to ask about, which is going to be, you know, what’s your date of birth so they can get your age, they’re going to ask if you use any tobacco products. Then they want to know how many people are in your household and what’s your income size. And once we do all this and we get everything, they give us all of the quotes pretty much and it’s a list of how much each plan would cost and then what you would have to pay in the event that you had a claim, which would be like going to the doctor.

RL – Whether it has a big deductible, like a bronze plan, which would have a maybe a $7,000 deductible and which is also the same as the maximum out-of-pocket or maybe a silver plan which may have a $3,000 deductible and more cost-sharing in the middle. So, depending on how quickly you’re consuming healthcare, as to when you would reach that maximum out of pocket.

CM – And then also what you’re budgeting for your healthcare if you think you’re going to use a lot of your insurance and you just want to hit that deductible as quickly as possible, the bronze, you’ll probably hit the deductible faster than the silver, but the silver, you’re not making as big of payments all upfront. And the same with the gold. The gold is also a good plan because of that has even a smaller deductible. So you hit your deductible faster and then you have that cost-sharing for a longer period of time.

RL – Because the maximum out of pocket might be the same. It just depends on how fast you get there. So if you’re going to have a $100,000 worth of bills, you’re going to get through that maximum out of pocket. If you’re going to have $10,000 worth of bills, well then it’s a whole different story. Then you have to factor in the fact that the plans, each have a different cost. Obviously the higher deductible and the sooner in the plan, the lower the cost of the plan. That’s why this is complicated. Don’t do this on your own folks, call for some professional help.

CM – So a lot of people look at the printout, right? And they go, well, duh, I’m gonna pick the cheap one. Alright, okay, cool. Great job, shopping over. But it’s not and it’s not over. Because we have doctors we like to go to and all of these companies have doctor networks and so if your doctor isn’t in the network of that company, then you’re paying out-of-network costs, which can be a lot more expensive.

That’s one of the things I always like to tell my customers to do or I do with them. As I say, who’s your doctor? Who are you going to? What clinic do you go to? If you get sick, let’s look them up in that provider and make sure that they’re covered because there’s nothing like going to your doctor and handing him the card and they go, great, I’d like to see that bill paid in full. Please. Not a good thing. One of the other things to look at is if you do need additional services like maybe you need to go to OHSU, you make sure that’s in-network because not all the plans will have all of the hospitals in Oregon in-network. Some of them will. So that’s something to keep in mind. Are there things that are kind of hidden costs, you could say, are pre-approvals.


RL – Oh yes. The topic of pre-approvals. I always, always love my friends who, you know, say, well we can’t have socialized medicine because the government will be making a decision as to, you know, when and where you could have healthcare and with whom. And then I say, well, you know, there’s not a whole lot different than we have right now where if you have health insurance, the health insurance company tells you whether or not you can go and whether or not you’re going to have the care.

CM – Yeah. Your doctor might say, I’d really like to send you to Dr. X or Dr. Y and then the doctor has to put that into the health insurance company. And the health insurance company say, ‘Oh, you’re going to go to Dr. Y because he’s in-network or because we contract with that individual.

RL – Then there’s a good chance that the company might say, no, we don’t think you need surgery yet. You need to go through 40 more visits to a physical therapist to see whether or not they can go on.

CM – I mean even pre-approvals on tests and things like that. Like, do you really need a cat scan? And you’re like, well yeah, my doctor ordered it. They’re like, well, we’re not going to pre-approve it.

RL – Then they have to go back to the doctor and the doctor has to write them a long copious memo about why it’s needed. And then more than likely they will be approved, but it might be a while and, of course, you’re walking around in pain for a month while they do it.

CM – Give, us a call at (800) 452-6826 for questions on health insurance. CM – We’re going to continue our talk on kind of those hidden costs or shopping things you should look at when you’re looking at health insurance and this is individual health insurance through healthcare.gov and you can also buy it directly through the company.

What are Medical Homes?

CM – Anyway, we were talking about the pre-approval. Nobody likes pre-approvals. Okay. We got it. Yeah. One of the other things that I always tell my customers to look at is if, some companies like to use “medical homes” and you can’t see me right now, but I’m like literally holding up my quotation marks “medical homes”.

RL – Okay. It’s an actually defined phrase.

CM – What’s that mean? And does it matter? So for some individuals, it means that they have to be seen by a doctor in a specific location. So you can’t just go to any clinic. And say, “Hey, I’m here, I’m sick. Take care of me,” because it won’t be covered cause you’re not in the medical home. And the idea of the medical home is that you’re going in and you’re getting all of your care in one building, one house. Hence the home thing.

RL – It’s a version of the HMO – health maintenance organization, which has been, loved and vilified, down through the last three decades. I remember when the first HMO came out, I was living in New Jersey and we had one and I had to go to a doctor that was like 30 miles away because that was the doctor for the HMO.

CM – And that’s kind of how it is. That’s kind of what a medical home is. You have to make sure that if you are seeing a doctor in your medical home, so if you live somewhere in Central Oregon, you better make sure that your medical home is nearby. Or you could be driving 30 minutes or 45 minutes or paying for the benefit yourself. Paying out of networker or a high copay or having to pay more money and it’s not going to be covered by the insurance because you’re not going to that medical home and getting that referral or getting those services within that building.

RL – In the larger context, when you’re buying health insurance, you need that. There’s always a doctor list. Check to see whether your doctors on the list, please do it because huge, because literally, we’re doing this between the November 1st and December 15th. Once you make a decision, you’re stuck with it for a year. If you don’t check the see that your doctor has a relationship with the insurance company you choose, it’s going to cost you.

Drug Formulary

CM – And another one I always like to tell people to check is the drug formulary and you might think, Oh yeah, whatever.

RL – Let’s talk about what is a formulary?

CM – It’s a really fancy name for a long drug list and these are pharmaceutical drugs, not recreational. These are the ones you get from the doctor. But you know, one plan might put your drug in a tier-one, which is just a fancy way to say it’s generic and they charge you less at the pharmacy or one drug might put it as a tier-three and you’re paying three times as much to fill that prescription drug that you would have paid on a different plan. There’s different in and out of network pharmacies. Maybe it’s cheaper to pick it up at Costco or Walmart or it’s cheaper to pick it up at your local drug store. You never know exactly where you’re going to be. Now, something else they do, they can change them. They changed them all the time. So if you think, you know, you go through a year and you’re taking a certain drug and you know it’s costing you a $10 copay every time you’d go and you don’t come January time to fill your prescription, it could be $50 and they don’t have to tell you. Please check those things.

Why is it Called the Affordable Healthcare Act?

CM – I am going to go into the next part, which is probably the biggest part, the reason why we call the affordable healthcare act “affordable healthcare” is because if you go through the affordable healthcare act, you will be putting in your income information as well as your household size information. And at that time the computer does its job and says, is the health insurance that is on the market now affordable for you and your family? If you’re having multiple people enroll at the same time. So say it’s you, a spouse and three children. Now the three children might be on Oregon Health Plan and maybe they don’t need coverage.

RL – I think 90% of the children in Oregon are qualified for the Oregon Health Plan.

CM – So a lot of times we’ll see the kids on Oregon Health Plan and then the parents will have to get insurance through healthcare.gov. So, that’s a family of five. And I actually have my spreadsheet here. So a family of five could start seeing cost-sharing if their annual gross income is higher. Well, it’s between $44,000 and $117,000 a year. If you’re in between that range, which is a really big range. You can receive help to pay for your health insurance, making it “affordable”. Hence again, the name

RL – If you think we’ve what we’ve been talking about in the first two segments is complicated, boy, wait until we get you into the third segment.

RL – We’ve been talking about health insurance for a couple of shows now. Well, actually we did like three shows on Medicare. A couple shows on group health. Now, we’re into our second show on individual health insurance. This is complicated, you know, don’t do this at home.

CM – What we were talking about right before we took a break was, what makes the affordable health care act affordable and why would we care?

RL – Well, the reason is that depending on what your income is, the government will actually help you pay for it, which is great.

CM – So they look at your income and they say, based on your income and the number of individuals in your household and your age and smoking and other things that we put into the computer, they will give you a certain amount of money every month to help pay for your insurance. So in the end, what it looks like is the health insurance company says this plan cost, let’s just say $500 to make it easy. Because of your income, the government is going to pay $250, so half of the cost. That means that the individual who’s getting the health insurance then has to pay the rest, the $250.

RL – And we’ve seen situations where the individual can pay as little as $10 of that $500.

CM –  I’ve seen multiple individuals under $20 for a, yeah, it’s under $20 a month for a plan that originally might cost them $700 or $800 a month. So that’s really, really big savings and it’s making sure that they have that maximum out-of-pocket. And one thing we haven’t touched on, we touched on the silver plans and kind of how they had that cost-sharing, but if you are in a certain income bracket, they also have something that adds additional savings onto a silver. So they make the silver even less money than a bronze a lot of times. And then they lower the deductible and they lower the maximum out of pocket and they lower those copays so that individuals that are in a certain income range really are getting a good healthcare plan.

RL – Right? So if you’re low income and you think, Oh my God, I can’t afford health insurance. Pick up the phone, go online, figure it out. You might be able to.

CM – You might be able to afford a lot more coverage than you think. Then you’re covered for that, “What if?” That big catastrophe or just like you said, an appendix or something.

RL – About 70% of all individual bankruptcies in this country are because of health insurance costs.

CM – This is something that’s extremely affordable. It really does make health insurance affordable. I can’t say it enough. Do the shopping, go on to healthcare.gov and at least look at it. Don’t be too afraid.

RL – One of these do to be aware of is this income thing. So you’re going to be making an estimate of your income? Okay. People change jobs. Their income might go up during the year, their income might come down. If there are any changes in your income, you need to let the ACA know, let us know so we can go on that and adjust your income online. Because what’ll happen is, is if you tell the government that you’re making $30,000 a year and you get a nice big fat raise and you’re making $40,000 a year, well that $35 you’re paying a month for that insurance policy might go to $65.

CM –  This is actually pretty tricky and this happens a lot to my customers when they get a raise or sometimes maybe they switched careers and get a better job and so they see more out or maybe they just see more hours at the location they’re currently working. The federal government, again, they’re doing that calculation when we enroll to say, is your health insurance affordable based on your income? If your income goes up and you report that on your taxes at the end of the year, the government’s going to say, we gave you too much help. We gave you too much help throughout the year on your health insurance. And so they’ll take that money back. They’ll take it back at the end of the year when you do your taxes, there’s no cheating the system here guys, you must do your taxes.

RL – We had a guy come in a couple of weeks ago and he had a great price, but he’d got a very large settlement on a workers’ comp case. He went from having a very nice subsidy, several hundred dollars a month to zero. And they’ll ask for that $1,000 and at the end of the year, so be on your toes on this.

CM –  And this is one of those ones where I get people coming in all the time and they say, well, what’s counted as income? You know, your self-employment, your regular job. If you sell a home that’s going to be income, social security payments, that’s income. If you’re taking draws for from retirement, that’s also income.

RL – If it goes on a tax form, it’s income.

CM – Rentals. If you’ve got rentals and you’re getting income from the rentals, that’s also income. Because that’s when people get really angry when they file their taxes and they say, well that government said I was affordable healthcare, but now they’re taking it all back.

RL – The government’s point of view is, well we’ve got to set boundaries and set prices and that’s how they do it.

You Can Afford Health Insurance

CM – Again, Affordable Healthcare Act, you can go online and try it yourself at healthcare.gov or if you want assistance looking through the plans and really deciding on, you know, is my doctor and network do I have what’s going on for my medical homes, what’s going on for my drug costs, what’s going on for my deductible, the formulary. Probably my number one question I get is how can I even calculate my annual estimated gross income? You know, just even sitting down and doing that. And this is for your whole household. It’s not just for you. So it’s going to be for your spouse, yourself, and maybe if you have children working that are still on your taxes, it’s going to be for everybody in the household. So call us. I think Rex said it 10 times. Don’t do this alone. 1-800-452-8626. This is our busy season because open enrollment starts November 1st and ends December 15th. Don’t wait till December 14th to call me.

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