All We Know (so far) About the AHCA

We wrote a blog post a few days ago regarding why we are no longer taking new clients in the Individual Market due to the decision by insurance companies to stop working with agents and/or stop paying commissions. We also mentioned that there are constant changes in this industry and we are doing our best to stay on top of them.

Today, we want to briefly touch on some of the important things to know about the American Health Care Act (AHCA) that passed through the House of Representatives last week. Please know, now is not the time to panic. The bill did pass through the House but now it goes to Senate. This will be an extremely long process as Senate will make changes to it and send it back to the House. IF the bill is approved, it will then be signed into law by the President.

We have already started to receive calls and emails from clients wanting to change their plan. We want to be sure to clarify: the American Health Care Act (AHCA) is NOT the law as of yet. The Affordable Care Act (ACA, “Obamacare”) is still the law. This means all the regulations and penalties associated with the Affordable Care Act are still law as well. 

Below is a chart summarizing and highlighting different provisions of the AHCA created by the National Association of Health Underwriters (NAHU) which we are members of.

AHCA

We will keep everyone up to date the more we know but as of right now, there are no windows to make changes to your health plan.

For questions, comments, or concerns feel free to leave a note below or give us a call.

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The times they are a-changin’

frustrated

Let me preface this by saying, this post will not be a post where we bash companies or have any kind of negative comments; we will not be name dropping any of the carriers. The point of our blog is to keep people informed by giving them truthful accounts of our experiences. Many of these circumstances are out of our control but trust me when I say, we hear your comments and concerns and are hopeful things will turn around.

Today’s post is regarding why so many Texas (we are only discussing Texas changes in this post) health insurance brokers are no longer offering Individual/Family health plans. You or someone you know may have called a local broker to get quotes for a health insurance plan for yourself and/or your family only to be told “Sorry, we no longer work in that market. You will have to call the insurance company and/or the Marketplace directly.” This leaves many people frustrated and confused and we totally get it!

This year, our agency had to make the tough decision to stop taking on new clients in the Individual/Family market. This was indeed a very difficult decision for us to make. What we love about being brokers is that we are able to offer multiple products to give our clients unbiased options for a plan that suits their specific needs.

Before we dive into this topic too deeply, let’s rewind to 2015. In 2015, one of the insurance companies that offers health insurance plans in the Individual/Family market made the announcement that they would no longer offer PPO plans in the State of Texas (other states as well but this post is only about Texas) and would only be offering HMO plans for 2016. This was a huge and disappointing announcement for many people – we received A LOT of frustrated calls and emails. After this announcement, many other insurance companies in Texas decided to follow their lead and stopped offering PPO health plans as well.

What is a PPO plan you ask? This definition of a PPO is taken directly from healthcare.gov: Preferred Provider Organization (PPO) – a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost. 

Nutshell definition: A network plan that allows you to go in and out of network and does not require referrals from a Primary Care Provider to see specialists.

For a better understanding, let’s also look at the definition of a HMO. This definition is taken directly from Healthcare.gov as well: Health Maintenance Organization (HMO) – a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Nutshell definition: A network that requires you to stay in-network for services received and typically requires referrals from a Primary Care Provider to see specialists.

Now, we cannot speak poorly of the decision to no longer offer PPO plans in Texas. There are MANY factors as to why some of these carriers made the decision and we see all sides of the spectrum. However, we had to make the best of the situation to do what we could to remain compliant and still be able to work in this market for 2016. Luckily, we were still able to provide multiple options and assist our clients for 2016 plans.

However, things changed for 2017 health plans. In 2016, many carriers made the decision to either stop working with agents entirely or stop offering commissions during certain time frames for 2017 health plans. Now, we don’t want to sound greedy or selfish but we do still have to make a living. This was a huge blow and disappointment to brokers. We pride ourselves on being able to take time to explain plan benefits, service clients’ plans, and be a go-to source for consumers. We want our clients to call us before they call a 1-800 number; we don’t want them to feel they are on their own when it comes to their health insurance. The decision to no longer work with agents and/or no longer pay agents for their job stripped away our ability to be a broker because we are no longer able to provide multiple options to our clients.

As mentioned above, it was an extremely hard decision to choose to turn people away for Individual/Family health plans. For our clients that are eligible, we can still assist with a group health plan. We are also helping any of our clients that are approaching Medicare eligibility and we also still offer supplemental plans like: accidental, dental, vision, etc.

We are hopeful that we will be able to help clients again in the Individual/Family market soon. We do our best to stay informed and up to date on the changes in the insurance world – and trust me, there are ALWAYS new changes. We wanted to write this post to give people an explanation as to why we decided to make this decision that we hope is only temporary.

If you have any questions or concerns, please feel free to comment or give us a call! Just know, we are constantly staying on top of changes and doing our best to be able to provide our clients with Individual/Family health plan options again.

True Story: 1

Today we wanted to share our first true story of an experience we had with one of our Medicare clients recently. Short disclaimer, all names and sensitive client information will remain anonymous to protect client’s identity.

This client signed up on a Medicare Supplement (Medigap) plan F when they were first eligible for Medicare. Before we jump into this story, it’s important to understand how a Medigap Plan F works.

What is a Medicare Supplement plan? It is a type of health insurance plan sold by private insurance companies to cover the gaps in traditional Medicare. Thus where it gets the term, “Medigap”. When someone chooses a Medigap, original Medicare remains primary and their Medigap plan is secondary. The Medigap plan helps to pay for costs that would normally be the client’s responsibility under traditional Medicare such as copays, coinsurance, and deductibles. With Medigap plans, Medicare pays first then the Medigap plan steps in and pays its share. Depending on the Medigap plan selected, this could mean the remainder of a bill.

In this post, we are talking only about Medigap Plan F. Take a look at the chart below that shows the Medigap Plan F benefits:

Medigap Plan F

As you can see, Medigap Plan F pays for all the gaps in traditional Medicare Part A and B (Part A deductible and Part B outpatient deductible, Part B 20% that Medicare does not cover, excess charges, etc) Typically, this means anyone on a Plan F should not receive any bills for out-of-pocket costs from their providers.

Now, let’s get back to the story of our client. This particular client went to their provider and had to have lab services done. Lab services fall under Medicare Part B. The client showed the provider their Medicare ID card as well as their Medigap Plan F insurance ID card but still received a bill from their provider for $250. The client, worried their bill would go to collections, paid their provider the $250.

The client then remembered our previous conversations we had about their Medigap Plan F and called me to tell me of their scenario. I explained the bill was likely sent to them in error and possibly never made it to their Medigap Plan F insurance company. We called their insurance company and not only did they receive the claim, they had already paid it and showed the check was cleared. So, the client’s provider was double paid for the same service!

At this point, the client was understandably upset that no one from the provider’s office caught the error and reimbursed them for the services they were not responsible for. I made it my goal to ensure the client received all of their money back from the provider. We called the billing department for the lab every week for 2 months reminding them the client was owed their reimbursement. During this 2 month period, the lab took new ownership and had a total turn over on employees. It appeared that each time we called, we spoke to a brand new billing representative and had to state our case all over again. Though we were frustrated, we did not give up!

Eventually, the client was feeling defeated and called me to say that they had given up on the idea that they would be reimbursed their $250 and that maybe we should just forget about the whole situation. I, however, did not want to throw in the towel. It was important to me that they receive their reimbursement for a service they were not responsible for in the first place.

After about 3 months, the client FINALLY received their check in the mail from their provider for $250. The client called me elated and grateful that I, their insurance agent, took the time to help them and would not give up until they received the $250 that they were owed.

This story is a good example of a simple billing error that can cause issues and frustrations. The client was not responsible for the bill but was nervous of it going to collections and paid it any way. Typically, I advise my clients who have a Medigap plan to give me a call if they ever get a bill for services they receive before they pay it. This way we can review it together and possibly help avoid paying for something that may not actually be their responsibility. It is always a good idea to clarify!

We hope this post was helpful to anyone who may face similar situations. If you have any questions or concerns, please feel free to reach out.

I know it’s only Thursday, but have a great weekend everyone!