Off-Exchange Health Insurance Plans
Health insurance options outside of the Affordable Care Act/ ACA or sometimes referred to as "Private Plans" can vary. There are several a types of medical insurance plans that provide both short-term and long-term coverage for individuals and families who need immediate coverage.
These plans can be ideal ideal for people who do not qualify for a subsidized premium through the ACA, or ACA plans do not fulfill their specific needs in coverage, not offered health insurance through their employer, in between jobs and need to fill a gap in coverage, retired but pre-medicare, or various other circumstances.
These plans typically offer a range of medical benefits that include doctor visits, prescription medications, hospitalization, emergency care, ect. They are known for their flexibility. Unlike traditional health insurance policies, these plans may offer lower premiums and more customizable options based on your specific healthcare needs. Below are several examples of health plans we offer outside of the Affordable Care Act.
Short-Term Medical Plans
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.
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Short-term insurance may be the right choice for you if you’re:
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Waiting for open enrollment to apply for an Affordable Care Act (ACA) plan
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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
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Waiting for ACA coverage to start
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Looking for coverage to bridge you to Medicare
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Turning 26 and are coming off your parent's insurance
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Between jobs or waiting for benefits to begin at your new job
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Healthy and under 65
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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.
First-Dollar, Fixed Indemnity Benefit Health Plans
A fixed indemnity insurance 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 fixed, first-dollar or fee for service insurance. Indemnity plans can be great options 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.
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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 CHECK SHE RECEIVED.
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.
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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.
Healthcare Sharing 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:
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Are generally in good health
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Are not eligible for a tax credit based on income
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Lack access to insurance through an employer or government program
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Aren’t able to get coverage from missing open enrollment
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Only want/need catastrophic coverage
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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.
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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.
