Blog Archive

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UnitedHealth to Exit Obamacare in 16 States to Stem Losses

UnitedHealth Group Inc. will drop out of government-organized health insurance markets in at least 16 states as the U.S. industry leader tries to stem losses from participating in Obamacare, the healthcare overhaul that has brought coverage to millions of people. Read more here.

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Figuring out if your Doctor is in-network can be a CHALLENGE

We here at Texas Medical Plans, continuously hear from our clients that they have difficulty verifying whether or not their doctor is in-network with their health insurance provider. We hear things like: “I found my doctor on the health insurance company’s website, but the doctor’s office says they do not take it” or “My doctor is in-network but the hospital that they are preforming my procedure at is out-of-network” or our favorite “My doctor’s office says they do not take Obamacare” (NOTE: All the health insurance plans offered now, the health insurance plans that keep you from having to pay a tax penalty, are “Obamacare”. This means that the plans now meet the regulations set forth by the Affordable Care Act (ACA)).

Changes in the health care industry have people confused, misinformed, and FRUSTRATED! I know you may not want to hear this but WE UNDERSTAND! I could write a book about all of the difficulties I have had with my own health insurance. Yes, you would think that a health insurance agent would not have insurance issues, but that is not the nature of the individual health insurance industry these days.

Just one example: I took to my daughter to a doctor, whom I confirmed was in-network with my health insurance carrier and the doctor’s office prior to the visit. I paid the specialist copay as usual. I later received a bill for the office visit. Keep in mind this was an initial visit to examine my daughter and discuss treatment options. No testing was done in this visit. We saw the doctor in his office, which was in a building right next to the hospital, but it was billed out-patient. Apparently, because we did not see the doctor in the hospital it was out-patient and went towards the deductible verses the specialist copay as previously confirmed.

I think that if we had seen the doctor in the hospital as in-patient that we would have seen an additional bill from the hospital/facility. A lot of times you will see a doctor that is in-network, but the facility/hospital the doctor performed the procedure in was out-of-network. The only explanation I can offer you is that they are separate entities and they have separate contracts with different health insurance companies.

So, what does this all mean for you? You have to do your best to be educated and proactive. We suggest the following:

  1. Know your health insurance plan. Know if you have copays, coinsurance, what your deductible is and your out-of-pocket maximum. Do you have an HMO or a PPO network? Did you know that an HMO network requires prior authorization from your primary doctor before you can see a specialist? Health insurance can be confusing! The health insurance agents at Texas Medical Plans do our best to make health insurance simple for our clients.
  1. Check with your insurance provider. Call your health insurance company to confirm a doctor, facility, lab, anesthesiologist, the person that pokes their head in for 5 minutes to check on you while you are in the hospital, etc. is in-network. Keep detailed notes about your conversation with the representative, including who you spoke to, their department, get a reference number if possible, the more information you can record the better. Get pre-authorization when possible. If you have an upcoming procedure find out how each party (doctor, facility, etc.) codes it on their bills and check those codes with your insurance company. Does that procedure go towards your deductible and can they give you an idea of how much it will cost you? This keeps you from being surprised and also helps you to check the bill later for errors.
  1. Communicate with your doctor! Ask your doctor questions like are you in-network. How is this billed? What codes do you use when billing? Is this preventative? Sometimes we see where a client goes in for their physical (covered 100% under preventative care) but then they ask about a medical issue . . . now the doctor is addressing an issue and the visit is no longer preventative. Every doctor is different though. The list of questions can be endless and it really depends on the situation. The health insurance agents here at Texas Medical Plans encourage our clients to have open communication with their doctors and get an idea of what their billing process looks like.
  1. Check your Explanation of Benefits (EOB) and your bill. Compare your EOB and bill to see if they look correct. There are so many medical codes out there now that we constantly see errors in the way people are billed and errors in how health insurance companies process claims. Everyone is doing their best to process things correctly, but nothing is perfect. If you don’t understand something, ask your doctor’s billing department and ask your health insurance carrier. At the end of the day it is your money being spent so do your best to know exactly what it is being spent on.

It can seem like a full time job staying on top of your health insurance. Do your best and remember there are health insurance agents like us here at Texas Medical Plans that can help you to understand your health insurance and how it can work for you.

Courtney Mecklenburg

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Insurance and Being Prepared for a Natural Disaster

Risks Associated With Natural Disasters

When people consider insurance for a natural disaster it is generally about home and contents insurance, but it is important to consider life, health, and disability insurance as well. Some insurance risks associated with natural disasters include:

  • Underinsurance. Make sure you have the right level of coverage when it comes to home and contents.
  • Life insurance. It is important that you have financial protection in place in case something were to happen to you. Having a life insurance policy that protects you in the event of a natural disaster can help to secure your family’s financial future.
  • Effects on your health. It is important to have health coverage in the event you are injured. Even if you are unable to afford a comprehensive plan you should at least have a plan that covers catastrophic or severe injury or illness.
  • Having no income. If you were injured during the disaster and are unable to work, there is the challenge of rebuilding the damages and taking care of your family. Try to find a disability or life policy that offers income protection either as a standalone policy or an optional extra.

Ways You Can Plan Ahead of a Natural Disaster

It is imperative to be prepared for these situations in order to minimize the risks you and your family could face should disaster strike. There are a few simple things you can do to make sure your family is protected in the event of a natural disaster:

  • Check your health insurance: Know your options if you need medical care away from home. HMO plans may have area limitations to where you can seek medical attention, know what they are. Spend some time now gathering your health history and benefits information. And you’ll save yourself a lot of time and headaches if you’re ever forced to leave your home. Try filling out this Personal Health Information Record document. You can list doctors, medications, allergies and more – for you, your family and your pets, too. You can also attach copies of insurance cards, plan policies, prescriptions and immunization records for the whole family.
  • Check your life insurance: Review your plan to make sure that you are covered against natural disasters. Make sure you have sufficient coverage in place and a clear understanding of what will and will not be covered. Similar to your policy features , it is important to understand that policy exclusions also vary between providers.
  • Prepare for income loss: If you are injured during a natural disaster how will you support yourself and your family? Have disability coverage in place to cover you in the event you are not able to work.
  • Check which disasters your home and contents insurance covers you for: Policies vary, so knowing exactly what you’re covered for will help you avoid nasty surprises.

Prepare for the worst situation

Expect the best, but prepare for the toughest situation Mother Nature can throw at you. Prepare an evacuation box. It should be fireproof, with a lock. And small enough to grab it on the go. In it, store all your important financial documents, including legal papers, bank account information and insurance policies.

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You can still get 2015 health coverage until April 30, 2015

Open Enrollment for a 2015 Marketplace plan ended February 15, 2015, but you may still be able to get coverage.

DO YOU OWE THE FEE FOR NOT HAVING COVERAGE IN 2014? YOU MAY STILL BE ABLE TO ENROLL IN 2015 COVERAGE IF:

  • You didn’t know until after Open Enrollment ended on February 15, 2015 that the health care law required you and your household to have health coverage, or you didn’t understand how the requirement would impact you and your household
  • You owe the fee for not having coverage for one or more months in 2014
  • You are not already enrolled in 2015 coverage through the Health Insurance Marketplace or outside the Marketplace

Please note:

  • Even if you get coverage through this Special Enrollment Period (SEP), you may have to pay the 2014 fee for the months you didn’t have qualified health insurance
  • You don’t need to have filed your 2014 taxes before enrolling with this SEP—you just have to owe the fee
  • If any person in a household meets the criteria for this SEP, everyone in the household can enroll with it

If you have certain life changes you may qualify for a Special Enrollment Period. If you do, you can enroll in a Marketplace plan outside the annual Open Enrollment period.

Life events that may qualify you for a Special Enrollment Period:

  • Getting married or divorced
  • Having a baby
  • Adopting a child or placing a child for adoption or foster care
  • Losing other health coverage
  • Permanently moving outside your plan’s coverage area
  • Gaining citizenship or lawful presence in the U.S.
  • Gaining or continuing status as a member of an Indian tribe or an Alaska Native shareholder.
  • Leaving incarceration
  • For people already enrolled in Marketplace coverage: Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions

You may be able to enroll in coverage through Medicaid and the Children’s Health Insurance Program (CHIP). There’s no limited enrollment period for these programs, which provide free or low-cost health coverage to millions of these groups, and they can change plans as often as once a month.

If none of these work for you there are other options like short term and accident only plans that can give you a safety net if you cannot get or do not want a qualified health plan. You can also enroll in 2016 health coverage during the next Open Enrollment period. The Open Enrollment period for 2016 is November 1, 2015 to January 31, 2016.

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Countdown to Enrollment- 8 days

8 days until open enrollment. Sign up for insurance 11/15-12/15 in order to get a 1/1/15 effective date. All Affordable Care Act (ACA) plans include these essential health benefits:
1. Outpatient care—the kind you get without being admitted to a hospital
2. Trips to the emergency room
3. Treatment in the hospital for inpatient care
4. Care before and after your baby is born
5. Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
6. Your prescription drugs
7. Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
8. Your lab tests
9. Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
10. Pediatric services: This includes dental care and vision care for kids

Certified on Healthcare.gov – The Federal Facilitated Market Place
FFM User ID: homerg NPN: 1127503

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Recent News About ACA Subsidies

Two contradictory rulings have recently been issued by federal appeals courts on whether people enrolling through Federal Marketplaces (like in Texas) are eligible for subsidies to help pay for their coverage.
The Fourth Circuit Court of Appeals (Richmond, VA) ruled that individuals enrolled through Marketplaces established by the federal government are eligible for subsidies. The D.C. Circuit Court of Appeals ruled that subsidies could go only to individuals enrolled through Marketplaces established by states.
In both cases, a review by the full panel of judges on each of these Circuit Courts is almost certain to be requested, and appeals to the Supreme Court are likely if the lower courts remain split.
The law remains unchanged and current subsidies will remain in place until the legal case plays out, which I likely not to be until mid 2015.
For now, individuals will continue to get their plans subsidized for 2014 and 2015. If it is found by the courts that individuals purchasing on the Federal Exchange are not eligible for tax credits they will thereby be exempt from the individual mandate penalty as well as any employers over 50 that may have been required to offer coverage to their employees.*

*This document is for general informational purposes only. While I have attempted to provide current, accurate and clearly expressed information, this information is provided “as is” and Texas Medical Plans makes no representations or warranties regarding its accuracy or completeness. The information provided should not be construed as legal or tax advice or as a recommendation of any kind.

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Qualifying events can make you eligible for health insurance

Qualifying events can make you eligible to sign up for health insurance

Qualifying events can make you eligible to sign up for health insurance

Are you interested in signing up for a Texas health insurance plan, but not sure if you’re able to? For most Texans open enrollment is closed; however you can qualify for Marketplace Insurance Coverage if you have had some major changes in your life.

Open enrollment for Marketplace Insurance Coverage closed at the end of March, but under certain circumstances you can still enroll in a Texas medical plan. Known as Qualifying Life Events, these changes will make you eligible for a Special Enrollment Period. Qualifying Life Events include moving to a different coverage area, certain changes in income and changes in family size, such as adopting a child or getting a divorce.   

If you’ve had a major change in your life and need to enroll or make changes to your Texas health insurance plan, call us, there may be options. Short-term coverage is also available if you need coverage but have not had a Qualifying Life Event. While short-term insurance will not fulfill your responsibilities under the Affordable Care Act, it will help you pay for what can be devastating medical bills.  

 

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Preventative Services are an essential benefit

The Affordable Care Act requires that insurance plans cover 10 essential health benefits. This requirement is designed to help ensure that your Texas health insurance is there when you need it most.

One of the most popular benefits has proven to be the preventative health screenings. This benefit is actually a series of benefits, all designed to help you take control of your health.

While many of these screenings, vaccines and counseling were previously available, the Affordable Care Act mandates that they be offered to you free of charge, with no co-payment or co-insurance, no matter what your deductible may be.

These screenings include diabetes, blood pressure and colorectal cancer screening. Also included are screenings for depression and alcohol misuse as well as obesity and diet counseling. A wide range of immunizations for adults are covered, including hepatitis, pneumonia, influenza, varicella, tetanus and many more recommended vaccines. 

Health insurance in Texas offers many benefits, the greatest of which is the peace of mind of knowing that your finances are secure should your health needs increase. If you have any questions about your Texas medical plans, please contact us today. 

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Medicare Insurance Plans can help

Medcare supplements fill the gap

Medicare supplement insurance plans help seniors plan

Medicare supplement insurance plans help seniors plan

Once you’re eligible for Medicare you don’t have to worry about insurance, right?

It’s not that simple.

While Medicare does provide a great foundation of insurance for seniors, it doesn’t cover everything. Seniors who rely solely on Medicare to fund their medical expenses quickly find out that their financial situation is looking grim. Uncovered expenses can quickly expand into thousands of dollars. Most seniors are discovering that they need a Medicare Supplement plan to pay for those uncovered expenses.

A Medicare Supplement plan acts as a secondary insurance to Medicare, stepping up to pay where Medicare only partially does. Sometimes referred to as Medigap insurance, since it pays for the “gaps” in Medicare, these supplements plans are widely available. You can enroll in a Medicare Supplement plan three months before your 65th birthday, as soon as you enroll in Medicare and benefits will start on the first of the month in which you were born. These plans are offered by the same companies that offer traditional health insurance: BlueCross BlueShield of Texas, Humana, Cigna, Aetna and Mutual of Omaha.

For more information about determining which Medicare Supplement plan is right for you, call Texas Medical Plans today at (888) 750-3164.

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Getting the most out of your insurance

Now that you have a medical insurance plan in Texas, there are several ways to help keep your out of pocket expenses in line with your budget.

Whether your Texas medical plan includes a PPO (preferred provider organization) or an HMO (health maintenance organization) your costs will be lower when you chose a doctor and hospital that is within network. Not sure if your chosen provider is within your health insurance network? When you call to make your appointment, the physician’s office staff should be able to help you, just have your medical insurance plan card for reference.

Your medical insurance plan should also provide prescription coverage. Like many things, you’ll get the best deal when you choose generic options. Generic prescriptions have the same formulary as brand-name alternatives, without the expensive marketing costs. Because of that, they are much cheaper for the consumer. Be sure to tell your physician you would prefer generic options whenever possible.

One of the most expensive options for care is the hospital emergency room. Most Texas health insurance plans have a minimum deductible for emergency room visits. You can help avoid those costs by choosing to visit your regular physician whenever possible. In a life-threatening emergency, of course the emergency room should be your first line of defense.

PO Box 1270 Wimberley, TX, 78676
15577 RR 12 Wimberley, TX, 78676

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Phone: (888)750-3164
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