The Affordable Care Act (ACA) has created instability in the individual market, which has resulted in a dramatic escalation of premiums and an exodus of carriers providing coverage. The lack of carrier competition has reduced plan options and limited provider network availability. Consumers have been asking for coverage options outside of the ACA and UnitedHealthcare has responded by introducing Health ProtectorGuard, a hospital and doctor fixed indemnity insurance policy.
A fixed indemnity plan provides the consumer with a predetermined cash benefit, paid directly to the consumer, based on the medical service received by the provider. It is important to understand that a fixed indemnity plan, including the UnitedHealthcare Health ProtectorGuard, is not compliant with the ACA and does not provide the minimum essential coverage as required by the ACA and may result in an additional tax liability.
The benefit of Health ProtectorGuard is the premium reflects a level of benefits that a large segment of the market deems necessary for their particular health situation. Health ProtectorGuard premiums do not reflect the mandated benefits as required by the ACA that many consumers do not want or need. For example, benefits related to maternity, mental health, substance abuse, and preexisting conditions are not provided by Health ProtectorGuard, which translates into a lower premium. What Health ProtectorGuard does provide is a more comprehensive and enhanced benefit offering than other indemnity plans with a premium that is substantially less than an ACA compliant plan.
Health ProtectorGuard provides varying levels of benefits in the following six benefit categories.
Doctor Visits – a $100 payment is made for doctor visits. Depending on plan selected the payment is made for either two visits or five visits. Regardless of the charge for your doctor visit Health ProtectorGuard will pay the set amount. You can also rollover unused office visits for illness or injury at the end of the calendar year to the next calendar year.
Wellness/Preventive Care – After a six-month waiting period either a $100, $200 or $250 payment depending on the plans selected is made directly to you for wellness and preventative care services. Services under this benefit may include annual physicals, immunizations (other than flu shots), blood screenings, and mammograms.
Pharmacy Services – Combines a nationally recognized discount program with either a generic or brand name payment made based on the type of prescription. Generic prescriptions receive a $20 payment and brand name drugs receive a $40 payment. Prescription benefits are available up to 12 times combined generic and brand name per year. The prescription benefit is accessed by giving your pharmacist the National Prescription Savings Network discount card, which will result in savings up to 50% to 75%. The insured member will pay the discounted prescription price and the benefit will be paid directly to the member.
Outpatient Services – Both outpatient lab and imaging services are covered with a predetermined payment of either $200 or $300 for laboratory services and either $500, $800 or $1,000 for diagnostic imaging services. Outpatient lab and imaging services can be accessed once per year. The outpatient services benefit is available to diagnose an eligible injury or illness. Outpatient services also includes both oral and non-oral chemotherapy treatments. Benefits for oral chemotherapy range from $1,000 to $2,000 per month for either 3 month or 6 month treatment duration. Outpatient chemotherapy and radiation benefits are paid on a per day basis with either a maximum of 40 or 60 days. The per day benefit is either $1,000 or $2,000 per day.
Hospital Services – Inpatient benefits are available for an unlimited period of time at a per day rate of $1,000, $2,000, $3,000, $4,000 or $5,000. If the hospital confinement is classified as an Inpatient Hospital Intensive Care Unit (ICU) benefits are paid in addition to the inpatient hospital confinement benefit, which can increase the total benefit by $2,000, $4,000, $6,000, $8,000 or $10,000 per day.
Physician visits increase the inpatient hospital benefit at $100 per visit for either 1 visit or 2 visits per day depending on plan selected.
The Health ProtectorGuard will also increase the inpatient hospital confinement benefit related to injuries. Beginning in year 2 and continuing through year 5, in patient hospitalization related to an injury will increase 25% each year. For example, the Select Plus will pay a $4,000 benefit with a hospital confinement in year 1 but in year 2 will pay a $5,000 per day benefit for hospital stays related to an injury. The benefit does not compound from policy year to year and does not apply to hospital admissions related to sickness.
Surgical Services – Surgeon benefits are available for either inpatient or outpatient
Surgical benefits are assigned tiers to apply payments to insured members and are based on type of surgery.
Tier 1 (Extreme Listed Condition) – Significant, non-diagnostic, invasive procedures requiring general anesthesia and open incision. Examples of tier 1 procedures are open heart surgery (including bypass), major organ transplant, and brain injury. Tier 1 benefits pay $10,000 with unlimited number of days per calendar year.
Tier 2 (Major Listed Condition) – Non-diagnostic, open incision, surgical procedures that require general anesthesia. Procedures under tier 2 would include knee replacement, hip replacement, rotator cuff repair, and major organ removal or repair performed on an organ within the chest, abdomen or pelvic cavity that is not included in Tier 1 Tier 2 benefits will pay $5,000 with unlimited number of days.
Tier 3 (Non-Major Listed Condition) – This tier covers surgical procedures that require general anesthesia or conscious sedation such as stent placement, insertion of a pacemaker, balloon angioplasty, heart catherization and laparoscopic hernia repair. Benefits under Tier 3 are paid at $1,000 with unlimited number of days.
Tier 4 (Local/Minor Listed Conditions) – Tier 4 procedures require either a local or regional anesthesia such as an emergency C-section and closed treatment of a fracture or dislocation. Benefit is paid at $500 and unlimited number of days apply.
Surgical benefits also include an assistant surgeon under Tier 1 and Tier 2, which pays a benefit equal to 20% of the appropriate tier’s surgical benefit. Anesthesiologist receive benefits equal to 30% of the surgeon benefit. If more than one surgery is required in the same day the highest tiered amount is paid.
Premiums Comparison
A comparison of premiums between Health ProtectorGuard and various ACA plans demonstrates the value proposition for consumers. For example, a husband and wife who are both 45 and living in Austin would pay either $805 for a bronze plan with a $6,850 deductible or $1,026 for a silver plan with a $3,000 deductible. The premiums for these ACA compliant plans compare to Health ProctectorGuard plans at $354.42 for Choice Plus, $578.14 for Select Plus and $646.14 for Premier Plus. Of course, the Health ProtectorGuard plans are not ACA compliant and the individual may be subject to a tax penalty but the premium is extremely competitive and benefits may provide a suitable level of coverage.
Summary
Health ProtectorGuard now offers Texas consumers the opportunity to avoid over insuring for health conditions that the consumer is not at risk of experiencing. There are a substantial number of Texas consumers who, either based on health history or insurance needs, do not want to pay the premiums associated with ACA coverage. The consumer does not want or need the extensive benefits as offered by the ACA and is interested in a straight-forward approach to health insurance benefits.
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.
Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
Stateside is available to answer any general questions regarding your coverage options, can provide a subsidy determination, and even assist in creating and submitting online applications for ACA compliant plans during an Open Enrollment or throughout Special Enrollment periods.
Stateside can be contacted either by phone (866) 444-3332 (toll free) or by email at info@texasplans.com. Our Telephone Appointment System can be accessed through:
Phone Appointment Reservation.
By using the Telephone Appointment System, clients can take advantage of scheduling a health insurance discussion when convenient for their schedule. During Open Enrollment phone appointment availability is expanded to include extended hours and weekends.