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Texas health insurance Quotes  Understand Texas health coverage Evaluate Health Quote

How to Evaluate Your Health Insurance Quote

Unlike other Internet-based health insurance brokers, Stateside Insurance Services provides a great deal of information in their health insurance proposals for consumers to review.  Typically, online brokers will not provide monthly premium cost or major plan details hoping that consumers will rely on the broker's advice in order to make a plan decision.  Stateside learned a long time ago that consumers want to conduct the initial research on their health insurance plan options and will contact the insurance broker when it comes to carrier and plan comparisons.

In order to make an accurate comparison of plan options, Texas consumers should be knowledgeable of the important information included in the proposal.  The first information that should be confirmed is the accuracy of the census information.  Demographic information on the individual(s) such as gender, age, zip code and tobacco use are used to determine the quoted premium.  The demographic information is usually included on the last page of the proposal.  Any inaccuracy in the demographic information should be corrected because the information has a direct correlation to the amount of the quoted premium.

All online brokers quote preferred rates.  Since the premiums are generated directly from the carrier, the premiums available from one broker will not be different from another broker.  Quoted premiums can be increased based on tobacco use, height and weight, and overall health history.  Premiums that have been increased under these circumstances are referred to as standard rates.  Beginning January 1, 2014 premiums can only be increased due to smoking and age banding which limits the premiums for older policyholders to be no more than three times the amount charged to younger policyholders.

The proposed effective date of coverage should be stated in the proposal.  Stateside proposals always list the proposed effective date in the upper right-hand corner of each page included in the proposal, with the exception of the proposal cover page.

Stateside proposals typically list the plans in premium cost ascending order with the lowest cost listed first.  All Stateside proposals include premium cost and do not require the consumer to speak directly with one of our producers to receive the premium information.

All proposals should clearly indicate the carrier name and the commonly used plan name.  Proposals that reference the carrier's internal serial numbers instead of plan names can be confusing and make discussing plan options cumbersome.

Stateside proposals provide a summary of important plan benefits, providing both the in-network and out-of-network benefits.  In-network benefits will always be richer than out-of-network benefits, and Stateside proposals provide both benefit breakdowns so Texas consumers can understand how important it is to access the carrier's in-network providers.

The first major benefit component in a Stateside proposal is deductible.  A health insurance plan deductible is a predetermined amount of money that a policyholder must pay before the health insurance carrier is required to make any benefit payments. The purpose of a deductible is to keep costs reasonable by allocating the initial claims expense from the carrier to the policyholder.  Deductible will be expressed as an Individual Deductible and Family Deductible for both in-network and out-of-network providers.  The Individual Deductible is a single deductible amount, while the family deductible can be either two times or three times the Individual Deductible depending on the carrier. 

The next section detailed in a Stateside proposal covers the out-of-pocket maximum.  This term is used differently depending on the carrier.  Aetna for example considers the out-of-pocket maximum to be a combination of both the deductible and the coinsurance maximum, which is the maximum amount that a policyholder would pay during a calendar year.  Carriers such as Blue Cross Blue Shield, CIGNA, Humana, and UnitedHealthOne clearly state that the amount indicated as the out-of-pocket maximum does not include deductible.  These carriers consider the out-of-pocket maximum to be the amount of coinsurance the policyholder will pay.  

The basic concept of coinsurance, also known as percentage participation, is that the insured member and the insurance company share the risks of health care expenses. In health insurance, this usually translates into the insurance company paying a certain percentage of your healthcare expenses, while you pay the remaining percentage. The coinsurance provision helps to keep health insurance premiums affordable by sharing in an equitable manner those costs above the deductible.

Under an 80%/20% coinsurance provision, the carrier pays 80% of eligible medical charges above the plan deductible.  The insured member is required to pay the remaining 20%. Other coinsurance arrangements can include 50%/50%, 70%/30%, 85%/15% or 90%/10%.

The next important category is the office visit co-pay benefit.  The Stateside proposal will reflect the office visit co-pay as either a set amount ($25, $30, $35 or $40) or a percentage (15%, 20%, 25%, 30% or 100%).  The plans that indicate a set amount establishes that amount for consultation services provided by the physician.  Other services, such as lab, x-ray, injections or supplies are not paid by the office visit co-pay benefit and will be subject to the plan deductible and coinsurance.  If a percentage is indicated, the office visit will be billed at the negotiated rate and the percentage indicates the amount of the negotiated rate paid by the policyholder AFTER deductible has been met.  All Stateside proposals indicate in the proposal summary that any benefit listed with a % is subject to the plan deductible first, and the % sign reflects the coinsurance rate.

The next three major categories, Emergency Services, In-Patient Hospital and Out-Patient Surgery, usually reflect a percentage, which means they are subject to deductible first, after which the coinsurance percentage of the negotiated rate will be charged.  Some carriers will list a fee under Emergency Services.  This fee is known as a Facility Fee or Access Fee.  Some carriers will indicate that the fee will be waived if admitted to a hospital after an emergency room visit.  The purpose of the fee is to encourage insured members not to use the hospital emergency room for non-life threatening conditions and instead use minor emergency or urgent care facilities.

The Annual Physical category will indicate no charge, which is a new benefit that all carriers provide as a result of the passage of the Affordable Care Act.  Preventative care benefits according to Schedule A or Schedule B of the U.S. Preventative Care Services Task Force are paid 100% by the carrier with no deductible applied regardless of plan or carrier.

The Laboratory and X-Ray benefit will typically reflect a percentage, which means it is subject to the plan deductible and coinsurance.  However, carriers like Humana offer plans that include the first $300 or $500 of lab and x-ray services at no charge and then deductible and coinsurance would apply. 

Maternity coverage for the time being is shown as a benefit that is not covered.  Beginning January 1, 2014 all plans will cover maternity services as part of benefits mandated by the Affordable Care Act.

The Prescription Benefit will always list the various co-pays, whether generic, preferred brand, or non-preferred brand.  The deductible and how it is applied will also be indicated.

It is important to always review the Summary of Benefits and Coverage, which is provided online by Stateside at www.texasplans.com.  The Summary will list in very clear language the plan benefits and exclusions.  Stateside advises not to terminate an existing policy until a new policy is reviewed and premiums are confirmed.  Stateside personnel are available to discuss coverage benefits premiums so a well-informed decision can be made.

Of course, if you have questions, please contact us.  That's what we are here for.

email:  help@texasplans.com



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