AboutJohn (J.R.) McCollough Expertise I can answer questions pertaining to Health and Medicare insurance for individual and/or family coverage, students, retired/separated military members, small businesses under 20 employees and seniors in the United States.
Additionally, I can assist people in understanding their options if they've been turned down for insurance and do not know about what state and federal programs are available.
Experience I am the owner of a national agency that only attracts agents of the highest caliber to consult in Health, Life and Medicare insurance products. We emphasize a client-centered approach to the way we conduct business and can provide objective input to help you make an informed decision.
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I am 24 years old, male, good health, living in florida. I have written to you about insurance and I am going to take your recommendation on getting catastrophic coverage. I was hoping if you you could provide some insight and some real world perspective which could help me select the best option for me.
I found catastrophic coverage which has three options:
1. Premium: 19
Deductible: 2500
OOP Max: 5000
2. Premium: 25
Deductible: 1000
OOP Max: 5000
3. Premium: 30
Deductible: 250
OOP Max: 2500
What is covered is the same for all three choices. I was hoping you could help me make the best selection.
Thank you very much for your time,
Richard
ANSWER: Hello Again Ricky,
Based on the numbers you have given me I'm assuming that you're contemplating different group insurance plans. 99.9% of most people look at the numbers. It's my job to ensure that people understand what's behind the numbers. Are those numbers weekly, bi-weekly or monthly. I'm going to assume again that the numbers you have me are bi-weekly debits.
Right off the bat from an economical standpoint I'd suggest you go with the $30 plan since there isn't much of a savings vs. the $19 plan. The premium savings does not justify the additional $2500 you would be liable for in a calendar year. Same thing goes for the $25 plan.
Behind that I would have to look at the 3 plans in details since there are about 15 items I look for in every insurance contract. Here are some things to think about.
1)What are the out of network charges?
2)What is NOT COVERED?
3)What are the mental health benefits?
4)Are there any prescription caps? Some plans will limit you to a few thousand dollars a year.
5)Are there any caps at all? I don't like small caps!
6)Is it a POS, PPO, HMO, etc. type of plan. Some people don't like being told what to do so I don't recommend they choose an HMO!
7)What carrier is the plan through?
8) What is their financial rating and track record?
9) What happens in the event you should lose your job and become uninsurable? Things can get a bit tricky regarding HIPAA and COBRA, so you should know your options and possible exit strategies.
10) What is the lifetime maximum? Anything less than $2M in my opinion is risky!
11) What services are covered? What services receive a network discount? These are ALWAYS two separate items!
12) How large is the network and is it insurance owned or rented?
This small list should get you started, but make sure you read EVERYTHING before signing up. You might also want to look into obtaining your own individual plan in FL depending upon how the group plans stack up against the individual plans in benefits and pricing. There are some strong carriers down in FL!
Let me know how it goes.
-J.R.
---------- FOLLOW-UP ----------
QUESTION: Dear Mr. McCullough,
I want to thank you very much for your quick response and your guidance. I thought I would reply with a little more information about the health insurance plan I am considering.
It is an individual plan and the premiums I presented are monthly. The other two options ($19 and $29) I presented before are with the same carrier and the same coverage.
I thought I would answer the questions you provided me. I got the information from the benefit summary of the $30 premium plan ($250 deductible/$2500 OOP Max) and I was hoping if you could determine whether this a plan worth getting. If not are there other carriers you think I should consider looking into.
1)What are the out of network charges?
Calendar Year Deductible: $750
Out of network per admission deductible: $500
Coinsurance: 40%
Out of Pocket Maximum: $5000
2)What is NOT COVERED?
Allergy Injections
Adult Wellness Benefit Maximum
Routine Adult Physical Exam and Immunizations
Mental Health
Substance Dependency
Combined Outpatient Cardiac Rehabilitation and Occupational, Physical, Speech and Massage Therapies and Spinal Manipulations
Home Health Care
Skilled Nursing Facility
Any service which is not Medically Necessary
Elective cosmetic surgery
Hearing aids or eyeglasses, vision or dental care,or oral appliances
Elective abortions
Infertility services
Complementary and Alternative Healing Methods (CAM)
Routine foot care
Oral Contraceptives and Devices
3)What are the mental health benefits?
None
4)Are there any prescription caps? Some plans will limit you to a few thousand dollars a year.
Prescription discounts
5)Are there any caps at all? I don't like small caps!
Ground travel/air and water travel, per day maximum $400/$4000
Hospice $5200 Lifetime Max
Rehabilitation Services 21 days per calendar year
6)Is it a POS, PPO, HMO, etc. type of plan. Some people don't like being told what to do so I don't recommend they choose an HMO!
PPO
7)What carrier is the plan through?
Blue Cross and Blue Shield of Florida
8) What is their financial rating and track record?
Did not get this information
9) What happens in the event you should lose your job and become uninsurable? Things can get a bit tricky regarding HIPAA and COBRA, so you should know your options and possible exit strategies.
Did not get this information
10) What is the lifetime maximum? Anything less than $2M in my opinion is risky!
$5M
11) What services are covered? What services receive a network discount? These are ALWAYS two separate items!
I.
Covered Services are for in-network and out-of-network
1. In-Network: CYD ($250) + 20% Coinsurance for all covered services except:
a. In-Network e-office visit: $10 copayment
b. Non-Surgical services in the ER: PVD ($2500) + 20% Coinsurance
2. Out-of-Network: CYD ($750) + 40% Coinsurance for all covered services except:
a. Ambulance services: CYD ($750) + 20% Coinsurance
b. Non-Surgical Services in the ER: PVD-Per visit deductible ($2500) + 40% Coinsurance
c. Inpatient Hospital Facility and Rehabilitation Services: PAD-Per admission deductible ($500) + CYD ($750) + 40% Coinsurance
Physician Office Services (Coverage for Surgical Services only)
Family Physician
Specialist
e-Office Visit
Urgent Care Centers (Surgical Services Only)
Emergency Room Facility Services (per visit)
a. If Admitted or if a surgical service is performed
b. Non-Surgical Services
Per Visit Deductible (PVD) $2500
Ambulance Services (In- and Out-of-Network)
(Ground travel / Air and water travel, per day maximum) $400/$4000
Independent Diagnostic Testing Facility Services
(per visit) (services proximately related to Surgical Services) (e.g., X-rays)
(Includes Provider Services)
Independent Clinical Lab
(services proximately related to Surgical Services) (e.g., blood work)
Outpatient Hospital Facility Services (per visit) (Surgical Services Only)
(e.g., Surgeries, proximately related blood work and X-rays)
Provider Services at Hospital and ER
a. If Admitted or if a surgical service is performed
b. Non-Surgical Services
Per Visit Deductible (PVD) $2500
Provider Services at Locations other than Office, Hospital and ER
(Surgical Services Only)
Family Physician
Specialist
Durable Medical Equipment, Prosthetics and Orthotics
(If provided during Surgery or at time of discharge)
Hospice (Lifetime max) $5200
Ambulatory Surgical Center Facility (ASC) (Surgical Services Only)
Provider Services Rendered at an ASC (Surgical Services Only)
Family Physician
Specialist
Inpatient Hospital Facility and Rehabilitation Services (per admit)
II. Discounts
a. Generic, Preferred Brand Name and Non-Preferred Prescription Drugs
b. Many NetworkBlue physicians offer BlueOptions members a rate which is at least 25 percent below
the usual fees charged for services that are not Covered Services
12) How large is the network and is it insurance owned or rented?
Did not get this information
Answer Hi Ricky,
Overall, the plan looks good. I give it a B- for benefits and an A- for pricing. The deductible is really low, which some people think is a good thing. The coinsurance level and out of pocket maximum is more important to me because $750 is usually not going to bankrupt somebody since you can always set up a payment plan with most providers.
I STRONGLY recommend you get an HSA since you would be wasting money by not receiving the tax benefits of such an account in the event that you require ANY medical attention and have to pay for services.
You might also look into Golden Rule and Assurant for comparable plans! Do some of the research on your own and then find an agent knowledgeable about the Florida market who understands the underwriting guidelines of each insurance carrier.
