Confused About Health Coverage? Join the Club.
Let’s face it, when it comes to health insurance, even the smartest, most educated entrepreneurs struggle to keep up with the constant changes. As if things weren’t hard enough
we are in the midst of a pandemic, with quarantine orders and massive layoffs to add to the mix. All in all, if you are confused, just know that you are not alone.
If you do not work for a company that offers health insurance through a group benefits plan, and you do not qualify for Medicaid or Medicare, you have two main options for health coverage: ACA “marketplace” plans or non-ACA private plans. Here’s what you need to know about both:
ACA “MARKETPLACE” PLANS:
Ever since the Affordable Care Act (ACA) was signed into law, individuals may self-enroll in a health insurance plan that is ACA compliant during the annual Open Enrollment Period, which is currently November 1 – December 15. The coverage then becomes effective January 1 of the following calendar year. If you have a Qualifying Life Event (i.e., getting married or divorced, having a baby, losing your health coverage, etc.), you are given a 60-day window during which to enroll in a marketplace plan via “special enrollment.” In order to be ACA-compliant, the plans on the marketplace must follow certain guidelines including that they must cover pregnancy and maternity; psychiatry and mental health services; and substance abuse treatment, among other things. The insurance companies are not allowed to medically screen applicants seeking to enroll in these plans, and the plans must cover all pre-existing conditions.
This means that people with preexisting conditions are able to get health insurance, and thus the care that they need, and they can rely on having an annual cap on their out-of-pocket on their healthcare costs. While it varies by state, individuals can choose a plan that fits their budget and health needs, with some states having 50+ plans to choose from.
The down sides of the marketplace plan is are that there are very few Preferred Provider Organizations (PPOs) available; most of the plans are Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs), meaning more limited access to chosen doctors and hospitals, and often limited if any state-to-state coverage. The prices of the marketplace plans have dramatically skyrocketed over the years, and are far from “affordable.” Only those who are considered low-income, and qualify for government subsidies can avoid high monthly premiums and matching high deductibles.
NON-ACA PRIVATE COVERAGE:
Given the changes in the marketplace plans leading to a lack of that have made them less affordable, private coverage is becoming more and more popular for the self-employed, especially in the last few years. Unlike marketplace plans, many of the higher-end private plans are underwritten, meaning that not everyone may be accepted into the pool of insured people for every plan. When insurance companies are able to underwrite, they assess their risk and thus are able to offer more affordable monthly premiums, lower deductibles, and superior (often PPO) coverage to those who are able to pass the companies’ underwriting guidelines.
Small businesses (say, 2-20 employees) can really benefit from the perks of private underwritten coverage, such as low deductibles and out-of-pocket costs; expansive PPO networks (some even nationwide); and supplemental accident and hospital coverage, to name a few. Many private plans offer free access to telemedicine, giving you the ability to seek treatment from a medical professional from the comfort of your home (which is a HUGE consideration in these days of social distancing).
All in all, the world of health insurance is ever-changing and you should not have to navigate it on your own. Whether you are a single-member LLC or a small business with one to five employees, always make sure to consult with a knowledgeable, licensed, customer-service oriented insurance agent who will assess your specific situation (health and medical needs; income; budget, etc.), and give you the best options for your family and small business needs.
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Alexandra Kontos is a licensed insurance agent with USHEALTH Advisors, helping families and the self-employed nationwide find innovative and affordable health coverage solutions. She is also an attorney, sales trainer, and entrepreneur. Alex loves educating her clients so that they make empowered choices regarding their families’ health. Alex co-founded an all-women law firm that served over 1,000 clients and employed over 40 people. After developing a love/hate relationship with the practice of law, she created a series of inspirational workshops and retreats for women attorneys. Alex has presented at numerous conferences, including the Women’s Success Summit and the Office Depot Foundation’s Women’s Symposium. When she’s not working, you can find her in the gym, with her fiancé in Nashville, TN or with her daughters having dance parties in the living room. More at www.alexandrakontos.com and email at email@example.com.