Texas health insurance
Evaluate Health Quote
How to Evaluate Your Health
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
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
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
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
Of course, if you have questions, please
contact us. That's what we are here for.