Feel free to brows our FAQ section or to contact us if you need more information.
I have been a licensed agent since April 2013; I keep up with the education of the state’s health plans. If you are on a spouse’s health plan based on the company’s size eight out of ten times, if you qualify, there are plans with better coverage or a more affordable monthly premium or both. There are five types of health plans available for individual health plans in the state, they are. My goal is to be a one-stop for my clients and provide them with the best health plan that they qualify for to meet their needs and budget.
- Marketplace (ACA)
- Private health plan on PPO networks
- Short-term health plans
- Indemnity health plans
- Med-a-share health plans
Texas has four operating networks, HMO, EPO, POS & PPO. PPO is the best network to have on a plan because you have the flexibility to see any network doctor when needed. All PPO’s are not the same, have an agent that knows the ranking of the PPO and the percentage of the network contracts.
The stop-loss has also been called out of pocket or calendar year maximum. It means how much the client has to pay out of pocket before the insurance company pays 100%. The rate relies on if your deductible is exclusive or inclusive. Inclusive means your co-insurance of 60/40. 70/30 or 80/20 starts your payment of the lower percentage of the split. Exclusive you have a deductible amount to exhaust, then you begin to pay the co-insurance split amount until you reach the max of that amount, the stop-loss is the deductible plus the split amount.
This answer requires research by the agent, but the first thing I look at is the type of health policy the client has. If you are a self-employed or small business owner and have an individual health policy or are on your spouse’s plan, they issued you an individual health policy. You were injured or became sick while working; that possibly is the reason your declined claim. You have given an individual or business health plan. Workman’s comp is not a requirement in all states.
Not all PPO networks are the same in size or contract; the insurance company is separate but can be part of the same company. The network dept/company’s responsibility is to maintain or negotiate a deal with every medical facility, doctor on each medical code. The bigger/better the network, the better the contracted price. Here is an example:
Right ankle x-ray
PPO-A network; facility price $350 – contract $175 – Insurance $75 – Client cost $100
PPO-B network; facility price $350 – contract $235 – Insurance $75 – Client cost $40
As you see, PPO-B is a more extensive and better negotiated medical network.