Good Individual Health Coverage is Hard to Come By.

Individual health insurance is in a rough spot these days. Premiums, deductibles and out-of-pocket maximums are very high and doctor and facility networks are getting thinner by the month as providers are opting out of many individual plans. Some states have been hit worse than others. Some counties have only one ACA qualified plan and some have none.

a guide to big city life & love.I have clients who have watched their premiums go up and benefits go down each year for a few years now and more than ever people are looking for other options. Here’s what I tell them.

You have three categories of options:

  1. The Affordable Care Act (ACA): This includes any plan you find on or your state exchange, but often carriers will offer ACA compliant plans separate from the marketplace. Pros: These are good if you have preexisting conditions, or if you qualify for a subsidy that brings your premium down significantly. Cons: Usually these represent the most expensive, least beneficial plans and their doctor and facility networks get thinner by the month.
  2. Short Term/Indemnity plans: Indemnity plans are very inexpensive, first-dollar-coverage plans that I rarely recommend because they do not limit exposure. The better of these two options is Short Term Medical (STM) So many people have chosen the Short Term option that last year the length of terms was limited to 3 months. That ruling should be reversed in April. Pros: Short Term Medical is major medical coverage, usually with a better network of doctors and facilities than ACA plans and the cost is usually 1/3 to ½ the full price of comparable ACA plans. Cons: For 2018 you still may pay a tax penalty for having STM as they are not compliant with the mandate that doesn’t go away until 2019. Often the tax penalty combined with the savings because STMs are usually so much cheaper, still make it a less expensive. Also, STM plans can deny you for preexisting conditions so heaven forbid you develop a chronic illness. In that case you would be covered for the remaining term and might not be able to renew the policy for the next term.
  3. Health Sharing plans: These are not new, but many people are just hearing about them for the first time. They actually aren’t technically health insurance at all, but you can consider them major medical health coverage. Most of these organizations are founded as religious organizations and vary in their membership requirements. Pros: Generally less expensive and better benefits, they also keep you from paying a tax penalty as they are exempt from the mandate. Their doctor networks can be better and while some of the plans work very differently from regular health insurance, a few work very similar. Cons: Doctors and facilities are warming up to these plans, but a few still won’t take them even though they may be in network; and many of the plans have waiting periods for preexisting conditions. They also have limited drug benefits.


To summarize, the options for individual health coverage is not as robust as those with employer sponsored plans, but it’s not impossible to find coverage that meets your needs and generally you can find it cheaper by not going with an ACA plan. For most healthy people, I highly recommend looking in to health sharing plans. In my experience, the more people learn about them, the more they like them.

Two Essential Tools

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Ever wonder what a mammogram should cost? Have you ever looked at your provider’s statement and asked yourself it the charges were reasonable compared to other providers? Now you can find out.

Healthcare Bluebook ( is a great way to find out what is a fair price for procedures in your area. Their website states:

“By combining the best cost and quality data with industry-leading usability, Healthcare Bluebook provides people and organizations with everything they need to be more effective healthcare consumers. We’re forever changing the way people choose. We’re bringing fair to healthcare.”

The idea is to provide you with information that will help you decide according to both price and quality where is best to obtain healthcare.

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I have been recommending for quite some time now. It is an excellent way to find the best places to get prescriptions refilled. You don’t need a membership or a drug plan. It’s a simple search that provides you with the cheapest places to get a particular drug based on your zip code.

Good Rx ( is the best way I know to find out where to find the best price for prescription drugs in your area. Their website states:

“Most Americans assume that drug prices are regulated or fixed. That’s simply not true. Prices vary wildly in drugstores that are literally across the street from each other, especially when filling generic medications (which make up about 80% of the prescription fills in America).”

Very often I’ve found that the best price for a particular drug is less than your generic copay!

Armed with these two tools, you should have good information should you be trying to decide which carrier to choose and what doctor network or drug plan. You will have a dramatic information advantage.

Your Employees are Hurting

Unhappy manager     If you don’t provide health insurance to your employees it’s probably because you’ve decided you just can’t afford it. While it’s true that groups aren’t always cheaper there is another really important thing to consider. There is a dramatic difference between individual health insurance and group health insurance, and now more than ever. Here are 3 ways your employees will benefit from a group policy over the choices they now have on the individual marketplace:

Perhaps they really can keep their doctor.

     We all remember the famous promise that proved untrue. That’s because each carrier created separate doctor networks for their ACA Individual Marketplace plans and many doctors have opted out of those networks (or were asked to leave), in favor of other networks that offered more flexibility in managing care. For example, United Healthcare’s ACA network is called Compass Balanced whereas the network for their group plans is called Choice Plus. The Choice Plus network is considered a much better network. This applies to every major carrier in the industry. It’s more likely that your employee will find their family doctor in the Choice Plus network than the Compass Balanced.

They might save money.

Most groups are billed compositely, which means that older employees are going to benefit from being in a group with younger people. I recently wrote a group policy for a title company in Texas. One of their best employees was struggling because her husband had been diagnosed with cancer, couldn’t find an ACA plan that had MD Anderson in network, and was paying $1,800 in monthly premiums. Once the new plan was in place, MD Anderson was in network and her paycheck deduction was reduced to just over $600! Now how loyal do you think she feels about her employer?

They will typically get better benefits.

Group policies often provide benefits that you just won’t find on the individual marketplace. Nowhere is this more evident than with dental plans. I rarely recommend dental policies on the individual marketplace. The coverage is typically very limited, have long waiting periods, and simply do not cover things like orthodontia.

Most small businesses compete for the best talent and health insurance is one of the best ways to do it, especially since Obamacare has struggled to live up to the hype. Group insurance isn’t for every small company, but for some it may be the difference between keeping or losing your best people.

Overspending On Insurance

“When I give someone my insurance card, I want benefits!”
     I get it. If I had a nickel for every time I heard someone say, “Why should I pay monthly for a premium and still have to pay full price for my doctors visit or medications?” The answer to that question is a sharp pencil and a calculator.
     Remember the purpose of insurance—to manage risk—and unless we’re talking about certain life insurance products, health insurance is almost never considered an investment. It’s a sunk cost that we hope we’ll never have to use much less get a return on, because that means we’ve been really sick or injured! The goal then becomes to get the best value at the best price and to do that we have to look at more than monthly premiums. While cash flow is important to most people, it’s not the only way to judge which policy to pick. Often the most important way to judge is by looking at yearly costs, which include variables such as deductibles, coinsurance rates and maximums, and copays.  Here are some common mistakes people make when approaching health insurance:
  • Paying more for a lower deductible they will never meet.
     If you’re young and have no history of illness it rarely makes sense to pay more for a policy that has a lower deductible. If you aren’t likely to meet a $2,500 deductible, why pay more in premiums to have it that low? It’s often better to take a plan with a higher deductible, and add a supplemental policy that will pay your deductible for you. You will almost always save money and get better coverage that way.
  • Paying too much to get a plan with a copay.
     How often do you go to the doctor in a year? If it’s less than two or three times then it’s generally cheaper to take a plan without copays. Remember copays only pay for the visit—the part where the doctor takes your temperature, hammers your kneecap and asks you what’s wrong. The negotiated rate for that part of the visit can range anywhere from $150 to $250 depending on the doctor and the carrier. If you need blood work or x-rays, your copay isn’t going to cover that. This is where your calculator comes in handy. Often copay plans can cost $100/month or more than plans without copays. Lets say you go to the doctor three times a year. That means you have spent an extra $400, plus whatever your copay is for each visit. Let’s say your copay is $25. So the visit that would have only cost you $150-$250 has now cost you $425 in this scenario, and you STILL have to pay for any testing you have done. You get the idea.
  • Buying the wrong dental insurance, or buying it at all.
I imagine most agents would rarely tell you not to buy something, but in the case with dental insurance, there are not many good choices out there these days unless they are bundled with your employer’s group policy. If your teeth are healthy, have no family history of problems, and all you do is get them cleaned twice a year you’re often better off negotiating directly with your dentists for your cleanings. Most individual dental plans have waiting periods and offer very little coverage. That said there are plans available that can benefit you greatly if you know you are going to need work done.
  • Thinking that a major medical policy alone can meet all your needs.
     Supplemental policies are a great way to customize your coverage and if packaged right, can save you in monthly premiums and get you better coverage! Add an accident policy or a critical illness policy to a higher deductible plan and you will likely pay less per month. Consider a discount drug program instead of paying more for a drug copay if you don’t take tier 3 or 4 medications.
     A good agent can help you navigate your options and save you money. The best agents get paid from the insurance carriers and their services don’t cost you anything, and generally not using an agent won’t save you any money. Major carriers don’t have one price for using an agent and another for going directly to their website or through Find someone you trust and it could make all the difference next year!

A Health Insurance Audit

As you think about your health insurance coverage it’s important to know that one size definitely does not fit all. In my experience, most people sign on with a company and take what they’re given, regardless if it fits or not. When I work with a client, my goal is to customize her plan to fit with her needs. Most of the time I can get her better coverage for less money!

Think about your current coverage and consider these options:

  • Dental/Vision – Although I can write dental coverage with most major carriers, the one I overwhelmingly recommend covers you up to $2,000/year instead of most plans which only go up to $1,000/year. No waiting periods and you choose your own Dentist and Eye Care Doctor.
  • Accident Plan – Covers you in case of an accident, (Car accident, sport injuries, biking accidents, etc.) It pays the first (Your Deductible Amount) in case of an accident and also wipes out your deductible). With 87% of hospital related incidents coming from Accidents, it really pays to have this plan in place, especially those of you with children.
  • Critical Illness – Pays you cash in case of a Major Illness (Heart Attack, Cancer, Stroke, such as AFLAC). You should figure how much you would need if you lost 3 months of income which is the average time it takes for treatment from a Heart Attack, Cancer, or Stroke. Coverage amounts from $10,000 – $50,000 are available at really low premiums. It will help you sleep better knowing you are covered for these life events with this plan.
  • Life Insurance – What would your family do if all of a sudden you and your monthly income were gone? How would they make it financially without you? You can get a plan in place that would take care of the ones you love in the event you can no longer provide for them. We have very affordable plans available.

Let’s be wise about your coverage and make sure you’re not paying more than you have to for something that’s inadequate. You never know what a day can bring!

You Still May Have Options

The Open Enrollment period for most health plans has ended, but if you’re healthy and don’t have coverage, or just want better coverage, there are still options available.

You might consider an annual plan, otherwise known as Short Term Medical insurance. It’s a major medical policy, often with $1 million in coverage, available with or without copays and deductibles as low as $1000. There are pros and cons to this option so let me explain:

Pros: The premium for most STM plans are significantly cheaper than ACA plans at full price. The doctor networks are usually much better and they are PPO plans.

Cons: Some who take the STM plan may still pay an extra tax for not having ACA coverage. The plans do not cover preexisting conditions nor pregnancy and some preexisting conditions can cause a denial of coverage.

That said, many people find that the savings in premium save money at the end of the year even with the extra tax. These plans are a great way for some people to keep their doctor and get excellent coverage year after year, or at least until Open Enrollment begins again later this year.

Call me. I’d be happy to discuss whether a Short Term Medical plan is right for you.

Annual Enrollment Period Now Open

November 1st is upon us and the new rates are published. There are a few changes this year from last year in two main areas: subsidies and rates.


Most carriers are increasing their rates substantially, particularly those who kept their rates low last year in hopes of attracting new policyholders. Since rates change nearly every year these days the times of setting your coverage and forgetting it are gone. Now it’s important to check your policy every year and compare them with the new rates published by other companies. Since part of the law now includes the ability to enroll without fear of denial due to pre existing conditions, this makes it easy to switch from year to year, though it’s still a hassle to keep up with. That’s where I come in! The rates from some carriers this year will jump as much as 30% so let’s take a look at what you currently have and how much it will change come January first. There’s plenty of time to make adjustments and explore your options.


In the past, subsidies mainly pertained to premiums, which left many people frustrated with a low premium, but a deductible that was still prohibitive. This year cost reductions for many will extend beyond premiums to co-insurance as well. I found a policy for one of my clients with a major carrier whose rates, including the subsidy, were a $15/month premium and a $500 deductible! I’m not guaranteeing I can find that for everyone, but it’s possible for some.

Other miscellaneous changes:

Blue Cross and Blue Shield of Texas is doing away with their PPO. If you currently have that plan with BCBS you’ve probably already received a letter informing you of this. If you live in Texas and prefer PPOs there are still some available to you depending on where you live.

In addition to that, I have expanded my list of appointments to include Blue Cross Blue Shield of Texas, and Scott and White to go along with Humana, United Healthcare, Aetna, Cigna and Assurant. Keep in mind however that I am able to help you with any marketplace plan even if it’s with a company with which I am not appointed. Just refer me to your friends!

As one of my mentors is famous for saying: “You can have everything you want in life if you just help enough other people get what they want.”

For Life, Health, and Peace of mind,


Special Enrollment Period Now Open

Excerpted from

OK, let’s try this one more time. Again.

A month after Obamacare’s open enrollment season closed, the federal government Sunday starts a special enrollment period for people who only now are finding out they face a penalty for failing to have obtained some form of health insurance in 2014.

“We clearly are very hopeful that people will avail themselves of the chance to get covered, to get insurance during this period,” said Kevin Counihan, CEO of, the federal Obamacare insurance marketplace that serves 37 states.

But it’s unclear how many people will take advantage of that offer and end up adding to the 11.7 million people or so who already signed up for 2015 health plans on government Obamacare exchanges.

“We haven’t set a projection,” Sylvia Burwell, secretary of the U.S. Department Health and Human Services, said Thursday when asked her about the number of sign-ups she expected to see, during an event at Montefiore Medical Center in New York.

A survey released Monday by the Jackson Hewitt Tax Service suggested that many eligible people might not even know about the offer of what will amount to their third bite at the Obamacare enrollment apple.

The study found that 48 percent of adults believed the deadline to sign up for health coverage this year had expired, and another 27 percent “don’t know” if the deadline had expired. While open enrollment for Obamacare insurance ended in most of the country on Feb. 15, special enrollment periods for tax season were announced in the week following that initial deadline.

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A man holds a sign directing people to an insurance company where they can sign up for the Affordable Care Act, in Miami last month.

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A man holds a sign directing people to an insurance company where they can sign up for the Affordable Care Act, in Miami last month.

Counihan, in a conference call with reporters Friday, also said officials were working on getting corrected tax forms out to more than 800,000 Obamacare customers who had previously been sent forms that contained some incorrect information. But officials did not reveal how many of those corrected forms have been sent.

The forms are necessary for those tax filers to reconcile what they received in subsidies with what they are actually entitled to; 50,000 or so people who received the incorrect 1095-A forms had already filed their taxes at the time the error became public.

The grace period for signing up for a health plan this year is available to people who didn’t have coverage last year and didn’t know until this current tax season that there’s a fine for not having such coverage. People using the special period also must not already be enrolled in an insurance plan for 2015. Those eligible for the grace period still have to pay any Obamacare penalty they are assessed for 2014.

The special enrollment period for customers of will run from Sunday through April 30. A top federal official said the grace period is a onetime deal: It will not be offered in future years.

Six other state-run insurance marketplaces, have already begun their own special enrollment period. Four others are starting such periods Sunday, and Connecticut is beginning its own special season on April 1.

Just three states, Colorado, Idaho and Massachusetts, are not having a special enrollment period.

Read MoreBig medical bills, too little cash

The decision to grant the special sign-up season reflects still-high levels of ignorance about Obamacare among uninsured Americans, and a lag in the timing of some of the law’s provisions.

Beginning in 2014, most Americans were required to have some form of health coverage or pay a tax penalty equal to the higher of $95 per adult, or 1 percent of taxable household income. But that penalty is only being collected starting this year, with the filing of 2014 tax returns.

As a result, many people are becoming aware of that penalty only after the close of enrollment for 2015 health plans. If there were no special enrollment period available this year, some people would not only owe a penalty for 2014, they’d also next year would owe a penalty for failing to have insurance in 2015. The penalty for the 2015 tax season rises to the greater of $325 per adult or 2 percent of household income.

“We do know that there are people who still don’t know about the fee,” said Andy Slavitt, acting administrator of the federal Centers for Medicare and Medicaid Services, the agency that oversees Obamacare.

Slavitt cited a McKinsey study from earlier this week that found that about 40 percent of uninsured people were aware of the Obamacare penalty.

“We do know that are some people … that didn’t learn about open enrollment and didn’t learn about the requirement to have coverage until they paid their taxes,” Slavitt said. “For many people, this will be the first time they discover they have the opportunity to get coverage for themselves and their families.” 

This tax season is the first time that filers must declare their health coverage status.

Most filers, about 75 percent of them, will only be required to check a box on their tax returns to indicate they have some form of coverage, said Mark Mazur, assistant secretary for tax policy at the U.S. Treasury Department.

For people who do not have health coverage, “We expect the majority of them will qualify for exemptions” from the Obamacare penalty. Those exemptions can include not having the option to buy “affordable” insurance as defined under the law, having recently filed for bankruptcy, religious reasons and other categories.

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People who received federal subsidies, or tax credits, to help pay the monthly premiums for plans purchased through Obamacare marketplaces are required to file forms reconciling the subsidies they received to what they ended up being actually entitled to given their income and the price of the plans.

While some of those people will have to pay the IRS some of their subsidies, “We expect the overwhelming majority of these taxpayers to still receive a net tax payment” in the form of a refund, Mazur said.