Texas Individual Health Insurance
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Texas PPO Plans

Individual Texas Health Insurance Plans

Complete Major Medical PPO Plans for Texas Residents

Individual and family health insurance plans represent the best value in health insurance. However, as with any product, there are certain companies that you need to stay clear of and certain realities you must face. We will provide you with the information you need to select the right plan.

Health Insurance Underwriting - The Gauntlet

"When is the government going to do something about health insurance?" is a question asked to us every day. The short answer is - not any time soon. Does it come as any surprise to you that the insurance company wants only relatively healthy applicants? Texas health insurance plans will reject a large number of applicants based on prior health history or put permanent exclusion riders on any preexisting condition. Yes, they can do that. I don't care what your friend, neighbor or brother-in-law told you, they can and will pick and choose whom they wish to insure.

Remember, the number one reason you have health insurance is to protect you against the major, expensive medical problems. Don't get hung up on expensive doctor copay and prescription options.

Medical Declines

There are a certain category of illnesses and conditions that will give you an automatic decline. Diabetes, cancer, heart conditions, colitis, hepatitis C and many others. A good agent knows what they are and will not submit your application if they see them checked off. The problem is, many agents receive an advance commission on submitted business. So, they send off your application, collect their commission and then replace it with other business after you are rejected. Unfortunately, while waiting for this rejection letter, which could take months, you may have missed out on an opportunity for a guaranteed issue plan. Plus, you will have to tell the next carrier that you have been medically declined.

Some health insurance applications ask their questions within a time frame. For example, did you have any of the following in the past seven years? If you had cancer 15 years ago, was successfully treated and never had a problem since, you could honestly answer the question "No". You would have gotten past an automatic decline question. Other forms will go back indefinitely and here you are forced to reveal your entire medical history. At this stage, it is up to the individual underwriter to determine your insurability.

There is a catch. If you for instance had cancer 12 years ago, was completely cured and had no treatment since, you could have answered no to the question on the medical history portion of the form. However, if the underwriter sees a reference to this in your medical records when looking for something else, they can deny you coverage.

This puts you in a difficult situation. Do you tell your new family physician about these prior illnesses so they can include it in your records? Or, do you omit this information to get coverage? I would explain the situation to your doctor and hopefully they will understand. If they can keep it out of your records it could help you get insurance in the future.

A doctor's note can kill you

Perhaps I am being a bit over dramatic about the title. But, the truth is that a small clinical note in your medical records can prevent you from ever getting health insurance. We have spoken to more than one dividable whose physician put a "diagnostic guess" in a record only to later find out that they were wrong. Or, sometimes a physician will list a diagnosis without suitable testing or in an area that is clearly out of there specialty. A note saying "very depressed" or "severely depressed" from a general practioner can destroy your chance of obtaining health insurance. What should be an observation becomes a diagnosis. You will have the devil of a time getting it changed.

On the same note, it is important for you to not try your own hand at diagnosis either. One client went to the emergency room with pain that he thought was a kidney stone. He overheard someone mention it as a possibility. No complete diagnosis was made and he went home. The medical records never indicated a kidney stone. So, you might ask, why did he put it down on his medical history that he had kidney problems? Leave the diagnostic guessing to the doctor.

Finally, you should know that when a doctor says to you "Everything looks pretty good. Come back in 12 months", that is not necessarily what they wrote on their chart. The clinical note could mention the possibility of a problem though nothing was found. Or, it might state that retesting should be done in the future. The insurance carrier does not like to see this. They want closure to a medical problem. Therefore, it is important to make the doctor understand that if they find nothing, the need to say so. An insurance underwriter will be wondering why you need to keep being retested if all results were negative? I am not saying it is wrong of the physician to write whatever they please on your record. Just let them know the consequences of their actions.

What are the underwriters looking for when evaluating a Texas health insurance plan?

An insurance company is asking themselves the following questions:
1. What is the likelihood that this individual will require treatment of any type for their illness in the future? The answer needs to be that is no more likelihood than anyone else. So, if you have controlled high blood pressure but smoke and are a little too heavy, they might not like the odds.

2. Has the physician written anything in the medical records to indicate that surgery or any special medical procedures will be required in the future. A little note like "might require a blah-blah in the future" can eliminate you very easily.

3. Will your medical history make you more likely to develop other related problems in the future. Sometimes this situation is handled with riders to exclude the possibility of the insurance company getting stuck for a bill. Even if your blood pressure is controlled with medication, if you smoke a pack a day and haven't seen your toes in ten years, forget about health insurance.

I thought they can't exclude something permanently if I had prior coverage?

This is the most common Texas insurance myth. Keep in ming that we are talking about health insurance plans in Texas. Some states have very different rules. Nevertheless, if the insurance companies were not allowed to exclude certain conditions from your health insurance plan, they would just deny you insurance completely. Certain conditions will yield a "rate-up" where they only increase the premium slightly but do not exclude the condition. However, if you have had back problems for example, you can bet that there will be a permanent exclusion rider for all subsequent back problems. Theoretically, the rider can come off in the future. But, I have rarely seen this happen.

Exclusions and Limitations - What is actually covered?

There is a very well known health insurance company that will tell you that they will cover you anywhere in the United States. What they don't tell you is that they will pay your expenses based on the lowest priced provider of that service. They also somehow forget to tell you that if you are outside your home area the coverage becomes reduced and the cap on maximum out of pocket is thrown out the window. With clauses like these you can see why you need to read your policy very carefully.

To avoid this problem we recommend that your plan utilize a national PPO network. With a strong national network you can usually find a hospital if not a doctor who is a participating member. Furthermore, all pricing for procedures have been pre-negotiated. There can be no arguments about usual and customary fees. The hospital has signed a contract with the PPO network agreeing to their schedule.

Exclusions can be found in your outline of coverage and to a lesser extent in the company's marketing literature. The exclusions are generally what you would expect. However, there are many procedures that are excluded the first six months of a plan that might surprise you. Be sure to look at this list.

Limitations also need a once over. While the chances for an organ transplant are very, very remote, you will find many plans putting a cap on these procedures that is far lower than the rest of the plan. If you have $100,000 coverage for organ transplant procedures, they will not even put you on the donor list. Watch out for this one.

One last word on exclusions. You do not have to have actually been to a physician to have something excluded. If you crack your ribs while horsing around with a friend and then quickly get health insurance so you can go to a doctor, you will get a nasty surprise. The insurance company will tell you that a reasonable and prudent person would have seen a physician for the problem and waiting to get health insurance was not effective. Your claim will not be covered. So, don't sit around doubled over in pain waiting for your health insurance to kick in.

Talk the talk - Health insurance Deductibles, Coinsurance and Copays

Before I state my case on what you need versus what you want. Let me clear up some terms first. You have just bought a plan with a $2500 deductible with coinsurance of 80/20 to $5000. It also has a $35 copay for doctor visits. Now what does this all mean?

A $2500 deductible means that you will be responsible for the first $2500 of medical expenses each year. After that the coinsurance takes effect.

80/20 to $5000 means that after you paid the deductible, the next $5000 of medical expenses will be shared between you and the insurance company. They will pay 80% or $4000 and you will pay 20% or $1000. After that, the insurance company will cover all medical expenses 100%.

The $35 copay is not subject to a deductible. It does mean that if you are sick (not for checkups) the participating doctor's fee is $35. This does not include tests or other office procedures. They go against the $2500 deductible.

In almost all instances, higher deductibles will save you money. Sounds crazy doesn't it? A plan where you pay more of your medical expenses will possibly save you thousands of dollars a year. When you look at the rate tables you will see that lowering your deductible from $2500 to $1500 might increase your premium by more than $1000 per year. If you bring it all the way down to $500, you will see that a $2000 reduction in deductible will probably cost you $3000 a year more in premium. Get the message? The insurance company will make mince meat out of you if you get a low deductible. This is not like income tax. There are no refunds at the end of the year. Statistically you will save money with higher deductibles.

The same is true for prescription drugs. Get a plan with a high deductible for the Rx benefits. If you want low copays for brand name drugs they will soak you. Considering that they generally won't cover your current medication, this too becomes a "fool's errand". Having a high deductible on prescriptions protects you against an illness that requires expensive maintenance medication.

I could go on and on with actual numbers. When you are getting your quotes, do the math yourself. The cost-benefit of spending an extra dollar on premium should return an equivalent benefit. If you insist on low deductibles you will pay a fortune for a Texas health insurance plan.

Let me put it another way. An insurance agent is a commissioned salesperson. If you spend more on a low deductible plan, I make more. I am telling you to save your money. I will make less but I know that you are getting more for your money. I am a firm believer that in life, what goes around, comes around. Besides, use the savings to get disability insurance so you won't lose your house if you get sick. Perhaps you can buy some dental insurance so you won't need dentures before you are 40.

Texas Health Insurance Plans

Texas PPO Plans

A PPO (Preferred Provider Organization) is a health insurance plan that utilizes a large network of medical services providers who have contracted with the network and agreed to a discounted rate structure. In most instances the PPO network and the insurance company are separate and distinct organizations. Although, some very large health insurance carriers will recruit and maintain their own PPO network. It will not be uncommon for an agent to tell you that the insurance is underwritten by the Acme Insurance Company but the PPO network is the All America Network. You will find, that unless your carrier advertises during the Super Bowl, the physician will be more familiar with the network than the insurance company.

For the consumer, the most important function that a PPO performs is the repricing of the bill. Let's use an illustration to show how the repricing feature of a network works and saves you money. What I am about to show you is one of the most important aspect of a PPO plan.

You have major medical PPO plan with a $2500 deductible and coinsurance of 80/20 to $5,000. You all now know what this means. You go to the doctor because you have a stomach pain. The doctor, who is part of your PPO network, normally charges $150 for new patient visits. You present your insurance card to the doctor's staff who will take your card and submit the bill to your insurance company. After a time you will receive an Explanation of Benefits (EOB). The physician also receives a copy of this statement. It shows the amount they billed, the amount that was disallowed and the amount you owe. Typically you might owe 30-50% less than the billed amount.

The doctor wanted some more tests done so they scheduled you for a colonoscopy. Again, the hospital will take your card and bill the insurance company. This time they billed for $3500 and the insurance company only allowed $1200. That is what you owe as you have not met your deductible.

This same pattern is true for all PPO providers. You are entitled to the same discounts that the insurance company receives from a PPO provider. These discounts can be very substantial. We have seen $100,000 hospital bills reduced by 80%. Always have the bill repriced.

A PPO plan provides the maximum flexibility in choosing your medical services provider.

Most PPO plans will permit you to go out of the PPO network. The coinsurance is changed and your share of the expenses is higher. Plus, there is no repricing. However, hospital bills are frequently negotiable. The hospital wants to get paid and will work with you. Do not be afraid to ask for a discount and payment terms.

Texas HMO Plans

HMO (Health Maintenance Organization) is a health insurance plan type that relies on the use of a primary care physician. This physician, except for special circumstances, must be seen before you are able to receive specialty care. The popularity of this type of plan has fallen off in recent years due to quality of care issues and the inability of the carriers to maintain an adequate network. Consumers have demanded the right to bring suit against HMO plans and these plans seem to provide a constant stream of material for late night comics.

Here are some pros and cons to Texas HMO health insurance plan:

Texas HMO Plans Cons

1. Require a primary care provider to provide a referral before you may see a specialist.
2. The primary physician often is required to treat medical problems that a specialist would be better off handling
3. There are often financial incentives for the primary physician to limit your access to specialty care.
4. You cannot venture out-of-network to seek higher quality care. Local coverage only.
5. Treatment protocols that must be followed are often not as thorough or complete as the physician would choose
6. Physicians often leave the plan forcing you to find a new primary care provider.
7. In many areas the "top" physicians are not HMO providers.

Texas HMO Plans Pros

1. Usually require the insured to pay less out of pocket expenses for routine care.
2. Offer doctor copays, prescriptions and in some instances maternity care.

As Texas health insurance plans go, I am not a big fan of HMO plans. You be the judge.

Indemnity Plans

Generally, we find two types of plans in this category; temporary and traditional.

Traditional plans are a throwback to the plans of twenty or thirty years ago. There are no networks and you can use any physician and any hospital. The lack of a network is a double-edged sword. It means that the fees are essentially unregulated. With a PPO to control costs a procedure might cost $10,000. With the indemnity plan, the hospital might charge you $30,000. The insurance carrier could determine that $12,000 is usual and customary. Guess who is stuck with the difference?

The traditional plan makes little sense today since most Texas PPO plans permit out-of-network coverage at an increased coinsurance rate. The 20-30% higher premium for a traditional plan makes it a poor choice for the consumer.

Temporary health insurance or short-term health insurance plans are traditional plans that are sold for a limited time period. You can find temporary insurance plans that can be used from 30 days to 3 years. Again, there are no networks associated with these plans. However, the premiums for temporary health insurance are usually much less than a similar PPO plan. Underwriting is also simplified and consists of a few yes/no questions. The plans can often be put into effect within 24 hours.

If you are denied coverage

Finding health insurance coverage after a medical decline is not easy. We do have some alternatives and have found insurance for even the most difficult cases. Call us for more information and visit our Guaranteed Issue Health Insurance web page.


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