Florida Health Insurance Plans

Consumer's Guide to Selecting a
Florida Health Insurance Plan

In a word - YES! Often, when we speak with someone who is coming from a group plan, they are attempting to duplicate the benefits they had while they were employed. They forget that an employer was footing at least half of the bill. I know you think you need to have everything covered with little or no out-of-pocket expense. Get a grip on yourself. The Megabucks corporation is not paying your health insurance premiums anymore. The premium is going to come out of your pocket and unless they are very deep, you need to figure out what is important and what is not.

Let's start by avoiding getting "sucker punched" with a "sucker's rate" for health insurance. What does this mean? It simply means that if you lower your deductible from say $2000 to $500, you should not pay an extra $1500 a year. Chances are you will never reach either deductible and you will only make the insurance company rich.

You would be amazed at how many people will pay $500 a year in insurance premiums so that they can get a $200 allowance for an annual physical. What are they thinking about!

If you have a business background you know about something called a "cost benefit". In other words, if I spend another $100 a month on health insurance, what extra benefits do I get? Are they worth it? Part of my job is to give you comparison quotes from different levels of coverage and help you to decide if the benefit is worth the extra cost. In most instances, high deductible plans are much better value than low deductibles.

Each insurance company arranges their rate charts to make certain deductibles more attractive than others. Depending on the company, this is generally between $1500 and $2500. If you move to a higher deductible the savings are negligible. If you try to move lower they will increase the premium by at least the difference if not more. Remember, this deductible generally only comes into play if you have a serious illness and are hospitalized.

TIP: Take out your calculator and ask your agent to give you a few different deductibles and coinsurance choices. A good agent will tell you where the plan's sweet spot is regarding deductible and coinsurance options. However, you can easily do this yourself.

I want you to understand what a doctor copay feature means. This is important and will avoid a lot of misunderstanding when you use your plan bennefits.

A doctor copay feature is the fixed amount you pay for an office visit when if you visit the doctor when you are sick. It usually is available when immediately and not subject to any deductibles.

Now for the fine print. This copay is for non-well visits only. It does not apply to physicals. If the plan has a copay that covers testing and x-rays, it does not cover any testing or procedures performed outside the doctor's office. If covered, those tests must be performed when you visit the doctor and the doctor must bill you for it directly. Not a usual occurrence since most physicians use outside labs and radiology facilities.

TIP: I will explain later on about PPO discounts. However, even without a doctor copay feature in your plan, you can usually see most doctors at the discounted PPO rate. This is typically somewhere between $35 and $50. Lab visits and x-rays are also deeply discounted.

Most of the plans we sell have some provision for annual checkups either every year or every other year. Many plans will require that you are on the plan for 12 months before you can use this feature. The allowance for physicals runs between $100 and $200. Some plans offer a separate allowance for mammograms.

Even though the Health Channel or 60 Minutes,recommends you get a colonoscopy and/or an MRI every few years, remember that you will be paying for it yourself.

Most states have special provisions for children's well care visits that avoid deductibles and other limitations. Check with your department of insurance for specific details.

If you are currently taking a medication on a regular basis, it is highly unlikely that an insurance company will pick up the tab without increasing your premiums. At this point, I often hear - "Then what the hell do I need health insurance for". I was always told that there is no such thing as a stupid question. But, this one comes real close.How anyone can ask why a company will not pay a $150 prescription bill when they are paying $250 in premiums is beyond me.

You have health insurance because you can die without it. Its the ugly truth. If you want to go into a hospital without any insurance, and become a science fair project for an intern that hasn't gone through puberty, that's your business. You buy health insurance to make sure you don't lose your retirement savings from a bypass operation and have access to the best possible medical care. Not to pay for your heartburn medication.

A few plans will cover some medications you are already taking by kicking your premium up. Which I do not consider a benefit at all. The sooner you stop complaining about the fact that you will have to pay for your own medication, the sooner your stomach will stop hurting and your blood pressure will go down.

If you can afford it, having prescription coverage for medications that you might need in the future is a real nice feature. There are chronic illness that have staggering medication costs. There is a middle ground. You can get high prescription deductibles or find plans that cover prescriptions after a plan deductible is fulfilled.

If you are a diabetic, cancer survivor of less than 10 years, or haven't been able to look down and see your feet since 1985, you will have difficulty getting coverage, and probably won't be able to get coverage at all. High blood pressure and cholesterol are usually not a problem if controlled. Antidepressants are fine if you haven't been hospitalized. Most problems of this nature will not get you denied. Although, some companies are much tougher than others. I can usually tell you in advance if there will be a problem.

Now I don't want you to get upset (which translates to stop blaming me) but the fact is, your current medical conditions will in most instances not be covered. When faced with a preexisting condition, a company will either; 1) Cover it with no exclusions, 2) Cover it but raise your premium a bit, 3) Insure you, but rider out the condition so that any treatment for the condition is not covered or 4) Deny coverage completely.

The most common question I hear is -"When will they cover my preexisting conditions and prescriptions?"
When? I'll tell you when. When Osma has a Bar Mitzvah. Ridersare usually forever.

I should have put this at the top of the page but better late than never.Here is how it works.

The plan deductible is your out-of-pocket contribution. It is usually per person with a maximum of three per family. The coinsurance, that 80/20 thing comes after the deductible. So, if an agent says to you "It has a $2000 deductible and then 80/20 to $5000", it means that if your hospital bill was $20,000, you would pay:
1. the first $2000 of the bill
2. then 20% of the next $5000 of the bill (which is $1000).
So, your maximum out of pocket, per person, per year is $3,000 ($2,000 deductible and $1,000 coinsurance). If Got it?

When a plan has doctor copay features, prescription coverage, etc., this is not part of the deductible. These features are available immediately. So, if you want all the bells and whistles to pay for the things you are most likely to use (doctor visits, prescriptions), get a high deductible plan and save money on the features you are much less likely to use.

Many of my conversations start out with someone telling me that they can't afford a high deductible. What they eventually find out is that they can't afford a low deductible. As I mentioned earlier, the insurance company will soak you good for a low deductible. I am a commissioned salesman. Don't you think I would love to sell you a plan with a $500 deductible? I clip coupons and look for two for one specials in the supermarket. It is against my very nature to let you throw your money away. You are better off using your insurance dollar to buy disability insurance or more life insurance than pay for a low deductible. Heck, take the money and take a vacation. You'll probably feel better and not need so much medical care.

Let's say you had a huge deductible and coinsurance that amounted to $3500 out of pocket expense if you went into a hospital. However, you save $125 a month in premium over a plan that has a total out of pocket of $2000. Now watch carefully:
Year 1 - No hospital visits - you saved $1500 ($125 a month times 12)
Year 2 - No hospital visits - you saved $3000
Year 3 - No hospital visits - you saved $4500
It is unlikely that you will go to the hospital (statistically speaking). If you do, you can pay off the hospital bill. Why do you want to pay for something that might never happen? This isn't income taxes pal. There is no refund at the end of the year. If it makes you feel more secure to have a low deductible by all means do so, I can use the extra commission. Then I'll be able to take a vacation.

This is important. Very important. A PPO network has already negotiated a discounted rate with all of their providers. By belonging to the network, the providers have agreed to accept this rate schedule for their services. If you have a PPO plan and utilize one of these providers (doctor, labs, hospital) you are entitled to the discounted schedule rate. It is rare that I hear of a doctor who will not honor this discount.

The discounts, by the way, are very substantial. I have seen lab fees reduced 75% and major out-patient procedures reduced 50%. I personally have a $2500 deductible and either have the doctor bill me so I can see the PPO rate on the bill when it comes back from the insurance company, or pay the PPO rate in the office. If you are going to have testing (colonoscopy, MRI, etc.) make sure you find out what the PPO rate is beforehand.

Here are the facts:
1. If you have had your previous child by C-section than you cannot get coverage until you have had another child by vaginal delivery.
2. You must take the maternity coverage when you buy the plan. You cannot add it later.
3. There is a 12 month waiting period before the coverage becomes effective.
4. Most plans do not even have maternity riders available.
5. If you are already pregnant give me a call after the baby is born because you are not insurable, your husband is not insurable nor are any of your children. If you are interested in learning why, you can call me and I will explain it.
6. Go to the hospital and negotiate a fixed price for delivery. Everything is negotiable. Ask what the PPO rate is.

Even if you do not have maternity coverage, the new-born infant is covered immediately upon birth (assuming you have coverage) and complications to pregnancy are also covered. Don't sweat it. The cost to deliver a baby is only a down payment. Wait till you have to pay your kid's car insurance.

Folks, its a jungle out there. I am going to give you just a few rules that should prevent most of the buying mistakes:

Rule #1: Avoid plans with a schedule of payment. There are a few low cost plans that have surgical schedules and limitations on the number of doctor visits. You might find yourself paying huge hospital bills for things you thought were covered. However, for some of you, a medical supplement coupled with PPO access might be all that is available or the only plan that is affordable. In this case get the highest indemnity levels you can and a quality PPO access plan. We have such plans and will sell them in special situations.

Rule #2: Never buy from an agent that sells only one plan. These are the agents that work for the marketing armies and will tell you anything you want to hear to sell a plan. These monsters get paid every week on each plan they submit. Later, if the plan is rejected, or you find out the truth and cancel the plan, they have months to replace it with other business. They often sell the plans found in Rule #1.

Rule #3: Never lie on an insurance application. It is a felony, will get you blacklisted and you will have problems getting insurance in the future. If someone suggests that you lie, throw them out.

Once again I have to remind you that the kind of coverage you had when you worked for a large corporation is not available to you. You must be on drugs if you think that a company will take $20 a month from you and immediately pay for $3000 worth of crowns and root canals. If that is what you are looking for, save the phone call.

I do have plans where you can go to any dentist but they are very expensive and limit your benefit to not much more than the premiums. Some discounted fee for service plans can be great deal. I have a plan that will let you get 2 free cleanings, x-rays and oral exam for $10.95 a month ($24.85 for the whole family). If you can find a dentist in the plan you like its a great deal. You can look at our dental site for more information about dental plans.

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