How to Choose a Carrier.

Health Care Reform has leveled the playing field as far as coverage benefits and eligibility goes. Plans are standardized and fall into four distinct benefit levels (Bronze, Silver, Gold, and Platinum) and must be actuarially equivalent. Pre- existing conditions no longer restrict your access to coverage or result in higher premiums. By removing these two critical elements, what’s left to compare? Plenty!

As the second open enrollment period approaches, you will soon decide to stay with your current carrier, choose a new carrier, or enroll in a plan for the first time. As you compare carriers, there are several things to consider before making a decision.

Note: There are different criteria when choosing your plan type (Bronze, Silver, Gold, or Platinum).Plan type is best determined by the amount of medical treatment anticipated, the provider network, and your share of costs (premium plus out-of-pocket costs).
But carrier choice matters, too. An insurance company has a responsibility to pay your claims promptly, provide you with easy to understand plan information, supply an ID card, offer billing options and carryout your requests efficiently. How well they perform and meet these obligations could save you time and money.

Here are some things to consider:

  1. How is the carrier rated? A.M. Best is one of several rating services used to measure a company’s financial stability. Included in that rating is the ability to pay claims. A score of A- or better is an indication the company has an excellent ability to meet their ongoing obligations to policyholders.
  2. What is the extent of the carrier’s provider network? Call your doctors to see if they participate in the carrier’s plan. But also consider things in the event of major illness or accident. Where would you want to be treated and by whom? Make sure those facilities and providers are in the carrier’s network.
  3. What provider search tools are offered by the carrier? Some search tools require no less than a PhD to figure them out. The more complicated the search process, the greater chance for an error and inaccurate results.
  4. Does the carrier’s pharmacy formulary drug list cover your medications? Carriers don’t cover all medications prescribed. These lists are often available on carrier web sites.
  5. What is the coverage out-of-state and out-of-country? If you have children away at school or trips abroad are planned this could be an important consideration. Coverage and provider access varies among carriers.
  6. How long does it take for customer service to answer the phone? During the first open enrollment some carriers never did! If you think you found a plan and carrier you like, call their customer service line and see how quickly they answer and how friendly and knowledgeable they are.
  7. How long does it take to process a claim? This may not be as easy to obtain, but many carriers have this posted on their web site. It won’t be long before a rating system is in place where you can compare this data among carriers. Is the member correspondence clear? One of the major complaints last year was the vague literature provided by carriers. If you are currently covered you will be receiving a renewal packet later this year from your carrier. Review it carefully and write down any questions or concerns you have. Then call their customer service line and see how informed their front line people are. If their own people aren’t clear, there’s a problem.
  8. Is the member correspondence clear? One of the major complaints last year was the vague literature provided by carriers. If you are currently covered you will be receiving a renewal packet later this year from your carrier. Review it carefully and write down any questions or concerns you have. Then call their customer service line and see how informed their front line people are. If their own people aren’t clear, there’s a problem.
  9. What is your provider’s opinion of the carrier? A provider’s opinion can give you insight as to how efficient the communication is with a doctor’s office and how authorizations are handled. When you call your doctor’s office to check on their network participation, ask them their opinion about the carrier(s). You’ll get some very honest answers.

This year’s open enrollment period kicks off November 15 and runs through February 15, 2015. For more information about open enrollment, refer to my last blog posting by clicking here.

Phil Dougherty

Next Open Enrollment Period Uncorked…

In addition to sizing up a turkey or sniffing a yam, you might add squeezing a health plan or two into your Thanksgiving shopping list. This year’s open enrollment period was moved from October 15 – December 7 to November 15 – February 15, 2015, and if you want to ring in the New Year with a “fresh” plan, you’ll have a shorter amount of time to act this year.  Let’s look a little closer to see what this enrollment period date change really means. Continue reading

Employers & Employees Beware.

Popular among small employers was an arrangement by which they would pay the employee’s individual insurance plan premiums on a pre-tax basis. Market reforms within our new healthcare law now prohibit this.

Starting January 1, 2014, employers who reimburse or pay premiums directly to a carrier for any employee’s individual or family health insurance policy will no longer be able to do so tax-free. This may adversely affect both employer and employee. Continue reading

Short Term Insurance still has a place.

Our new health care reform law has made it possible now for virtually anyone to obtain health insurance. Those with a pre-existing condition(s) cannot be denied insurance, charged a higher premium or have coverage restricted in any way. This is a huge step forward in our health care system and the ramifications of this step are being played out as I write this message.

But there has been another significant change that was less publicized. There are only certain times of the year when you can enroll in or change coverage, called Open Enrollment. What! Did we fix one problem in our system just to create another?

Continue reading

Special Open Enrollment Period (limited to certain life change events).

With open enrollment now over, obtaining individual or family health insurance before the next open enrollment (currently scheduled for October 15 – December 7, 2014) is only possible with certain “life change” events.  Some of these events must result in a loss of minimum essential coverage such as a divorce or legal separation, a move out of state or service area, change in employment status (i.e., reduction in hours), loss of employer coverage, or the death of a parent or spouse.  Proof of a loss in minimum essential coverage is required. 

Or, if the life change event results in gaining or becoming a new dependent such as a marriage (including domestic partners) or the birth or adoption of a child, one can also acquire new coverage outside of next open enrollment period. Proof of these changes is required as well.

Being unhappy with the coverage you obtained during the initial open enrollment period or a change in a physician’s network status* does not qualify as a special enrollment opportunity.

The state has recognized this issue and has taken some steps to assist those who are in the middle of certain treatment.  It is called Continuity of Care. Click here for the web page from the Department of Managed Health Care, which explains Continuity of Care in detail. If you think you may qualify, contact your insurance carrier to begin the process.

*Since there are two exchanges in which to acquire new insurance (Covered CA and the private exchange) and multiple plan options within the same carrier in each exchange, there are network discrepancies surfacing between carriers and providers. Always check with your provider first before making appointments to see if they accept your insurance.  In speaking with them on the phone be as descriptive as you can and have your ID card handy.

As the plan year moves along, clarification and exceptions to rules are likely. Feel free to contact me if you have a question and I’ll do my best to provide you with the latest information.

Phil Dougherty

Tax day is also the last day to enroll in coverage.

Presentation3It appears no more delays or postponements are in the works.  April 15 is the last day to enroll in a plan for individuals and families.  In the private marketplace (not CoveredCA) several carriers (Anthem Blue Cross, HealthNet, and Blue Shield) have kept their doors open for those who have not yet enrolled in coverage and do not have a qualified alternative (group insurance or a grandfathered plan, for example).

You can obtain a quote and enroll online on our website:

The next open enrollment is October 15 – December 7, 2014 for a January 1, 2015 effective date.

Phil Dougherty


ACA open enrollment ends on Monday, March 31.

When the initial open enrollment period winds up at the end of March, the opportunity to purchase an ACA-compliant plan will close until the next open enrollment, which runs from October 15 through December 7th, 2014, for an effective date of January 1, 2015.  In the meantime, a “Special Enrollment Period” is available to change plans, or enroll for the first time, for those with a life changing event.  These include marriage, divorce, birth or adoption of a child, or loss of a job. Continue reading

Out of state…read the fine print!

171 (5)For decades the “Blues” (Blue Shield and Blue Cross) provided access to their nationwide provider network so you could stay in-network when out of state.  That was huge for families with sons or daughters in out-of-state colleges and a real advantage over HMO’s and less robust PPO’s that provided emergency only coverage when out of state.

Well, Blue Cross and some of the Blue Shield plans sold in the new private and public marketplaces today provide only emergency coverage. This is disappointing to say the least. Continue reading

Health Care Reform. A State of Change.

If you’ve been following my blog, you’ll know we’ve been gearing up for the important changes to our health care system. We’ve spent months preparing and planning for the most significant changes since the introduction of Medicare in 1966.  The key word here is “change”.  We knew the new Health Care law was going to create a lot of it. What we know now is the best way to manage that change is with patience, flexibility, and when appropriate…a sense of humor. More of each will be needed.

President Obama admitted in his speech, the complexities of the market were clearly underestimated and that people need help maneuvering through this labyrinth. (I wish he’d suggested calling a broker…but that would have been asking a lot.) Are we surprised that, in an industry as complex as health insurance, a government-run website was not going to be the fix-all. (Why we went to Canada for code instead of Silicon Valley is mind-boggling!)

Well, the bomb he dropped, asking insurance carriers to extend policies for 12 months, indicates there is still a lack of understanding of the market complexities.  It may seem a simple fix, but is anything but, and the insurance market is now in a new state of tizzy. Whether this plea for an extension can or will be implemented in California will be up to each carrier to analyze and decide.  There will certainly be pressure to comply from the Insurance Commissioner and consumers but this request is more than “crossing a‘t’ or dotting an ‘i’. It would certainly be a welcome “re-change” for some consumers who got a glimpse of some sizable rate increases.

As a broker, we continue to move forward and adapt to this ever-changing environment.  We are helping our clients sort through options, pointing out the new intricacies, and untangling the web of this new healthcare system.

Tip:  Since the new private marketplace is offering plans with the same essential benefits as the public exchange, unless you qualify for a subsidy, there is no compelling reason to enroll on the public exchange (Covered CA). The private market will offer more options and a more streamlined enrollment process.

We are currently unable to directly assist our clients with enrollment in Covered CA due to technical problems on the website that won’t allow us access to client accounts. (This is what we were to have tested in July!)  So we are advising clients who believe they will qualify for a subsidy to enroll directly through Covered CA’s website or by calling them at 800-300-1506.

Stayed tuned for more!

Phil Dougherty