Healthy Concepts
John Ulness

John Ulness

John Ulness is co-owner of Ulness Health Insurance & Wellness in Appleton. He helps people in Wisconsin understand their health insurance options to control costs and enroll. He can be reached at 1-800-386-0876 or [email protected]

Tuesday, 31 October 2017 16:45

Five basics to know about health insurance

When you buy health insurance, you want to look at five basic items to find the best plan that meets your wants and needs.

1. Premium

You can pay a monthly premium from $0 up to about $1,200 per month. Tax credits based on your household income and other government programs such as Medicare and Medicaid can lower your monthly premium cost. If you have an employer group plan, your employer will pay a large portion of your premium with the balance taken off your paycheck. You always want to know your premium cost options to compare your plan benefits.

2. Out-of-Pocket-Cost

Deductibles, co-insurance and co-pays make up your maximum out-of-pocket (MOOP) costs, or sometimes called your out-of-pocket limit. This is the most you would pay in any given plan year or calendar year. You can see MOOP costs up to $7,150 for one and $14,300 for a family of two or more. As these costs increase, you want to be more aware of your health and ask more questions about medical care benefits and cost.

3. Provider Network

HMO, PPO, POS, EPO and PFFS are all different types of insurance plan options to access providers. Preferred Provider Organizations allow you to see any doctor while the Health Maintenance Organizations require you to see specific providers.

You want to know your cost and access to providers both at home and away to avoid billing surprises.

4. Rx Formulary

A list of covered drugs, at different tier levels, encourages you to use lower cost medicines. If your medicine is not on the formulary, it is not covered.

5. Wellness

More health insurance plans are offering benefits to improve your health. Some of the plan offerings can be free fitness club memberships, health coaches, doctor visits online and by phone, over-the-counter products and devices to track your health improvement. Wellness plan designs can include HSA and MSA plans that offer a savings account for your health care expenses. Your incentive is to eat healthy and be active to reduce your need for expensive medical care. Any money left in your account at the end of the year rolls over to increase your HSA or MSA savings account while your deductible stays the same.

You can get expert help on all this with a licensed health insurance advisor during your annual open enrollment period.

Marketplace OEP is November 1 to December 15.

Medicare OEP is October 15 to December 7.

Employer group plans set their own annual open enrollment period. 

The annual open enrollment period (OEP) is when you can enroll or change your health insurance plan.

Employer group plans have their own OEP dates, but if you have Medicare or buy health insurance on or off the Marketplace, you have a set OEP each year that follows a calendar year.

The 2018 Marketplace OEP is November 1 – December 15.

The Marketplace OEP is shorter this year, and we are expecting a very busy OEP due to the fewer days and more insurance carriers ending their Marketplace place plans. Anthem Blue Cross and Blue Shield and Molina Healthcare are ending their Marketplace plans on 12/31/2017.

If you have an Anthem BCBS or Molina plan, you will need to pick a different company and plan during the 2018 OEP. If your current plan is continuing in 2018, you will be able to review any changes to determine if you want to stay or change. If you have no health insurance, this is your opportunity to enroll.

After you enroll and pay your first month premium, your new plan begins January 1.

2018 plan offerings and prices will be released Wednesday, November 1.

For your convenience, on November 1, you can visit our website at www.ulnesshealth.com to see 2018 Marketplace plans, prices and tax credits for 2018. Just click on health insurance for Wisconsin and put in your information to view and compare plans, tax credits and prices.

The Medicare 2018 OEP is October 15 – December 7.

It is your opportunity to change or add plans for January 1.

As a current Medicare member of a Part D prescription drug plan or a Medicare Part C (Choice) Advantage plan, you will receive your notice of any changes for 2018. Your annual notice of change (ANOC) letter from your current plan is mailed to you by October 1. It gives you any changes on your current plan by line item for 2018. If you are OK with any changes, your current plan will automatically renew.

Please feel free to call our office to get 2018 plan information on Medicare plans beginning October 1. You can also go to www.ulnesshealth.com to see schedules for educational and informational meeting opportunities to learn more about 2018 plans. Other insurance agents and companies will be holding meetings that you can attend as well.

You want expert help during the 2018 OEP to avoid any surprises in the New Year. 

Thursday, 31 August 2017 03:08

Who pays?

It happened at 3 a.m. and something that you never expected. But two trips to the hospital emergency room over three days and a $34,000 bill later, the question is what was more painful: the kidney stone or the bill? 

Who would have thought that going to the emergency room could cost that much?

The $34,000 bill was reduced to $19,000 by insurance discounts, but your $5,000 deductible with a $7,150 maximum out-of-pocket (MOOP) limit can put the hurt on anyone.

What should you do when pain hits? 

On the second visit when the ER urologist suggested a procedure of inserting a stent to help remove the stone, your initial reaction is to do it, but what about cost? If you knew the cost was over $30,000, would that change your decision to proceed? Years ago, when you paid less and insurance paid more, this decision would be easy, but not anymore. You want to know your cost, health care benefit and risk. Until you reach your $7,150 limit, you will pay much of the bill. 

Using this example, see what you pay and what insurance pays as follows:

Individual pays

Insurance pays

$34,000

$15,000

(Billed charges)

(Insurance discount)

$19,000

 

(Approved amount)

$5,000

(Deductible)

$14,000

(Balance)

$2,150

$8,600

(20% co-insurance)

(80% co-insurance)

 

$3,250

 

(Balance due)

$7,150

$11,850

(Total you paid) 38%

(Total insurance paid) 62%

Now that you’ve reached your maximum out-of-pocket for the calendar year, your health insurance plan will pay 100 percent of approved medical charges for the rest of the year. Hopefully the kidney stone did not occur in December, because in January your deductible and MOOP start all over again. When pain hits, you want to ask questions about your options to best address the root cause of it at the best cost.

In regard to cost, you want to know your insurance out-of-pocket costs in the form of deductibles, co-insurance and co-pays. It is these costs that make up your annual MOOP limit. In the hospital, your MOOP limit can be reached very quickly. Tell your doctor or other health professional right up front that you have a higher deductible and need to know the approximate procedure’s cost, expected benefit and risk for doing a certain procedure, and on the flip side what is the cost, benefit and risk for not doing it or doing a different approach. 

Also, always ask what you can do to manage your condition better at lower cost. This is something that frustrates doctors because many people will not actually follow recommended options to manage or reverse a health condition. The kidney stone episode is a learning experience on cost, benefit and risk. 

Understanding more about your health care and insurance is more important as these costs are shifted to us, the consumer. It requires a greater awareness about all this and lots of questions to stay in control of your decisions. Once you have greater control, you can do more to help yourself improve health, lower cost and save money. 

Monday, 31 July 2017 18:10

Your path to healthy living

Your “path to healthy living” is not only the mission of this magazine; it is also becoming the goal for many health insurance plans as they offer more benefits designed to avoid or reduce your need for expensive medical care.

More health insurance plans are focusing on health by offering benefits for fitness, nutrition and stress-relief that we can use every day. Gym club memberships, cooking classes, and many other health and disease educational program options are being offered at low or no cost to us. These benefit plan options are designed to educate, empower and engage us to help us achieve better health or better manage pre-existing conditions.

The incentives are great.

Mickey Mantle once said, “If I had known I was going to live this long, I would have taken better care of myself.” We are living longer and given new opportunities, we can do more to help ourselves. Our risks to age related diseases like cancer, heart, brain and many others can be reduced by taking action earlier rather than later.

In addition to better health, we can avoid paying higher out-of-pocket costs in the form of higher deductibles, co-insurance and co-pays.

Many HSA plans and Medicare MSA plans offer a third incentive and that is to save money for the future or to use these dollars we need for qualified health expenses that are not covered by our health plan. Dental, vision, over-the-counter medicines and acupuncture are examples of this.

The incentives are great, but there can be more. Just like the adage, “you can lead a horse to water, but you can’t make him drink it.” We cannot be forced to do things if we do not want to, but some plans are doing more to help us improve our health.

These health insurance benefits use the latest health technology that connects us and gives us new health awareness about our health. The best part is when we act on our health and show improvement — we get paid.

The best incentive of all can be our ability to take control of our health and our health care dollars to save or spend on what we need most.

It is a different time in health insurance benefits that put a smile on many faces.

Health insurance has become more complicated and expensive. Remember to always work with a licensed health insurance advisor to guide you through your many options that can save you money and improve your health. 

Government? Insurance companies? Doctors? Hospitals? Employers? Or should it be us, and our families and friends working with health professionals to decide how we spend money on health care?

This is part of the debate that is moving through our government legislative process as the U.S. House of Representatives have sent a bill to the U.S. Senate that makes changes to the Affordable Care Act of 2010.

We can spend our money any way that we want, but when faced with expensive medical care bills, the many rules and regulations of health insurance take over.

As health insurance plans move to higher deductibles, we have incentive to take charge of how we spend our health care dollars.

No one knows what the legislative process outcome will be, but one thing is certain, and that is, we will need to make more informed decisions about our health to reduce our health risks and lower our need for expensive medical care.

To our advantage, new technology is available that uncovers disease risks before symptoms appear; and new health information is available to reverse it. Test results showing high risk for diseases like cancer, diabetes or heart disease can be addressed.

For example, the latest genomics health information research is showing that gene expression can be controlled by nutrition and nutritional supplementation to turn off bad genes and turn on good genes. It follows the same path as antioxidant protection at the cellular level for our whole body. The more we learn about things we do every day to reverse pre-disease risks, the more we can do something about it.

The current system does not offer direct benefits to reverse pre-disease. This is why we as consumers, using our own money will demand health care help to address disease before it happens.

It may be a while before health insurance plans direct us to focus on health before disease, but the expansion of health savings account type plans can motivate us to drive innovation using our own health care dollars to improve heath and lower cost.

Health savings account plan designs are available to people on Medicare, individual plans and many people who receive their health insurance through their employer.

Remember to always work with a licensed health insurance advisor to choose your health insurance plan to determine what plan is best for you. 

Wednesday, 31 May 2017 20:56

Take charge of your health

Higher health care and insurance costs require us to take charge of our health. The good news is that new programs are emerging to control cost and improve health.

A few years ago a client called about coverage for monthly cholesterol screenings. His doctor wanted to put him on a statin drug for high cholesterol, but he wanted to try diet and exercise first to avoid the cost of medicine and potential side effects.

His health insurance plan would only cover cholesterol tests if his doctor recommended it as being “medically necessary,” and since his doctor already recommended a medicine, it would not be covered.

He told me his last cholesterol test covered by insurance was billed at $212, but reduced to $80 after applying the insurance discount.

Someone who wants access to a cholesterol test at a set price any time without a doctor or insurance company approval can travel to Manitowoc. Holy Family Memorial (HFM) has three clinics there that offer direct lab tests. It’s like going to McDonalds. You check off what tests you want from a menu of 73 items, pay up front, sign a release form and have your blood drawn. That’s it. The test results are mailed directly to you within a week.

The HFM direct lab test for cholesterol costs $20. It is listed as a lipid panel that includes total cholesterol, HDL, LDL and triglycerides.

To learn more about the HFM program, www.hfmhealth.org and click on “Services,” then “Lab Services” and finally, “Direct Lab Testing.”

The direct lab program is an example of how people are changing health care to be more patient-centered — it offers access, set pricing and convenience.

Faced with higher deductible plans, providers are realizing that more payments come directly from the consumer and not insurance. As a result, health care providers are rethinking their services to meet consumer wants and needs. The big shift is a focus on health. More consumers are asking for help to avoid the need for expensive medical care because they do not want to pay their higher deductible.

Finding new ways to engage health consumers to achieve better health is one of the big challenges for providers. Whether it is a diet and exercise approach before medicine or access to tests to measure health progress from a lifestyle approach, more people want help to improve health and lower cost.

Remember to always use a licensed health insurance advisor to learn more about your health insurance options for health care. 

Sunday, 30 April 2017 23:22

Solving the health insurance cost puzzle

Buying health insurance has become very expensive. For many years, most of us received health insurance through our employer’s group plan. We paid little or nothing toward the premium and out-of-pocket costs. We never got a bill, because the group health insurance plan paid it.

To show you a perspective on how costs have increased, in 1963 a family plan cost the employer about $2.50/month or $30/year. In 2017 or 54 years later, that same plan will cost about $2,500/month or $30,000/year.

Today, these higher costs are being shifted to the individual and family in the form of premium contribution and deductibles. This cost shift is the new reality for people who receive their insurance through an employer or buy insurance on their own.

Five tips for buying health insurance:

  1. Know your monthly premium and annual maximum out-of-pocket limit. If you have a large health care bill, this is your total financial risk each year.
  2. Know your existing health care costs. What are the names, dosages, quantities and costs of your prescription medicines? What are your anticipated office visits, labs, tests and other product costs for the year?
  3. Know how these health care costs are covered by your plan. Compare the coverage of these costs to your annual premium cost. Does it make sense to pay more in premium to have lower out-of-pocket expenses, or does it make sense to save the lower premium for when you need it?
  4. Know your health insurance plan options. Many people today have health insurance options to choose from such as HSA qualified plans with health savings accounts, HMOs and PPOs that determine the doctors and hospitals you can access.
  5. Ask questions. Every year plans can change. You want to access a health insurance advisor to make informed decisions about your insurance cost and coverage.

After you purchase your health insurance plan, your other purchase decision is health care. Here you want to assemble your team of health professionals who can help you assess your health risks, and work with you to improve your health to avoid paying high out-of-pocket costs each year. 

Thursday, 30 March 2017 19:48

Health insurance changes

Higher health insurance costs require us to know more about premium and out-of-pocket costs to help us determine which insurance coverage is best for us.

Below are three different health insurance plan examples to review:

 

Plan 1

Plan 2

Plan 3

Monthly premium cost:

$200

$400

$600

Annual cost:

$2,400

$4,800

$7,200

 

Out-of-Pocket Cost:

Deductible:

(Annual)

$6,000

$4,000

$2,000

Co-insurance:

(After deductible)

50/50

70/30

80/20

Co-pays:

(Before deductible)

N/A

N/A

$35

Maximum out-of-pocket:

(Annual/calendar year)

$7,150

$7,150

$7,150

 

Total costs:

(Annual premium + MOOP)

$8,400

$11,950

$14,350

More people are looking for greater premium savings to offset higher out-of-pocket costs.

Plan 1 offers $4,800 premium savings each year compared to Plan 3. When you apply the premium savings, the $6,000 Plan 1 deductible becomes $1,200.

This is lower than the Plan 3 deductible of $2,000. Your $35 office visit is not offered in Plan 1, but more people are moving to higher deductibles to access the monthly premium savings.

When you have greater control of your money, you can do more to access the health care you want and need.

Since 2014, the Affordable Care Act offers everyone access to health insurance. It also offers affordability to lower income households below 400 percent of the federal poverty level (FPL). In 2017 that number is about <$47,000 for a one-person household and <$65,000 for a household of two.

The best plan for you will depend on many considerations, such as your current medicines, doctors, medical care needs and household income.

As the market moves to higher deductible plans to lower premium cost, we need to know more about our health and what we can do to avoid expensive medical care.

Changes in health care and insurance make it more important than ever to work with a licensed health insurance broker to review your options.

 

Subscribe Today
Community Partners Directory
Find a Newsstand
Community Calendar