Healthcare Consultants News

Health insurance broker, health insurance agent

The Difference Between a Health Insurance Broker and Agent

A health insurance broker is a professional who can help you secure the best policy for your needs. But how are they different from a health insurance agent? What should you know before using either of their services? Do you get a better deal using one over the other?

When it comes time to search for a new insurance company or employee policy it pays to understand the difference between an agent and a broker. Before you sign on the dotted line for your next policy review what each has to offer and some finer points you may be unaware of.

What a Health Insurance Broker Does

A health insurance broker’s primary job involves working one-on-one with clients to locate a health insurance policy that’s right for them. These brokers are authorized to guide clients through the various policies available to them. They explain the nuances of each plan so clients can make a well-informed decision. They also assist clients in enrolling in a Qualified Health Plan (QHP) via the marketplace.

Brokers are licensed and must have passed a series of examinations and courses to attain that license. After they’ve received their legal license, brokers may be required to take additional classes by the state. Once they’ve passed these examinations, they are required to stay up to date with the latest policy and law changes. Currently, health care reform has required brokers continuously educate themselves to ensure they can provide their clients with relevant information. Additionally, states constantly change their health care policy, making it an even greater challenge to be a broker.

In addition to securing and negotiating health care coverage for clients, brokers are also involved in day-to-day insurance activities. They resolve claim disputes, assist with enrollments, manage the status of family and child care policies, and resolve billing problems. They are more than just a middleman between the individual and the insurance company.

Most brokers are independent of insurance companies. They work as “free” brokers and are given the authorization to offer clients a host of insurance plans. A health insurance broker earns more by finding clients affordable plans with high benefits, which works in the favor of his clients.

Brokers may also be paid a fee by companies to isolate the best plan in the local marketplace for their business.

The Affordable Care Act (ACA) has increased demand for brokers as the complexities of the bill are difficult to follow. Individuals and small businesses are in particular need of brokers to identify the best plans available.

To recap, health insurance brokers do the following for clients:

  • Shop local healthcare markets to find the best plan options
  • Help clients with claims
  • Negotiate rates
  • Assist with billing issues
  • Outline plan designs and options

What a Health Insurance Agent Does

A health insurance agent is a bit different. While their primary job description is the same as a health insurance broker (identifying the right plan for clients), who they answer to is different. Most brokers are able to offer a wide variety of health insurance policies to their clients because they don’t work for just one. Instead, they receive a commission on the sale of policies, but this does not increase the costs for their clients.

Agents, on the other hand, may represent a single insurance company, instead of several. They are paid by that company in a more generalized sense. The number of plans they can offer is limited to that company. Obviously, this can cause their clients to pay more for the same or similar policies that a broker might suggest.

Interestingly, however, a health insurance agent may be employed by a health insurance broker. These agents work with brokers to isolate the best plan from a specific company. The word “agent” and “broker” may also be used interchangeably, but most brokers will advertise that they are a broker since most in the market associate that title with greater options and lower priced plans.

Health insurance agents, like brokers, can also help their clients understand the benefits offered by non-government exchange plan options. The marketplace is designed to bring about lower priced premiums, but recently that hasn’t been the case. To get a more affordable plan, most individuals and employers need a qualified and highly educated agent in their corner working to explain their plan options. However, with most agents, you won’t be able to purchase the plan through them since they are restricted by the company they work for. Nonetheless, the information they provide is invaluable.

Another offshoot of health insurance agent is a “captive” health insurance agent.

What Are Captive Insurance Agents?

Captive agents, also known as “direct” agents, sell policies exclusively for a single insurance company. You can easily spot these captive agents via their marketing. Notice a specific insurance logo in their emails or invoices? If so, they are likely a captive agent.

An independent agent is usually called a “broker” as they shop the marketplace for the best policy and then once they identify a plan that works for you, they become your ‘agent’. Because they aren’t bound by the insurance company’s options, they won’t sell you a policy that might not be right for you. Captive agents, however, are bound by the company and will do their best to sell you plans that may or may not be right for your needs.

How You’re Affected

Whether you’re hiring a health insurance broker to find a good group employee plan or an individual family health care plan, a broker is a crucial tool in lowering insurance costs. Additionally, the right broker can secure a plan that has all the benefits you need and more. They save you time and money along the way.

A health insurance agent can also save you money, but if they are a captive agent they might corner you into a plan you don’t want because they don’t have the freedom to search the entire marketplace. If you’re looking for the best plan option, then the best route to take is to hire a health insurance broker who can then become an independent agent once they find the right plan.

Also, working with multiple agents won’t save you money. An independent broker can provide the cost savings you’re looking for without the headache of working with multiple agents.

Companies are particularly in need of a broker. Negotiating employer-sponsored plans is difficult and outsourcing this task to a professional saves time and money.

Either route you go, remember that entering the market without a broker or agent can cost you big time. The savings you can secure with a professional on your side is incomparable.

Share this:
Individual Market Houston

Individual Market Losing Carriers—What Does it Mean for Group Plans?

In 2016, insurance carriers lost some $7.5 billion. While that rate has improved slightly since the Affordable Care Act was first signed into law, losses are still extremely high. In Texas, where the number of the uninsured is highest, the individual insurance market is seeing carriers drop out of the market at an alarming rate. As Houston healthcare consultants, we’ve watched the steady decline of carriers in Houston since the ACA took effect. The question is, how will this ultimately affect group insurance plans and what does it mean for the individual market?

Fewer Insurance Carriers—Why It Matters

On the surface, it might seem as though it doesn’t really matter that more insurance carriers are dropping out of the individual market. However, this development has the potential to undermine some of the ACA’s strongest features.

Fewer Options

Customers, in general, prefer more options to compare and select from. A dwindling number of carriers means fewer choices for customers leading to less satisfaction and a sense of being “forced” into purchasing insurance. As Houston healthcare consultants, we’ve witnessed as this has caused confusion among customers who want to know what their options are. With fewer exchange options available, more people are being pushed off and into the hands of non-exchange insurance carriers.

Increased Costs

The ACA was built on the premise of a strong network of insurance carriers. Without a strong marketplace, competition wouldn’t keep costs affordable—which was the entire point of the bill. As more and more insurers leave the individual insurance market, the costs have seen a significant rise.

The number of carriers on the exchange continues to decrease while premiums have grown more unaffordable. Not only are consumers left with fewer choices, those choices continue to grow more expensive as premium hikes are imposed each year (some jumping up as much as 18% from the previous year).

How Houston Has Been Affected

Texas has long been the face of ACA opposition. Former Gov. Rick Perry refused to expand Medicaid under the ACA, despite the federal government pledging to pay some $100 billion of the costs over the next decade.

When it comes to the exchange, the climate hasn’t changed much. Insurance carriers continue to leave Houston’s exchange networks. Currently, there are only three insurance carriers on the individual market in Houston. They include BlueCross and Blue Shield of Texas, Community Health Choice, and Molina Healthcare.

That number has dropped from seven individual market insurance carriers in 2016. Some of the major players who are dropping out of the market include Atena (who has been pulling out of exchanges around the country), Humana, and Cigna.

As these insurers are leaving the market, they take their coverage options with them leaving thousands in the Houston area without affordable health care options.

Plan options have also changed. Carriers are required to maintain the minimum essential health benefits, but the rates of those plans continue to increase due to two or three carriers carrying the brunt of the burden. That burden, of course, is passed on to participating consumers.

Insurance Carrier Price Hikes

On the heels of this news, the remaining three insurance carriers in Houston have announced significant price hikes.

Community Health Choice has announced a 16 percent hike in premiums and has warned more may be needed. Blue Cross and Blue Shield of Texas hasn’t yet announced their premium hike, although some reports say they are seeking up to a 60 percent hike throughout the country.

Coupled with premium rate hikes we will also see a reduced number of plans overall. Insurance carriers are looking for ways to cut costs while staying on the exchange, and limiting plan options is one way to do it.

As companies struggle to stay on the exchange and scramble to deal with Congress’ overhaul of the ACA, consumers are caught in the crosshairs. Even those in Houston. Using Houston healthcare consultants to select the ideal plan is a route most companies are now taking.

What Does This Mean For Group Plans?

Group plans are directly affected by any decision insurance carriers make. Just as rates increase on the individual market, so do they for group plans.

Ultimately, this will result in increased premiums for both employees and employers. Employers typically pay about 1 percent more (a bit over half) for employee insurance plans. As these rates rise, this will cost employers in a major way while employees continue to have support from their employer.

It could also change the way group plans are structured, particularly if a reversal of the ACA actually happens. Additionally, uninsured rates are likely to rise and costs for the federal government will increase.

What The Future of The Individual Market Carriers Looks Like

The future of the individual market carriers in Houston and around the nation is uncertain. Most of the carriers pulling out of the market are citing losses and chaos as the main culprits. Reversing this trend will not be easy.

Uncertainty isn’t good for any product, but especially so for insurance providers. However, if Congress can pass a new bill that transforms the market the results could be positive. Insurers may have greater flexibility to offer their products and plans, and consumers will have more options to choose from. This could produce a healthier marketplace in the long run.

In the short-term, uncertainty is likely to cause more insurance providers to drop out of the Houston exchange. For example, the Memorial Hermann Health System has opted to quit the individual insurance business in Houston.

The company has spent 3 years trying to master the exchange with nothing but losses to show for it. The company will continue to offer Medicare Advantage coverage options for businesses, but they are permanently leaving the individual marketplace. Some 66,000 plus people currently have those plans but will be unable to resign for them in 2018.

Additionally, consumers aren’t likely to get the affordable plans they were promised from Obamacare. Fewer options reduce competition leaving companies who stick with the exchange an opportunity to increase their premiums.

With no way to estimate who they’ll be covering, how sick policyholders will be, or what will come in the future insurers are left with little other option but to pull out of the individual market. Uncertainty is on the rise, and until the federal government can come to an agreement on what they’ll be offering consumers, it will continue.

How We Can Help

As Houston healthcare consultants, we help both individuals and employers navigate the complex and confusing individual insurance market. We understand it’s nearly impossible to understand your options. And we want to help.

If you need assistance selecting the right employer sponsored or individual health insurance plan in Houston, please contact our team. We are ready to give you the guidance you need to opt for the right plan.


Share this:
healthcare costs, healthcare management

10 Healthcare Management Mistakes Costing Your Business Money

Each year, some 20% of health care costs are wasted in the United States. Most of this waste is caused by a poor understanding of coverage. Proper healthcare management for businesses is, therefore, a crucial component to reduce costs. However, business health insurance and group plans can be a source of reprieve for employees and businesses, if they’re used correctly.

Unfortunately, many CTO’s simply don’t know what they can and can’t do with employee health plans. Additionally, employees are often overwhelmed by their benefit options. Complex healthcare lingo only complicates things further.

The result of all this confusion? Increased health care costs. But it doesn’t have to be that way. The first step is to figure out where your company is going wrong.

Let’s look at some of the most common healthcare management mistakes that are costing your business money right now.

1. Lack of Healthcare Cost Awareness

Ignorance is not always bliss. Companies hemorrhage money when they don’t understand the true cost of healthcare. Seemingly minor details like what a PPO charges for hospitalized visits can end up costing your business big. Additionally, if you aren’t fully aware of how much your plan pays for XYZ, how do you expect your employees to?

Time spent scrutinizing your company’s business health insurance plan is time well spent. Health care costs rise each year. Don’t be on the wrong end of those costs just because you don’t understand them.

2. Not Realizing You Can Lower Healthcare Costs

Do you assume that what you have now is the best you can get? You might be wrong. There are countless business health insurance plans in Houston, and you might have overlooked one that can save you thousands.

Some studies have shown that health and wellness programs can slow the growth of healthcare costs by up to 15%. That number can increase as your employees take greater advantage of in-house gyms, meditation centers, and other wellness benefits.

You can also save money with discount drug programs. Brokering deals with pharmacies can slash the cost of pharmaceuticals for you and your employees as well.

Simply understanding your options can save you thousands every year.

3. Not Communicating with Your HR Department Regarding Healthcare Costs

Most HR departments are under little to no direction from their manager to reduce health care costs. Healthcare management is often left to the higher ups. When those higher ups aren’t aware of this, costs increase.

Communicating with your HR department and incentivizing them to perform better reduces costs. Offer bonuses if health care spending dips. Many would gladly pursue better deals for your company if they had a reason to. With an average spending of $12,000-14,000 per employee on healthcare, there’s no better time to demand more of your HR team.

4. Not Understanding ACA Compliance

Despite recent headlines, we are still under the Affordable Care Act (ACA). That law requires employees offer compliant health insurance plans. Leaving compliance in the hands of a third party could be a costly mistake—especially if you choose the wrong provider.

Failure to adhere to ACA compliance too can result in stiff fines and wasted time spent sorting things out. Make sure you understand the benefits required by the ACA and how best to handle them in your business. We’ve also outlined these requirements in our Health Insurance Plans Buyer’s Guide.

5. Shying Away from High-Deductible Group Medical Plans

High-deductible group medical plans are typically far more inexpensive than low-deductible plans. They are also surprisingly beneficial. For example, when combined with a Health Savings Account (HSA) or a Flexible Spending Account (FSA), healthcare management is easier and costs are reduced.

That’s precisely what former CEO of Whole Foods, John Mackey did for his employees. His company saved about $1,689 per individual and $782 per family than they would with the average PPO. Imagine what savings like that could do for your company. Additionally, employee’s save money on taxes thanks to tax-free savings accounts.  Employees get comprehensive coverage and affordable rates and your business saves money when you choose an HSA.

6. Offering Employees “Free” Health Benefits

The saying is true. Nothing is truly ‘free’. Offering employees free health benefits severely hurts your costs. Instead, asking employees to contribute even a small portion to their benefits goes a long way to improving costs. When employees are cognizant of the costs you keep rates more affordable. Needless ER or doctor visits are greatly reduced along with costs.

7. Buying Inflexible Group Plans for Employees

If you own a small business, your business health insurance should focus on a few core benefits:

  • Vision care
  • Disability
  • Medical
  • Dental

Additional coverage options like life insurance, accidental death, pet insurance etc. should be up to your employees to add to the plan. For those extremely budget conscious, you can even leave off dental and vision allowing employees to add that instead.

You don’t have to take away your employees’ options. Simply let them choose the care they want and enjoy greater healthcare cost savings.

8. Outdated Health Reimbursement Arrangements (HRAs)

Insurance is complicated. Healthcare management is even more complicated. The rules for HRAs constantly change, and not staying on top of these changes could be costing you big time. The ACA changed how they are used and in 2017, a new Small Business HRA was released. Not taking advantage of this offer could result in penalties from the IRS.

9. Overlooking Total Healthcare Costs

Many companies look at monthly premiums instead of the total cost of healthcare for their employees. While monthly premiums typically make up the greatest amount you’ll pay, other factors contribute to your costs. These include:

  • Co-pays
  • Out-of-network costs
  • Deductibles for In and Out of Network Providers
  • Drug coverage costs
  • Quality of Coverage
  • Gated and Non-Gated Coverage Options

Each of these factors can increase your health care costs if overlooked. Paying attention to how each affects your overall premiums and what the benefits are long-term of each add-on benefit, plays an important role in healthcare management.

10. Not Getting Help from HCI to Reduce Costs

At Healthcare Consultants Inc., we help businesses get their business health insurance in Houston under control.

We pinpoint precisely where you could be saving money, what options are available for you company’s size, and how to take the next steps. We also work with employees to help them understand their coverage and how to lower their costs over the long term.

Whether you need to design a better plan for your business or want to encourage your employees to improve their own healthcare management, HCI is a trusted source for countless companies in the Houston area.

Let us help you get back on track or improve your healthcare costs as they stand. Please contact our team today.


Share this:
precertification, health insurance, health consultants inc

Everything You Need to Know About Precertification & Health Insurance

Precertification for health care services is a requirement for countless plans. As the patient, you are responsible for understanding your policy, but that doesn’t mean that you do.

To help you better understand your plan, what your options are, and how to avoid penalties for failing to get preauthorization for your health care services, we created a complete overview of this clause. No matter where you get Houston health insurance, we encourage you to understand your coverage. Doing so can save you thousands of dollars.

Here is what you need to know about precertification and how it affects your investment in health care.

What is Precertification?

If your plan has a preauthorization or precertification clause, you’re required by them to get approval for certain medical services. Even if your doctor has already approved of treatment in her office, you must get approval from your insurance provider. Also known as “prior authorization” or “preapproval,” (we’re using these three terms interchangeably in this post) this process isn’t as painful as it might seem. Many of the top Houston health insurance plans require this certification on common medical procedures.

Ultimately, preauthorization is all about insurance coverage. As the patient, you should make sure you are covered for a specific medical procedure or determine if a prescription drug as is necessary before you move forward with treatment. Some health insurance companies also require you meet a set criteria before they provide coverage for the treatment or drugs your doctor has recommended.

Insurance companies reserve the right to change their policy terms without notifying you, which is why they often require this process on their plans. While this isn’t the case for every insurance plan, it is important that you are aware of what your plan states and whether or not a preauthorization is required. One way to find out is to read through your entire insurance policy. An easier way is to simply contact your provider and ask them.

Failure to adhere to your insurance policy’s requirements can cost you thousands of dollars out-of-pocket, but with pre-authorization, you can save money and avoid penalties from your insurance provider.

When is it Required?

Not every health care treatment requires pre-approval. Basic health care performed by your primary health care practitioner like checkups etc. doesn’t typically require approval from your provider. However, specialized services do require it.

Coverage plans will outline which services require preauthorization, but it’s important to have a basic understanding of what those might be. Having a healthcare consultant in your corner eliminates any confusion surrounding your coverage, but most of the services that require pre-certification include:

  • Home Care Services—Skilled nurses, hospice, therapy etc.
  • Surgical Procedures—Nearly all surgeries must have the approval of your insurance provider.
  • Non-life-threatening Ambulance Service—If your life isn’t in immediate danger, you may have to get pre-approval from your insurance company before using this service.
  • Radiology examinations—X-Rays, MRI’s, CT Scans, and Ultrasounds.
  • Services for Pain Management—Trigger Point Injections, Discogram, Joint Injections, and Facet Joint Injection
  • Mental health therapies—Experimental therapies, drugs etc.
  • Inpatient Facilities—Post-Acute Facilities
  • Laboratory Services—Out-of-network laboratory services most often require pre-authorization.
  • Specialized Pharmaceutical Drugs—Depending on the drug, prior authorization is required. Contact your insurance provider for more detailed information.
  • Extensive Occupational Therapies—Many plans cover the initial visit without pre-approval, but after that first visit you may be required to get certification for their use.
  • Vision Services—Depending on your plan, eye care may require prior authorization.

Why Get Preapproval?

If you decide to go ahead with a treatment that requires your insurance provider’s preapproval you could end up paying full costs for the services. Even services that are clearly covered in your plan won’t be covered if your insurance company requests precertification. If you have surgery, for example, and fail to get authorization you could be left with a bill for tens of thousands of dollars with no help from your insurance company.

How Do You Get Authorization?

Once you have your list of covered healthcare services in hand, the next step is to figure out how to get authorization for the services that aren’t automatically covered.

Yes, your doctor may have already approved you for their recommended service or prescription drug, but your health insurance company needs to verify that care is absolutely necessary. They do this for two reasons, 1. To protect you from receiving unnecessary medical treatment, and 2. To save on costs.

You may not need an elective specialized therapy, for example, but your doctor may have recommended it. Your insurance company may disagree with your doctor’s recommendation.  Because of this, your provider requires you request that pre-certification.

Once your doctor recommends a treatment that requires preauthorization the next step is to have him or her contact your insurance provider.

For expensive prescription medications, your doctor must clearly explain that the drugs are medically necessary for your health. Immediately notify your doctor’s office if you discover their prescribed medication requires pre-approval.

For medical treatments like out-patient or in-patient procedures, your doctormust once again have to contact your insurance company to explain the reason he or she has recommended the procedure and why it is the only way to ensure your health.

If you’re considering going out-of-network, contact your provider and explain why you plan to do so. While they may not offer full coverage for any out-of-network treatments, they may partially cover the costs. Call before seeing any out-of-network provider to be sure.

What to Do If You Don’t Get Approval

When coverage for health care services or expensive prescription drugs is denied, you will have to pay in full for the service or medication. However, you do have the right to appeal the decision made by your health care provider. Your benefits documents will have a step-by-step process for how to appeal those decisions.

Alternatively, if your doctor provides a prescription that your health care insurance company rejects they may recommend generic medications or a different medicine they believe will work just as well. This saves your provider money and reduces any headache on your part. If you find that the medication doesn’t work as well, you can again appeal their decision.

If these tips don’t work, you can always contact Healthcare Consultants Inc to help negotiate your coverage options for you.

Preauthorization is a complicated process and can be time-consuming for you. Giving this task to a professional team who deals with pre-approval on a consistent basis allows you to focus on your health—instead of the complicated nuances of insurance plans. Let us start helping you today by reaching out to our team.

Share this:

A Healthcare Plan that Millennials Want.

A Healthcare Plan That Millennials Want

Understanding What Millennials Want from Your Healthcare Plan


Between 1980 and 2000 some 80 million babies were born. This generation is known as the millennials. Born in the information age, millennials are far more skeptical than their counterparts, and require far more information to make concrete decisions.
For employers, this means that their benefits packages must be fully transparent and capable of handling the influx of millennials now hitting the job market. The question is, what is it that millennials are looking for? How do these needs translate into employer-based healthcare? And how can employers create a healthcare plan to meet these unique demands?

What Millennials Value

First, let’s examine the values that Millennials hold and how they guide their decision making.

Independence & Cost Control

Millennials want to shop for the best value. They are cognizant of how limiting their options can cause increased costs, and they want to pay the least amount possible for goods and services. Purchasing independence is important to them. Transparency is critical if you expect them to make a purchase.
What this means for employer-based healthcare plans:
To attract top-tier millennial talent, provide options for healthcare coverage. Plans that allow employees to adjust their costs and coverage are highly sought after.


Millennials grew up in an age where the internet emerged. They understand the value it can have and how convenient it can make their lives. 24/7 access to information that directly relates to their decisions is a must-have. Tablets, smartphones and laptops are like accessories to a millennial.
What this means for employers:
Apps, online portals, and individual profiles that provide direct access to employee benefits are non-negotiable when dealing with millennials. Setting up a system that provides quick and convenient access to these resources is essential.


When surveyed regarding what they value the most in an insurance company, millennials responded that ‘trust’ was the most important factor. Second to that was reasonable copays and premiums.
What this means for individual healthcare plans:
More important for individual insurance companies, this means that branding and image play a pivotal role in gaining the interest of millennials in their healthcare plan.
Understanding what millennials value is only half the battle. You also need to understand the healthcare plan benefits they prefer.

Top Healthcare Benefits Millennials Want

Millennials are the ‘on-demand’ generation. They know precisely what they want and aren’t afraid to ask for it.
• Employer-provided wellness programs (stress management, yoga, gamification, dietary consultations etc.)
• Cafeteria planning (employees get to pick and choose their own benefits with the money employers set aside for them)
Vision, dental and ‘extra’ health benefits (not only do they want their general checkups included in their insurance plan, they also expect benefit rich options like vision and dental)
• Short-term and long-term disability benefits (53 percent of millennials say they are interested in disability benefits especially with an employer-based health insurance plan.)
• Convenient access to their plan (online statements, apps, and clear communication are a must-have).

Meeting Millennial’s Demands

While there are already tens of millions of millennials already in the job market, there are millions more who are about to enter it. If your company is unprepared for the increase in this younger generation, then now is the time to plan.
Employer-based healthcare is a driving factor in attracting key talent to your business. Understanding how to craft an individual healthcare plan that has the benefits they want isn’t quite so easy. However, the Affordable Healthcare Act has made it easier to appeal to millennials through your healthcare plan.
By setting a dollar amount for employee benefits, they can shop for the benefits they want. The addition of HAS and FSA can add to the shop-ability of your benefits all while providing technology and financial control for employees. This in turn keeps health care costs affordable for your business.

How We Can Help

With over thirty years in the healthcare insurance field, we know how to help organizations adjust to changing market trends. Millennials represent only one change we’ve had to maneuver through. To create a plan that appeals to this latest worker generation, to keep your healthcare costs low, and to maintain a strong relationship with your networks give our team a call. We’ll walk you through the options available and how to make a smart choice that benefits all sides.

Share this:

What the Media Isn’t Telling You About President Trump’s Health Care Amendment (AHCA)


President Trump’s Actual Health Care Amendment

You’ve probably read the headlines: “The New Study That Shows Trumpcare’s Damage,” The New York Times, “GOP Health Plan: Don’t Get Sick (Especially If You Live in a Red State)”, The Huffington Post.

Frightening, and perhaps even borderline unethical, many of these articles are written with a clearly biased tone against President Trump and the GOP’s valiant effort to create a sustainable health care plan for all Americans.

But what’s the truth? Where do we stand now that the American Health Care Act has passed the House and is moving to the Senate? Are you really going to lose all your health care coverage and be left destitute like the Dem’s and the liberal media claim?

In short, no.

To clear the air, and hopefully explain what to expect from this amendment, we’re covering the most important points of the AHCA and how they will affect you as an individual and as a business owner.

It’s important to note that today the amendment was passed only in the House, and that the Senate is less likely to be as accommodating to GOP interests. Nevertheless, Americans deserve to be properly informed about this significant piece of legislation.

Pre-Existing Conditions Will be Covered

One of the biggest complaints and half-truth’s being spewed by the media is that under the AHCA pre-existing conditions will be gutted. Insurers can supposedly give you any lousy coverage they deem fit.

Not so.

The AHCA has been reworked since the previous House failure, and new amendments were set in place to guarantee coverage for all Americans.

Fred Upton and Billy Long met with the president to agree to add $8 Billion over the cost of five years to help cover the costs of those with pre-existing conditions who otherwise would be priced out of insurance.

Instead of high-risk, low-income, individuals increase premiums for the entire pool, these individuals will be allocated to high-risk pools for coverage. Called the Upton Amendment, you can read the full story here.

Waivers are another feature of the amendment that holds out coverage for those with pre-existing coverage. States will be issued waivers enabling carriers in their state to set premiums based on medical backgrounds.

However, enrollees in these plans who experience an increase in their premiums will have access to high-risk pools that offset costs. States, therefore, wouldn’t be left footing the bill on their own. They would in fact get some help from the federal government.

High Risk Pools Could Lower Costs

There’s so much talk about how high-risk pools are bad for the sick and elderly. However, they’ve never been fully utilized in the American healthcare marketplace.

A revision to the AHCA provides greater coverage via the waivers we mentioned before. This allows states to rescind Obamacare requirements if they can provide explicit evidence that doing so would reduce costs to people in their state.

Called the MacArthur amendment, it creates an easy transition into high-risk pools and also opens up the way for larger reinsurance programs, all offered at lower costs than Obamacare.

Money from the government goes to insurers to help reduce premiums for the sickest in each pool. This in effect stabilizes the individual insurance market for individuals who do not have employer or government backed coverage, such as Medicare.

This MacArthur Amendment lowers costs for high-risk allocation from $20 billion, under Obamacare, to $15 billion through the AHCA. In reality, it saves both consumers and the government money.

Another area where the amendment provides cost reduction is through the community rating.

Previously, insurers were obligated to charge consumers the same price regardless of the average health, age, or gender in their specific area. This often resulted in high costs.

Under this new bill, however, states could get around the community rating in one of three ways:

  • Provide funding for people with pre-existing conditions so they too can get coverage
  • Participate in invisible high-risk pools
  • Provide incentives to appropriate entities

These options are extremely appealing to employers who foot the bill for high insurance costs based on an arbitrary community rating.

The Individual Mandate and Employer Penalties Are No More!

Almost universally, Obama’s individual and employer mandates were rejected by consumers. No one likes to be penalized for not paying for a service they may or may not need.

Obamacare penalties effected millions of Americans, over 6.5 million in 2015 alone. Individuals who didn’t have coverage through the marketplace were forced to pay a penalty of up to $695 or 2.5 percent of their yearly income—whichever was greater. This mandate did little to nothing to encourage people to purchase healthcare. In fact, there was no change in employer coverage under Obamacare.

For employers, the penalties were far steeper. Even small businesses with as few as 50 employees were subjected to the tax penalty.

Now, however, that will change.

Employers will no longer be subjected to the mandate and no tax penalties will be applied for that alone. The Senate may adjust this once the bill makes it to them, however.

In lieu of that tax, there will be penalties for lapses in coverage. Insurers, under the AHCA, can now impose a 30% surcharge on accounts that have lapsed in coverage for more than 63 days. This surcharge can be maintained for a year, but would only be applicable to insurance bought in individual or small group markets. In other words, large group insurance wouldn’t be effected.

American’s Will See Lump Tax Credits for Insurance

Another feature of the AHCA, conveniently left out of most media coverage, is tax credits for insurance.

Under Obamacare, tax credits were based strictly on income and cost of coverage. President Trump’s health care reform bill provides better credits based on age and income instead.

The new income brackets would go something like this:

  • People in their 20s will be given a $2,000 credit
  • People in their 60s will be given a $4,000 credit
  • Individuals who earn $75,000 would see tax credits start to wane
  • Individuals earning more than $215,000 aren’t eligible.
  • Families with incomes of $150,000 would see few credits
  • Families earning more than $290,000 would not qualify for tax credits

Instead of tax credits that vary with each passing year, the AHCA would provide lump tax credits across the board.

American’s Will Have More Health Care Plan Options

Obamacare has dramatically cut providers and insurer options on the market.

In 2016, the most limited plan options to date were introduced to consumers through the healthcare marketplace, taking a dramatic 12 percent reduction in plan options.

Customizations are all but a thing of the past under the current healthcare plan. President Trump’s health care reform bill is set to change that.

Under the amendment, consumers can choose the healthcare that is right for their family’s needs. Whether that’s maternity care, vision, dental, or something more, the options will be available to Americans.

As a result of the flood of new plans into the marketplace, lowered premiums will be a natural result. More competition typically results in lowered premiums.

Maternity and Mental Health Care Are Included in the Amendment

Contrary to what the liberal media wants to tell you, the GOP’s new bill will in fact offer coverage for maternity and mental health care.

The bill will also add $15 billion to fund maternity, mental health and substance abuse services, until 2020, with an additional $15 billion to create invisible risk pools to help with high-cost policyholders.

Also, as of yesterday, lawmakers added another $8 billion over the course of five years to support those high-risk pools as we stated earlier. The money would go to states that seek waivers to opt out of two of Obamacare’s key insurance provisions.

In other words, coverage for these important, yet specialized, facets of health care remain a part of the bill but simply take on a different form.

How It Will Affect The Greater Houston Area

For many, one of the biggest concerns over Obamacare was the inability to pick and choose which hospital you’ll use for coverage.

Obamacare limited insurers because of extreme pressure to keep premiums low. This resulted in cuts to which provider’s individuals can utilize.

Larger networks hold out potential to lower costs and include coverage for a multitude of hospitals.

The AHCA takes aim at these limitations. The goal is to open up coverage across the board, and this could include coverage in previously nixed hospitals.

For example, the MD Anderson Cancer Center in Houston was eliminated from one consumer’s health care plan leaving her to foot the bill for her $10,000 a month experimental cancer treatments. The treatment single handily saved her life, but nonetheless has created more debt than she’d like to carry.

Under the AHCA, Houston’s largest cancer center could possibly be covered under new standard healthcare plans. Other hospitals like Methodist hospitals around the greater Texas areas could also be brought back under the standard policies.

While this is yet to be seen from the new health care reform, we can be certain that the drama surrounding how awful it will be is far from reality.

Pre-existing conditions will be covered. Lowered premiums are also likely to take effect. Tax credits will still be there. But what is the next step before it’s passed?

What’s Next for the AHCA?

Should the AHCA not get bi-partisan support, House Republicans won’t be able to completely repeal the ACA. Even with a Republican majority, the bill has an uphill battle to climb in the Senate.

Republican leadership in the Senate must first agree to amend the House bill, or add to it with a reconciliation bill. A simple majority (51 votes) would then be needed to pass the Senate, which means nearly all Republicans must be in agreement (there are 52 Republican senators).

As we move forward, you can be certain Healthcare Consultants, Inc., will stay on top of changes to the bill and provide complete coverage of amendments and how they will affect you. Stay tuned for the latest information.

Share this:

How Your Broker Should Negotiate For You

 Group Health Insurance Negotiation

Does Your Health Insurance Broker Negotiate for You?

If you’re a small business owner or individual, finding the right health insurance plan within a reasonable premium can be frustrating. Confusing exemptions, benefits, and legislation makes it nearly impossible to keep up with your plan each year.

There is a solution that many small businesses and individuals utilize: Brokers.

Brokers are independent, meaning they can provide more options and more holistic view of the marketplace than you can on your own. They are highly trained and skilled at evaluating the costs that will affect you and can help design plans with major insurance carriers in your area.

For smaller accounts, brokers are typically free. Their advice is invaluable, however, if you’re planning long-term and want to reduce costs on your health insurance.

One of the best parts of hiring a health insurance broker is letting them handle the health insurance negotiation of your health plan costs. They can help your organization save thousands, if not millions depending on the size of your company, on healthcare costs. They do this through health insurance negotiation with carriers.

Here’s a few ways a broker goes about this, and what you can expect when you use one.

They Know What Questions to Ask

For example, if you have 50+ employees, it’s unlikely you know small details about each one that could potentially help you lower your group rate. Questions like, “Do you have any claimants who no longer work with you? Is the health of your company improving?” This is a great starting point for negotiating lower costs for your renewal.

They Analyze Your Plan’s Benefits and See Where Cuts Can Be Made

Instead of continuing to pay for services no one in your company uses, Brokers take a look at your plan and help guide the appropriate cuts to each one. This enables you to reduce costs right off the bat, without having to negotiate for different plans.

They Negotiate to Customize Plans

By speaking directly with providers, brokers can discuss and show data from your company that shows where your employees are most in need of coverage. This can be extremely beneficial if you have a generally healthy and young workforce.

They Provide Competitive Data

A health insurance broker can provide competitive data to show that your company qualifies for certain reductions especially those in the community rating. Community ratings can climb dramatically, but with the help of a trained eye, you can see where reductions can be made. Thanks to a large network of businesses under brokers, they have more power to move the rate than an individual does on their own.

They View Claims Data

Claims data shows how much of your coverage your employees are using. A broker should scrutinize your claims data to see what your insurance company paid in comparison to your premiums paid. If the two don’t add up, then they can negotiate with the insurance company for lowered costs on your behalf.

Typically, insurers are looking for a loss ratio of 85 percent to provide renewal consistent with trends. Your broker will work hard to find that ratio so you can enjoy lowered rates giving him or her more room for negotiation.

They View Medical Conditions

Your plan is based on the overall health of your group. Because of this, a broker will take a close look at the medical conditions in the group to justify lowering costs. Limited chronic illnesses and claims can assist you in leveraging a lower premium come renewal time.

Key Takeaways

The most important thing to remember about health insurance brokers is that they provide quality insight you can’t find anywhere else. They know how to analyze your group’s health insurance plan to see where holes need to be filled or where you can leverage against higher premiums. The more individuals you have on your plan the more power a broker has to negotiate lowered costs.

Health insurance negotiation is tricky, but with the right team of diligent and up-to-date brokers on your side, you can find a way to lower costs for yourself and your employees.  Healthcare Consultants, Inc. are experts at health insurance negotiation for your company.


Share this:

Health Care Reform Where Does America Stand

health care reform

Health Care Reform

The moment the Affordable Care Act (ACA) was passed as law, the Republican party has fought to find a way to repeal it. With a Republican president and a Republican controlled house, they now stand the best opportunity for health care reform. And that is precisely what President Trump has vowed to do.
Repeal and replace are the focus of the Republicans, but even so their first attempt has already failed to capture the votes needed to get it passed. Even before it could be voted on, Republican leadership removed the bill due to a lack of support. The question is, where does the American Healthcare Act (AHCA) go from here? Why did the most recent repeal attempt fail to go through? What will trumpcare look like in the coming years of his administration?

Understanding Recent Repeal Attempts

The recent reform hurdle Republicans faced was far from child’s play. The Republicans attempted to form a bill that would focus primarily on reforming the ACA, but didn’t garner the support they needed to be successful. Much of this was due to the divided plight of the party itself. Moderates didn’t want to see an end to the Essential Benefits and tea partiers weren’t willing to settle for anything less than complete free market control. For most of the latter, the belief is that government involvement drives up costs of healthcare, not the market itself.
The failure to unite the party on fundamentals of the repeal was its downfall. Key provisions such as preexisting conditions, minimum essential benefits, and the ability for young people to stay on their parent’s healthcare plans until the age of 26, are favorites of the ACA and are difficult to repeal.
The primary focus of the AHCA, however, was the elimination of as much of the ACA’s taxes as possible. The health care reform was loaded with taxes and penalties for both individuals and employers who didn’t offer coverage. The employer mandate came with a tax of 4 percent over the price of insurance for employers who opted for private insurance over the exchange. Individual’s face a similar penalty for refusal to opt in to the healthcare exchange.
It is now past the point of no return for the AHCA. The bill failed to produce results. Because of this, republicans are now forced to take a harder look at where they are willing to compromise and provide real reform to the healthcare industry.

Trump Care—Where the President Stands on Healthcare Reform

After the bill went dead, President Trump publicly said that healthcare reform is at a standstill for the foreseeable future. However, there are still house republicans who wish to see more urgency in repealing the ACA.
Trump’s strict negotiating tactics have given the Republicans little choice but to follow suit or have the law remain as it stands. They now have to answer to constituents who are concerned about losing coverage.
Interestingly, house Republicans are considering reigniting trumpcare. After making a few slight changes to the bill, such as adding a $15 billion risk-sharing fund to help fund health insurers with high-cost patients, Trump has made it apparent he wants results on the healthcare bill. Speaker of the House, Paul Ryan, has said that he would happily bring members back to vote on the bill if a path towards 216 appeared. The issue trumpcare faces now is the Freedom Caucus.

What’s Next for Healthcare Under Trump’s Administration?

We aren’t a full six months into President Trump’s presidency, so it’s safe to assume that new amendments to the bill will come forward and we could very well still see health care reform within the next four years. For now, however, employers and individuals do well to adhere to the ACA as the individual mandate and employer mandate is still in effect.
While Republicans try to repeal the ACA for good, we can’t expect much in the way of changes to minimum essential benefits or other similar provisions. The penalties could be under fire, however, which many small business owners wouldn’t argue against. Still, it will take time to get a complete bill on the floor that can be supported by both sides of the aisle. Until then, Republicans are likely to turn their attention to tax reform, which could present even greater challenges.

Share this:

Reference Based Pricing and How Can Your Company Benefit From It?

Refrence based pricing

Employers are constantly on the lookout for cost containment plans for their employee benefits plans. One often overlooked option is reference based pricing for healthcare costs. Today we’re going to discuss how this method can reduce healthcare costs for your business, and what you should consider before using it for your employee plans.

What is Reference Based Pricing?

Reference based pricing is a solution employers use for cost containment on employer-sponsored healthcare plans. As healthcare costs continue to rise, employers are searching for ways to mitigate coverage costs. Reference-based pricing is a trend within self-funded benefits communities and accountable care organizations. It allows employers to eliminate high-cost providers from networks by narrowing the network itself. This in turn drives savings by way of avoiding massive insurance companies and expensive network contracts.

How Does it Work?

Spending limits are what allows reference-based pricing to cut healthcare costs. It does this within certain procedures. Employees under this plan are only covered up to the established limit and would then have to pay out of pocket for the remainder of the procedure.

It is typically recommended that limits are set on shoppable services, meaning services that aren’t urgent and are available through several providers. This allows employees to take their time finding a payable solution that works for them. Some suggestions include prescriptions, lab tests, MRI’s and similar such healthcare services. By negotiating cost reductions on standard healthcare procedures, such as these, employers have more power over cost containment.

Employers can negotiate these costs with the help of a third-party vendor. Healthcare pricing is complicated, so having an experienced team of consultants on your side positions you for the best coverage without paying large sums out-of-pocket. That vendor provides extensive market research to negotiate pricing with providers. Without assistance from this vendor, employers can be left overwhelmed by the prospect of negotiating costs. But how does this vendor negotiate costs?

Pricing is based on demographics and the fair pricing methodology. By using this method, employers gain a strong advantage, as fair pricing practices benefit both themselves and their employees. In traditional models, pricing is non-transparent, leading to unfair contracts and higher prices for employers and employees. The result is discounts that are based on already over-inflated prices. Reference-based pricing is a better way of handling cost containment.

Of course, another hurdle is getting your entire company onboard with this change. Here are a few benefits you can use to sway your organization should you decide to make the switch.

How Your Company Benefits

Referenced based pricing provides multiple benefits. One is increased transparency. Most patients are completely blind to healthcare costs, and aren’t often diligent about comparing one service to another. The healthcare system isn’t set up to help them find out, either.

With RBP, employees can see exactly where their out-of-pocket expenses will rise. This in turn motivates them to be more proactive about selecting the right provider. Understanding these costs in advance enables them to navigate the system much more easily to make smarter decisions that save themselves and their employer money.

Employers benefit by selecting high-cost healthcare coverage for price limits. Instead of paying ridiculously high fees for healthcare coverage, employers find themselves paying far less for the same services. Employees seek out those options and naturally reduce costs to employers. Experts estimate that low healthcare literacy costs the United States some $106 billion annually. By putting employees in a situation where research is required to lower costs, you not only improve the costs they incur but also those of the insurance industry.

One final benefit is lowered cost renewals at the beginning of the following plan year. That’s something all employers can get behind.

Is Reference Based Pricing Right for You?

As with all healthcare cost containment strategies, there are some downsides to RBP. These can include lack of established markets, reduced negotiation leverage for small businesses, and a slight potential for increased employee costs because of balance billing. However, overall, RBP offers a better way to cut costs and save employees and employers money.

To make the most out of RBP, you need a qualified vendor on your side. To learn how Healthcare Consultants Inc., can help reduce your healthcare costs through RBP contact our team today.

Share this:

Why Carving Out Your RX May Be a Good Idea

Why Carving Out Your RX May Be a Good Idea

Carving Out Your RX

As an employer, finding the right prescription plan is an important factor in your employee benefits offerings. If you’re looking for a way to reduce costs and give your employees better options, then carving out your RX is a good idea.

A pharmacy “carve-out” allows a plan sponsor to choose a Pharmacy Benefit Manger (PBM) to manage prescription drug benefits on their own. They are standalones from the PBM who is contracted with the health plan which administers claims. Carve-out RX plans can be either fully insured or self-funded.

The advantages of “carve-out” plans provide a strong case for switching gears on your plan. Here’s how to carve out your RX for the benefit of your personal budget or employee benefits plan.

How to “Carve Out” Your RX

The first step is to begin the carve-out process with an employer’s health plan for prescription drug coverage. Prescription benefits are one of the best money makers for insurance carriers and even specific PBM’s, but that doesn’t have to mean you lose money. Small employers with 50 or fewer employers can now use self-funded prescription plan options to reduce costs.

The next step is to use the right Prescription Benefit Manger. The goal is identifying one who is transparent and clearly working for you, not the pharmaceutical or insurance companies. They should only charge for prescriptions processed. With their help, you can isolate rebates that add to cost savings for you.

Another important part of this process is to do your own research. It’s a good idea to understand how the Average Wholesale Pricing (AWP) discounts work. The primary reason is to get a good handle on what pricing is acceptable and what isn’t. Discounts aren’t always the most important selling point. High discounts could in fact reveal a higher mark up on prescription costs for generic drugs than is acceptable. Higher priced drugs are particularly vulnerable to this type of ‘up-selling’. A professional PBM can isolate the correct pricing for your prescription plan reducing the overall costs.

Finally, hiring a transparent PBM not only helps you reduce costs based on a consistently lower prescription drug plan, it also enables you to reap benefits as factors change within the industry. They also guarantee compliance, disease management and advocacy for your employees. To determine how to carve-out your RX plan, hire a HCI who can do the heavy lifting for you.

3 Advantages of Carving Out Your RX

PBMs provide immediate discounts and improved clarity in your employee benefits plans. But here are three specific benefits of using them to carve out your RX.

  • Flexible Plan Designs Reduce Costs

Instead of paying for coverage on rarely used, and extremely expensive, prescription drugs, you can work with a PBM who can in turn create a detailed plan that is flexible to the needs of your employees. This allows you to adjust with the market, reducing coverage in areas where prices are higher than normal. Flexibility is always an advantage in the insurance market.

  • Pass-Through Rebates

Professional PBMs allow you to get better pricing through rebates. They will invoice you for every drug dispensed according to the PBM’s cost for the drug. This means you get prescriptions at wholesale prices after rebates. These pass-through costs are one of the greatest advantages to carve out RX plans.

  • Audit Rights

With a carved-out prescription plan, you have the right to audits. This includes claims audit, operational assessments, and rebate audits. This guarantees complete transparency on costs and expenditures. Access to pharmacy claims data also ensures you’re getting the best deal available.

Employers Benefit Greatly from Carve-Out Plans

Cost containment is the number one reason of carving out your RX plans. Prescription drug care is by far the most used healthcare coverage employee benefit. Pharmacy costs take care of about 30% of all healthcare costs. With an increase in prices for prescription drugs, it’s logical that employers will turn their attention to carve-out plans for their employees.

If you’re interested in better controlling pharmacy benefit costs, then carving out prescription drug benefits from your major-medical plan, is a good route to go.

To benefit from transparent drug pricing, auditing control, reduced costs for prescriptions, and so much more, consider carving out your prescription drug plan for your employee benefits.

For more information about carving out your RX in Texas, contact the HCI team. We’d be happy to help.

Share this: