Choosing the best Health Coverage for Yourself
Choosing the right health insurance plan can be a daunting task because there are a lot of products and offerings to choose from. That’s why choosing a broker is crucial if you want to get the best product for you that will not necessarily break the bank. This is where Jim comes in. With vast knowledge about different products and a lot of experience in different scenarios under his belt, you’ll know you’re in good hands.
HMO or PPO
Jim always comes across the question, “Which product is right for me?” There are so many products out there to choose from like HMOs, EPS, PPS, and Direct Access. He would only answer the question based on your census and the questions that he asks you, then limit the plans for you. For example, the PPO and the Direct Access are the exact same plan, they're just named differently depending on what carrier you go to. Both mean you have an out-of-network benefit.
There are times when Jim would explain to a lot of clients that having an out-of-network benefit is a waste of money because of the “reasonable and customary charges.” This means even if you have an out-of-network benefit if a doctor wants to charge $80,000, and even though your maximum out-of-pocket is only $30k, you're responsible for the $50,000 difference. So a lot of people are not going to use the out-of-network benefit because of that exposure.
Another really good rider is something called the BlueCard with Horizon and with Oxford it's called National Access. If you have something called an EPO or an HMO, but you put this rider on it, it gives you National Access. It means that it allows you to go to any state you want, as long as the doctor in that state takes that carrier in that state it's billed as in-network. So it kind of gives you the ability to have the out-of-network benefits without actually paying for the out-of-network benefit.
The cheapest plans are the HMO EPS without the rider. A lot of people still use these because with Oxford, they have something called the Metro Network. This gives you access to New York and New Jersey. The only situation where you might want to have National Access is if you have a child. In the event that the child gets sick and you want to go to Children's Hospital Pennsylvania, the National Access rider gives you the ability to go there.
“There is this saying ‘genes load the gun but lifestyle pulls the trigger’. This means, we may come from a genetic background where there are mental health issues in the family line, cardiac disease, or obesity but it doesn't necessarily mean that you are destined to repeat. How is that possible? We just don’t pull the trigger. What we need to do is cultivate and nurture this microbial community through our diet and our lifestyle so that the healthy species go ahead and pull the levers of our healthy genes.”
With a lot of experience under his belt, Jim has so many scenarios as a broker and they can answer all questions you might have regarding this. They don't just say, “Hey, go with this plan, go with this plan and go with that plan.” They try to understand and ask you questions, and then they customize a plan that they feel is best suited for you. They factor in premium dollars, what you're paying versus benefits out there. And then based on your comfortability, they try to find something that best suits you.
Whichever recommendation you get from Jim, in the end, it's always your decision. It's based on your comfort level, and that will be based on price in premium and what you want in benefit levels. It can be compared like, “Everybody wants the Ferrari, but nobody wants to pay for the Ferrari.” or “I don't want the out-of-network benefit because I don't want to pay that money in premium.”
ABOUT JAMES RESTAINO
James Restaino is part of Relax Benefits. He is a Managing Partner/Broker at Specialized Health Services LLC, an Employee Benefits Company that specializes in group health insurance, life insurance, and dental/vision insurance servicing companies in New Jersey and New York. His ideal clients are companies that have at least 2 enrolled employees on Employee Benefits. With his 25 years of experience, he can help you find the right coverage for you or your employees.
- Advantages of Getting Insurance from a Trusted Broker
- Health Insurance For Employees In Multiple States
- Can I Offer More Than One Plan Type To My Employees?
- As an Employer, How Much Do I Pay For Health Insurance
- The Role of a Broker in The Health Insurance Marketplace
- Why Choose a Level-Funded Health Plan?
- Is Reference-Based Pricing Right For My Business?