Ever since Obamacare took effect, we have spoken to so many consumers that have the misconception about their pre-existing conditions and that they must be covered now with the new law. According to the Affordable Care Act, insurers cannot discriminate against those with pre-existing conditions and must cover them from their effective date. That is true, however, there is a vast array of health insurance products that are being offered to consumers and the only products that must cover pre-existing conditions are Qualified Health Plans that comply with the new law. Not every health insurance product has to abide by these new laws. It is very confusing to most consumers and they seem so lost when this point is brought up in the discussion.

Let’s simply the options that are now available in the health insurance market. The plans that provide the most coverage are called Qualified Health Plans.

Qualified Health plans consist of 10 Essential Health Benefits so that they can be defined as Qualified Health Plans according to the Affordable Care Act. These 10 benefits are physician services, prescription benefits, emergency room services, hospital service, preventive services, mental health and substance abuse services, maternity, ambulatory services, surgical services and pediatric services. If the plans that you are looking are missing just one of these services, it is NOT a Qualified Health Plan and therefore it doesn’t have to abide by the rules of the Affordable Care Act. Therefore, the policy can exclude pre-existing conditions. Remember, just because the insurance company you are looking to by will insure you doesn’t mean they will COVER your pre-existing conditions. Those are 2 different terms and conditions. Qualified Health Plans are typically purchased through healthcare.gov or with an agent or agency that is certified to offer those plans. They are available during Open Enrollment which is the last 2 months of the year or if you have a qualifying life event within 60 days, you may qualify for Special Enrollment.

Faith Based plans are becoming more and more popular with consumers because they provide the second most comprehensive benefits to a Qualified Health Plan. They are not considered insurance because they are cost sharing plans. Regardless, these plans have paid billions of dollars in medical expenses over the last 5 years so don’t let the terminology scare you. Faith Based plans provide preventive coverage, sick and injury visits to a pcp or specialist with a small fee to pay out of pocket, prescription benefits and diagnostic testing. Most of these plans provide coverage for pre-existing conditions once your plan is effective. They do have waiting periods on pre-existing conditions for hospitalization, surgical services and the intensive care unit. Therefore, there are not benefits for pre-existing conditions for these services for a minimum of 12 months. So, if you are purchasing medical coverage because you need a surgery or you believe you may need to be hospitalized, a medical cost sharing plan is not for you. You are better off negotiating with the hospital or facility. Unless you are accepting of the fact that these plans will not cover it and you just hold off until the beginning of the year. This way you have coverage in place for the unexpected and have preventive services and office visits for sickness or injury.

Short Term Medical have been popular ever since the tax penalty was taken away at the beginning of 2019. Since consumers were no longer being penalized for not having a Qualified Health Plan, Short Term Medical plans were more affordable than Obamacare. These plans provide office visits for injury or sickness and they have catastrophic coverage that includes a maximum out of pocket. What is important to understand about Short Term Medical plans is that they do not cover pre-existing conditions from top to bottom. Whether you need an office visit covered or a prescription, they do NOT provide coverage for pre-existing conditions. Don’t confuse being approved for one with covering your existing medical conditions. As we mentioned previously, being approved for coverage is NOT the same as covering your medical conditions. They are different terms and conditions. So, if you answer a few medical questions, you can be approved for a Short-Term policy however they will only cover new medical conditions or accidents.

Fixed Indemnity Plans offer the least amount of coverage overall. These plans will typically cover office visits, prescriptions and testing for pre-existing conditions upon the effective of the plan. They will however have waiting periods for hospital and surgical services. Another important thing to consider is that a fixed indemnity plan is not traditional major medical insurance that is comprised of a deductible and max out of pocket. These plans pay fixed dollar amounts for all services. That means that once they pay their portion, the consumer is responsible for the difference which can be very costly. Be very cautious is someone calls you and offers you a plan that covers EVERYTHING and there is NO deductible. Remember, a $0 Deductible doesn’t mean that the insurance company will pay all your medical bills. If you feel that the plan you are being presented sounds too good to be true, make sure you get all the benefits in writing before making a financial decision. All insurance products have brochures and summary of benefits so if the agent you are speaking with gives you the run around or they want you to pay before you see everything, that is a red flag.

Next Level Benefits takes pride in making sure our clients understand what options are available to them with our transparent approach. You may not qualify for the best coverage now, but we will make sure to put you in the best possible situation until those options become available. We want you to be part of our family of insured clients for life.