Things may be better in other areas. However, I can speak only for the Houston, TX area. In our area of the state, health insurance plans are highly limited.
Self-employed individuals, who are not eligible for group health insurance through a spouse’s company, do not have access to doctors/hospitals they want to use unless they have agreed to the terms of a HMO plan.
American’s who work for a small company that does not offer group health insurance have no option but to buy government approved “managed care” health insurance.
Sadly this means that a little more than 25% of Americas tax payers must buy health insurance that, in most cases, will not allow them to use a specialist without first going to a Primary Care Physician to get permission and then only be able to use the specialist their PCP sends them to.
Also, few specialty hospitals will limit themselves to HMO requirements and are therefore not an option for people who need specialty care in the event of cancer or stroke.
In both cases, individuals not only have to pay for health insurance, but they have to pay cash for specialty care if the doctor/hospital they want to use is not in the HMO network.
The statement, “If you like your doctor you can keep him” was nothing more than a political lie.
If one removes all of the political spin, the remaining fact is that a little more than 25% of the population no longer has the freedom to choose where they will get healthcare from, except for emergencies.
YOU MAY HAVE OPTIONS
While it is true that roughly 25% of tax-payers are limited, it is not necessarily true that they do not have options.
In October of 2015 congress passed PACE and it was signed into law by then president Obama. PACE changed the federal definition of a qualifying group from a minimum of two covered people to just one.
Just be advised that while the definition may have changed on the federal level, it did not necessarily change on the state level. Some states may still require 2 or more covered individuals to form a group plan.
Here in TX, it still requires 2 individuals (either 2 owners, two full-time employees or an owner and full-time employee) to form a group but if one of them already has acceptable health insurance, only one employee is required to enroll in the group.
OTHER POTENTIAL REQUIREMENTS
A group health insurance plan may be a solution for you but only if you qualify. Group plans can be set up at any time of the year since they are not subject to any government mandated enrollment periods.
Also, it is important to remember that insurance companies still offer PPO coverage to people with group plans. That means that with a PPO plan you have your freedom to choose specialist and hospitals restored to you.
However, before you think that group health insurance is the best option for you, take time to consider a couple more requirements.
- CONTRIBUTION – Under current law the business owner must contribute, at least, 50% of the premium for employees. (Although the employee is allowed to add coverage for spouse and/or children, the business owner is NOT required to contribute anything toward their premium.)
- PARTICIPATION – In most cases group plans require that around 75% of “eligible” employees participate. (Please note that is NOT all employees. There are exceptions to the qualification, including, but not limited to, those people who have acceptable health insurance elsewhere may, or may not, elect to be classified as “eligible.”
- PAPER-WORK – The required paper-work for setting up a group plan is much more complicated than it is for an individual plan.
WHAT CAN YOU DO?
If you are not happy about your current health insurance options, there may be something you can do. Contact an insurance professional, who you trust, in your area to see what the rules are in your state and if group health insurance is even an option.
If you live in Texas, and want to see if group health insurance is an option for you, use the form below to contact me.