Is That Deductible? Health Insurance Changes In The New Year

Turning The Page To A New Year

Approximately six weeks ago, I received a notification that my current insurance plan with Anthem BC-BS, obtained through my state medical association, would be discontinued. Unfortunately, my state medical association decided not to provide an alternative product and instead encouraged members to seek other options. Reading between the lines, it is evident that with employment becoming the dominant model for physician labor, the number of individual physicians and private practices is shrinking. As a result, both Anthem and the medical association saw little need for this type of product. Many doctors simply obtain their health insurance from their employer.

This experience sent me on a journey of exploration for our family and its unique needs. In the past, I have written guides for our SimpliMD community, which include the following blogs:

• Sourcing Your Benefits As A Self-Employed Doctor

• The Self-Employment Advantage: Personalized Benefits

• Combining Health Sharing Plans with DPC Membership

• Health Sharing Plans For The Self-Employed Doctor

• Exploring DPC As An Alternative to Insurance For The Self-Employed

• 14 Health Insurance Tips For Self-Employed Doctors

Not it was time to use all that practical wisdom and go source my healthcare plan for myself.

Health Sharing or Insurance?

There are numerous considerations when it comes to this choice of going with traditional health insurance or using a health sharing account. So let’s break things down a bit between the two most common choices. Those include the following considerations:

Traditional Health Insurance:

1. Comprehensive Coverage:

   • Traditional health insurance plans often provide comprehensive coverage for a wide range of medical services, including preventive care, hospitalization, and prescription medications.

2. Network Restrictions:

   • Consider whether the insurance plan has a preferred network of healthcare providers and it’s convenience and accessibility to your home. I live in a rural location so my convenient network choices are more limited. Staying within the network may reduce out-of-pocket costs.

3. Costs:

   • Traditional health insurance costs more and copayments and deductible expenses are escalating. Understanding your maximum out of pocket costs is important.

4. Prescription Drug Coverage:

   • Evaluate the coverage for prescription medications, including the availability of generic alternatives and any tiered formulary systems. One shocking discovery for me over the past 5 years of being on traditional insurance is the insurance costs for medications are often HIGHER than paying cash price and using Good Rx coupons.

5. Labs & Imaging & Ancillaries

   • These services are covered at in-network facilities after your co-pay and deductible are met. On my experience the “insurance price” for these products are often much larger than the cash or non-insurance price.

6. Preventive Services:

   • Traditional plans often cover preventive services without cost-sharing. Check the details of preventive care coverage and associated benefits.

7. Tax Advantages:

   • HSAs offer tax advantages, allowing you to contribute pre-tax income, and withdrawals for qualified medical expenses are tax-free. This can be advantageous for individuals seeking tax benefits.

8. Catastrophic or Major Medical Condition Coverage:

   1. In the event of a catastrophic event or major medical event, insurance provides a great safety net. There are plan limits typically, but in most instances you won’t reach those ceilings.

Health Sharing Account (HSA) or Health Sharing Ministry:

1. Cost Savings:

   • Health sharing accounts often offer lower monthly contributions compared to traditional insurance premiums. The deductible is known as the “Annual Household Portion” which is the amount the household member agrees to pay towards eligible medical bills. Much like deductibles can vary with insurance, so can AHP can vary with health sharing accounts.

2. Faith-Based Considerations:

   • Health sharing ministries are often based on religious principles. Consider whether the values and beliefs of the health sharing community align with your own.

3. Coverage Limitations:

   • Health sharing plans may have limitations on coverage for certain medical services or pre-existing conditions. Review the terms and conditions carefully.

4. Prescriptions

   • Your prescriptions will be cash pay. Depending on your particular medications-this could be very expensive. There are a number of discounted prescription programs out there. My favorite local pharmacy program is GoodRX and for chronic medications that I can get on mail-order, I use Mark Cuban’s CostPlus Drug Company

5. Labs, Imaging, Ancillaries

   • You will be paying cash, or non-insurance prices for these services. With the emergence of direct to consumer labs and imaging facilities-in most places this is easily accessible and surprisingly cheap when the middle man (insurance is cut out). You can also use a cash pay voucher system called “MDSave” to search and find most services

6. Member Responsibility:

   • Members of health sharing programs are typically responsible for a portion of their medical expenses before cost-sharing among members begins. Understand the structure of cost-sharing responsibilities. Much like an insurance deductible this is known as the “Annual Household Portion” which is the amount the household member agrees to pay towards eligible medical bills.

7. Flexibility in Provider Choice:

   • Health sharing accounts often allow greater flexibility in choosing healthcare providers, as there may not be a network requirement. Members basically pay the discounted cash, or non-insured price for all medical services—thus you can see anyone you prefer.

8. HSA’s:

   • HSAs offer tax advantages, allowing you to contribute pre-tax income, and withdrawals for qualified medical expenses—making them tax-free. Not all sharing accounts offer HSA programs, so check this out closely if it’s important to you.

9. Telehealth Option

   • Most health sharing accounts have free or fully covered telehealth options embedded into plan. The convenience and cost benefit make this an appealing option. Some telehealth programs even support a PCP type model where you use the same provider for all your telehealth needs.

10. DPC Option

    • Some health sharing accounts are now allowing for an integrated direct primary care (DPC) model that further reduces the cost sharing expenses. This allows you to see one primary care provider in person and eliminates the need for telehealth

11. Catastrophic or Major Medical Condition Coverage:

    • This is really why you benefit from having a health share program, because these items are covered. A DPC program will not help you here, thus it’s risky to go with a DPC program only. In my opinion for a self-employed physician who likely deduct your healthcare expenses through your micro-corporation, those risks are not worth it! There are plan limits for these events typically, so read the fine print closely.

Personal Health Considerations:

1. Health Status:

   • Assess your current health status and potential future healthcare needs. Consider how often you seek medical care and the types of services you typically require.

2. Risk Tolerance:

   • Evaluate your risk tolerance for out-of-pocket costs. Health sharing plans may have higher deductibles and cost-sharing requirements.

3. Flexibility Needs:

   • Consider your need for flexibility in choosing healthcare providers and the level of control you want over your healthcare decisions. I like the portability and flexibility—including international medical care—that is offered by a healthshare program that has no network.

Getting Organized Through A Local Agent

I met with one of my patients who happens to be an independent insurance agent. During our discussion, we thoroughly reviewed various options ranging from traditional insurance plans to health share programs. It was beneficial to have a local and trusted individual who could share his firsthand experience with each of these options in our area. This included his work with several self-employed doctors who had chosen to utilize the more cost-effective health sharing programs.

My Part

Considering the health sharing or non-insurance option didn't scare me because we had previously used Christian Medi-Share about 7 years ago and had a relatively positive experience. This included full coverage for my oldest son's cardiac ablation procedure, which cost over $100, 000, to treat a ventricular arrhythmia. With this in mind, I felt comfortable exploring all available options.

So now it was time to do some comparison between the options for my family of 2 adults and 3 adult children under age 26—and I won’t bore you with my comprehensive spreadsheet—but here is our breakdown:

• Costs:

  • Insurance:

    • Annual Premium: $16,200

    • Family Deductible: $13,000

  • Health Share:

    • Annual Premium: $8760

    • Family Annual Household Portion (deductible): $7500

• HSA option:

  • Yes to both Insurance and Health Share* (I profiled a plan that included this)

• Wellness Exams, Imaging, Colonoscopy coverage

  • Insurance: Fully covered

  • Health Share*: covered after I profiled a plan that would cover this.

• Telehealth:

  • Insurance: not covered

  • Health Share: covered and free with unlimited access, thus really no need for a direct primary care program to be attached to it.

• Mental Health Counseling

  • Insurance: covered after co-pay and deductible met

  • Health Share: covered for 12 sessions free/year* (I profiled a plan that included this)

• Prescriptions:

  • Insurance: $3000 annually for my family for prescriptions using the insurance

  • Health Share: $1500 annually for my family for prescriptions using GoodRX and Mark Cuban’s CostPlus Drug Company

• Portability and International Coverage (after retiring in June I will be do a combo of travel medicine and pleasure travel a lot)

  • Insurance: not a good match due to narrow network

  • Health Share: covered and portable based on cash price for services at any location

• Health Status: Our family is relatively healthy, so there were no major medical conditions that needed to be surveyed for their connection to insurance or health share programs. However, it is worth noting that insurance does not have pre-existing health condition barriers, although services for certain conditions like obesity may be limited or not covered. Most health share programs have 1-2 year pre-existing condition waiting periods and may also limit coverage for certain conditions. It is important to read the fine print to understand the specifics.

What I Chose

In the end we chose a health share program due to the cost savings, but also do to it’s favorable profile for including wellness medical care, and HSA, comprehensive telehealth, mental health counseling, and it’s portability. The company I chose was HSA For America and their HSA Secure Plan. As a disclosure I receive nothing if you check out their products and services.

We are now all enrolled and the biggest initial task was changing all our prescriptions over to self-pay sources. Thankfully GoodRX and Mark Cuban’s CostPlus Drug Company make that easy to sort out at their websites.

Based on your state and family profile, you may come to a different conclusion with your personal choice.

Is That Deductible?

As we have organized our business enterprise to encompass all family healthcare expenses, including out-of-pocket costs, each decision we make is considered a covered business expense. However, as I approach my retirement from day-to-day clinical practice, I still need to oversee and account for the magnitude and range of those business expenses that must be supported by the revenue generated by my businesses.

You always hear me talk about the power of autonomy that is provided to you as a self-employed doctor who owns a micro-corporation. Sourcing my own health care option was satisfying because I was able to choose a plan that best matched my family’s needs. When you are a W-2 employee of a large healthcare company—you are stripped of these personalized options. If you are curious about whether you would benefit from forming a professional micro-corporation, reach out to me here and schedule a consultation that costs less than the price of a dinner.

Tod