Health Insurance
Individual and family health plans through leading carriers including Ambetter Healthcare, Anthem, and Oscar Insurance Company. We help you navigate plan options and find coverage that fits your needs and budget.
Major Medical Health Coverage
Major medical health insurance provides comprehensive, long-term coverage for individuals and families and is designed to meet the Affordable Care Act (ACA) requirements for essential health benefits (EHB). Most major medical plans are available through the Health Insurance Marketplace from private insurance carriers. Qualifying plans may also be purchased off-exchange through a licensed insurance broker or directly from an insurer, depending on the plan and carrier.
On-Exchange vs. Off-Exchange Plans
For many individuals and families, purchasing a major medical plan on-exchange during Open Enrollment can be a cost-effective option. Marketplace coverage may qualify you for federal premium tax credits or other financial assistance, depending on your household income and circumstances.
You may also purchase an off-exchange health plan through a licensed broker or directly from an insurance carrier. However, off-exchange plans generally do not qualify for Marketplace premium subsidies. You may also be eligible to enroll outside of Open Enrollment if you experience a qualifying life event, such as losing employer-sponsored coverage, getting married, having a baby, or moving to a new coverage area. These events may qualify you for a Special Enrollment Period.
What Do Major Medical Plans Cover?
Major medical plans are designed to help cover healthcare expenses related to illness, injury, hospitalization, and other significant medical needs. Depending on the plan, you may have a deductible, copayments, coinsurance, and an annual out-of-pocket maximum. Most Marketplace plans use provider networks such as HMO or EPO networks, although plan types and availability vary by insurance carrier and location. Marketplace plans also generally cover certain preventive services at no cost when provided by an in-network provider, including eligible checkups, immunizations, and screenings.
The ACA's Essential Health Benefits
Marketplace plans are required to cover the following 10 categories of essential health benefits:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including dental and vision care
If you prefer a PPO, POS, or HSA-compatible health plan, you may want to explore additional options available off-exchange. Plan availability, benefits, networks, and eligibility vary by insurance carrier and location.
Short-Term Medical Coverage
Whether you need temporary medical coverage during a gap in insurance, missed the Open Enrollment Period, are ineligible for an on-exchange or employer-sponsored health plan, or are looking for a more affordable alternative to traditional private insurance, short-term medical coverage may help provide a temporary solution.
Short-term medical plans are designed to help bridge gaps in coverage from one life event to another. They can provide benefits for unexpected illnesses and accidents, but they are not comprehensive major medical plans and are generally not subject to all of the consumer protections and coverage requirements of the Affordable Care Act (ACA). Short-term plans are typically purchased outside the health insurance Marketplace and may have different eligibility requirements, benefits, exclusions, and limitations than ACA-compliant plans. Coverage varies by insurer and plan, so it is important to carefully review the plan documents before enrolling.
Premiums for short-term plans may be lower than unsubsidized comprehensive health insurance, depending on factors such as the plan selected and your circumstances. However, these plans may have higher deductibles, limited benefits for certain services, and exclusions or limitations related to preventive care, physician visits, urgent care, emergency services, prescription drugs, and pre-existing conditions. Before choosing a short-term plan, make sure you understand what is — and is not — covered.
Dental Insurance
As most people would agree, a healthy mouth is an important part of a beautiful smile. Maintaining good oral health and a confident smile can be costly without dental coverage. Even if you do not use your benefits frequently, having dental insurance can provide valuable financial protection in the event of unexpected or complicated dental issues.
Individual dental insurance is designed to help you maintain good oral health and manage the cost of dental care. Whether you need a routine dental check-up, restorative care, or orthodontic treatment, there are a variety of options available — from basic preventive plans to comprehensive standalone dental plans. Your coverage and benefits will depend on the type of dental plan you choose.
Most dental plans have an annual maximum benefit, along with a deductible and coinsurance. You may be responsible for paying the deductible before your coverage begins. Once applicable deductibles are met, your dental insurance generally pays a percentage of covered dental expenses, up to the plan's annual maximum benefit.
Because every individual's dental needs are different, it is important to choose a plan that fits your expected usage and budget. Contact one of our Phanald IT agents for personalized guidance and help selecting the dental plan that best meets your needs.
Vision Insurance
Like dental insurance, vision insurance is not required for everyone, but it can be a valuable and affordable way to manage routine eye-care expenses. Having vision coverage can make it easier to access regular eye exams and reduce the cost of prescription eyeglasses or contact lenses.
Vision insurance is generally designed to cover routine preventive eye care and prescription eyewear, such as eyeglasses and contact lenses. Medical conditions affecting the eyes — including cataracts, eye diseases, or injuries — are generally handled through your medical insurance rather than a routine vision plan.
Many vision plans function as wellness or discount benefit plans, offering specific benefits and savings in exchange for an annual premium. Coverage, benefits, and out-of-pocket costs vary by plan. As with any insurance product, it is important to understand what you are purchasing and choose coverage based on your individual needs and expected usage. Our Phanald IT agents are available to help you understand your options and find vision coverage that fits your needs and budget.
Group Health Plans
Group health plans, also known as employer-sponsored health plans, are major medical insurance plans designed to help businesses with one or more employees cover health care expenses. Similar to individual medical plans, group health plans help cover eligible medical expenses associated with serious illnesses, injuries, and hospitalization. Depending on the plan, members may be responsible for coinsurance after meeting their deductible.
Group health insurance is purchased by employers and offered to eligible employees and their dependents. In general, group plans can be more affordable because the insurer's risk is spread across a larger group of participants. Employers may also choose to share the cost of premiums with their employees, making coverage more affordable for everyone. Employee contributions toward employer-sponsored health insurance are generally made on a pre-tax basis when the employer's plan is structured to allow it. This can reduce an employee's taxable income and may result in tax savings.
Common Types of Group Health Plans
Health Maintenance Organization (HMO): HMO plans generally require members to receive care from doctors and health care providers within the plan's network, except for certain emergencies. They may also require referrals to see specialists.
Exclusive Provider Organization (EPO): EPO plans generally cover care received from doctors and hospitals within the EPO network, with limited exceptions for emergencies. Members typically do not need a referral to see a specialist. EPO plans can also offer lower premiums than some PPO plans.
Preferred Provider Organization (PPO): PPO plans typically offer a broader network and greater flexibility when choosing doctors and hospitals. Members generally do not need referrals to see specialists and may receive care from both in-network and out-of-network providers, although out-of-network care usually costs more.
Choosing the right group health plan can make a significant difference for both your business and your employees. We can help you compare your options and find coverage that fits your company's needs and budget.
Understanding Your Medicare Coverage Options
Medicare is a federally funded health insurance program that provides coverage primarily to people age 65 and older. Medicare may also cover:
- Younger individuals with disabilities who receive Social Security disability benefits or certain disability benefits from the Railroad Retirement Board, generally after a 24-month waiting period.
- Individuals with End-Stage Renal Disease (ESRD) — permanent kidney failure requiring regular dialysis or a kidney transplant.
Different Parts of Medicare
Each part of Medicare helps cover different types of healthcare services.
Original Medicare — Part A & Part B
Part A helps cover:
- Inpatient hospital stays
- Care in a skilled nursing facility
- Hospice care
- Certain home health care services
Most people do not pay a monthly premium for Part A because they paid Medicare taxes through payroll deductions while working.
Part B helps cover:
- Doctors' services
- Outpatient care
- Medical supplies
- Preventive services
- Physical therapy
- Certain home health care services
Most people pay a monthly premium for Part B.
Medicare Advantage — Part C
Medicare Part C, also known as Medicare Advantage (MA), is an alternative to Original Medicare. Medicare Advantage plans are offered by private insurance companies approved by Medicare. Medicare Advantage plans provide coverage for all Medicare Part A and Part B services and may offer additional benefits, such as:
- Dental coverage
- Vision coverage
- Hearing benefits
- Fitness and wellness programs
- Other supplemental benefits
Plan benefits, costs, and provider networks vary by plan and insurance carrier.
Medicare Prescription Drug Coverage — Part D
Medicare Part D provides coverage for outpatient prescription drugs through private insurance plans approved by Medicare. Part D coverage is available through:
- Stand-alone Prescription Drug Plans (PDPs)
- Medicare Advantage plans that include prescription drug coverage (MA-PDs)
All Medicare Part D plans must follow federal Medicare guidelines. Insurance carriers submit their plan offerings to the Centers for Medicare & Medicaid Services (CMS) for review and approval.
Medigap — Medicare Supplement Insurance
Medigap, also known as Medicare Supplement Insurance, is sold by private insurance companies to help pay some of the healthcare costs that Original Medicare does not cover. Depending on the plan, Medigap may help pay for expenses such as:
- Deductibles
- Copayments
- Coinsurance
- Certain healthcare costs while traveling outside the United States
Medigap can be a good option for individuals who want more predictable healthcare expenses and potentially lower out-of-pocket costs when receiving covered services.
Important: Medigap is not a replacement for Original Medicare. It works alongside Original Medicare Part A and Part B and is different from a Medicare Advantage plan. Medigap plans generally do not include prescription drug coverage, so beneficiaries who want Part D coverage typically need a separate prescription drug plan.
Choosing Medicare coverage can feel complicated, but you do not have to navigate it alone. Give us a call today. One of the Phanald IT agents will be happy to sit down with you, review your options, and help you find Medicare coverage that fits your needs.
Contact us today for a no-obligation consultation. Our team is here to help you find the right coverage and services for your needs.
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