What’s the Best Health Insurance Option for You?

Originally published on

Despite efforts to improve the health plan-buying process, choosing health insurance isn’t like buying a car. Deciding between car accessories can be fun. Picking a health insurance plan can feel like a chore, but it’s one of the most decisions you make each year.

You might feel confused about health insurance terms and the myriad options available to you. You may feel like you’re not even sure where to start. We’re here to help.

On this page, we’ll go through possible avenues for health insurance coverage depending on your situation. Not all of these solutions may work for your specific case. Instead, it’s a guide of what’s likely a choice for you.

Now, before we get into options, let’s talk about what you should compare when choosing a health insurance plan:

  • Your finances. How much money do you have for out-of-pocket costs? Are you eligible for health insurance tax credits?
  • Family situation. Do you need a family health plan?
  • Health care need. What are your and your dependents’ health care needs?
  • Job status. Are you employed?
  • Location. What individual plans are offered in your state?
  • Your health plan preferences. Would you rather a restricted network of providers at a lower cost or more flexibility with higher premiums?

All of those factors play a part on what health insurance would work for you.


Open enrollment

Open enrollment is when most Americans sign up for or change health insurance. That period varies by how you get insurance.

Here’s when open enrollment is for different types of insurance:

  • Employer-sponsored health insurance: Businesses don’t have a uniform open enrollment period. Instead, each company picks a time for employees to make benefit changes. Ask your benefits department when open enrollment is for you.
  • MedicareMedicare open enrollment runs from Oct. 15 to Dec. 7. Beneficiaries can sign up for or change a Medicare plan.
  • Individual insurance/Affordable Care Act (ACA) exchange plans: Open enrollment is from Nov. 1 to Dec. 15 for most Americans. There are a handful of states that have longer open enrollment for the individual market. We’ll get more into that later.
  • Medicaid and Children’s Health Insurance Plans (CHIP): There is no open enrollment for Medicaid and CHIP. You can sign up at any time of the year if you’re eligible.

You can only make changes to your health insurance during open enrollment unless you have a qualifying event that kicks off a special enrollment period. This could be because of a job loss, reduced hours, a death, a divorce or a new child.


What health insurance is available for you?

Now, let’s go through 10 scenarios and likely health insurance options for you.

People with a job that offers health insurance

Having a job makes it much easier to get health insurance. Most Americans are covered through their job. Employer-sponsored coverage is usually cheaper than an individual plan. That said, there are other options even if you’re employed.

Here are five options (click on any plan to find out more):

Health insurance through your employer

Health insurance through your spouse’s employer


Individual market/Affordable Care Act exchanges

Short-term health plans


Someone with a spouse whose employer offers health insurance

Going with an employer-sponsored health plan is usually your best bet. Employers share the costs with employees. That results in lower premiums and out-of-pocket costs.

Don’t forget to explore your spouse’s employer’s insurance options.

Here are five options (click on any plan to find out more):

Health insurance through your employer

Health insurance through your spouse’s employer


Individual market/Affordable Care Act exchanges

Short-term health plans


Someone who’s unemployed

Not having a job is tough enough. It also means you lose an option of getting health insurance through your employer.

Your options were once more limited when you lost your job. In fact, COBRA might have been your only option. However, the ACA and recent Trump administration regulation changes give you more choices if you’re unemployed.

Here are six options (click on any plan to find out more):

Health insurance through your spouse’s employer



Individual market/Affordable Care Act exchanges

Short-term health plans

Children’s Health Insurance Program


Senior citizen

Turning 65 is a health insurance milestone. You become eligible for Medicare and can choose between original Medicare or Medicare Advantage.

You don’t have to sign up for Medicare at 65 years old, but it’s a wise choice. If you wait, you could get fined when you sign up. Not enrolling in Part B can also mean a 10 percent premium late-enrollment penalty for each year you don’t sign up.

One option is to get Medicare Part A (hospitalizations), which is free for most Americans, and keep your employer plan if you’re still employed. Make sure you take into account the possible late-enrollment penalty if you don’t sign up for Part B when you become eligible for Medicare.

Here are four options (click on any plan to find out more):

Health insurance through your employer

Health insurance through your spouse’s employer

Original Medicare

Medicare Advantage


Young adults/20-somethings

The ACA requires insurers allow members to keep their children on health plans until the child turns 26. The good news is there are multiple options for young adults and 20-somethings other than your parents’ insurance.

If you find regular health insurance plans are too pricey, you can explore a short-term health plan. These plans have low premiums but don’t offer the same protections as a regular health insurance plan. So, beware of the limited coverage and out-of-pocket costs associated with those plans.

Here are four options (click on any plan to find out more):

Health insurance through your employer

Health insurance through your spouse’s employer

Individual market/Affordable Care Act exchanges

Short-term health plans


Someone who’s middle class

Your family’s household income can play a part in your health insurance options.

The IRS provides premium tax credits for households with incomes between 100 percent and 400 percent of the federal poverty line.

Federal poverty level guidelines

Persons in Household Federal poverty level for continental U.S. Premium subsidy threshold (400% of federal poverty level)
1 $12,140 $48,560
2 $16,460 $65,840
3 $20,780 $83,120
4 $25,100 $100,400
5 $29,420 $117,680
6 $33,740 $134,960
7 $38,060 $152,240
8 $42,380 $169,520

Of course, you also may have the option of a plan through your job or your spouse’s job, which is likely a more affordable option than going with an individual or ACA plan even with tax credits.

Here are four options (click on any plan to find out more):

Health insurance through your employer

Health insurance through your spouse’s employer

Individual market/Affordable Care Act exchanges

Short-term health plans


Someone with a lower income

Americans will lower incomes have the potential for more help with their health insurance. The IRS offers premium tax credits and the ACA also kicks in funding to help offset out-of-pocket costs for lower-middle-class Americans with incomes less than 250 percent of the federal poverty level.

There’s also a public program option like Medicaid and the Children’s Health Insurance Program. States’ eligible income levels vary for Medicaid and CHIP. We’ll get more into that later.

Here are six options (click on any plan to find out more):

Health insurance through your employer

Health insurance through your spouse’s employer


Individual market/Affordable Care Act exchanges

Short-term health plans

Children’s Health Insurance Program


People with children

Getting your children covered is probably even more vital in your mind than getting insurance for yourself. Medicaid covers more than 45 million children and CHIP provides include for about 9 million.

Here are five options (click on any plan to find out more):

Health insurance through your employer

Health insurance through your spouse’s employer


Individual market/Affordable Care Act exchanges

Children’s Health Insurance Program


Someone with pre-existing conditions

Searching for affordable health insurance when you have a pre-existing condition, such as diabetes or heart disease, was once nearly impossible. Before the ACA, insurers could reject people with pre-existing conditions if they applied for an individual health plan. Alternatively, those insurers might charge high premiums because of the added risk.

The ACA ended that practice. Now, Americans with pre-existing conditions can’t get denied coverage and won’t pay a lot more for health insurance.

Here are four options (click on any plan to find out more):

Health insurance through your employer

Health insurance through your spouse’s employer


Individual market/Affordable Care Act exchanges


Small business owner or contractor

Being a small business owner or a contractor can limit your insurance options and you may face significant health coverage costs.

However, there are more options for small business owners and contractors in 2019. The Trump administration changed regulations that will expand short-term plan and association health plan options.

These low-cost options come with fewer consumer and patient protections. So, you want to decide if sacrificing regular health insurance plan benefits are worth the lower costs.

Here are three options (click on any plan to find out more):

Individual market/Affordable Care Act exchanges

Short-term health plans

Association health plans


Your options for health insurance

Health insurance isn’t one-size-fits all. Your options vary depending on your job status, age, income, family and what you want from your insurance. In other words, would you rather pay more for premiums and less out-of-pocket? Alternatively, do you want low premiums with the potential for substantial out-of-pocket costs?

Here are 10 health insurance options and descriptions about each one.


Health insurance through your employer

Employer-sponsored health insurance remains how more than half of Americans get their coverage. This coverage is also cheaper than many non-government options. That’s because your employer is chipping in to pay for health insurance.

Annual family premiums for employer-sponsored health insurance plans averaged $19,616 in 2018. Employees contributed $5,547 on average for those premiums. Single coverage averaged $6,896 with workers contributing an average of $1,186 annually, according to Kaiser Family Foundation.

Pros: Cheaper than the individual market.

Cons: Limited choices, employer must offer coverage.


Health insurance through your spouse’s employer

Most businesses allow employees to add their spouse and children to health plans, but it comes at a cost.

Some employers have removed the spouse tier for health insurance. In those cases, employees only have an individual or family plan option. That can result in higher premiums for a couple without children because they’re paying for family coverage.

When both you and your spouse have health insurance options, it’s a good idea to compare plans. You could actually save more than $1,000 each year depending on the health plan.

Where do you start? Compare the plans’ out-out-pocket costs, deductibles, copays and coinsurance. You might find your spouse’s plan makes more sense for your family. Just remember to check that your providers are part of that plan’s network.

Pros: Cheaper than the individual market.

Cons: Limited choices, employer must offer coverage.



If you lose your job, you are likely eligible for COBRA coverage for 18 months.

You must sign up by 60 days after the qualifying event, such as getting laid off. COBRA extends your employer-sponsored plan though you’re no longer employed. COBRA is costly since the employer no longer pays for your coverage. You pay as much of 102 percent of the costs of the plan.

The average annual family premiums for an employer-sponsored health insurance plan cost nearly $20,000 in 2018. Employees contributed about $5,500 on average. So, if you have a COBRA plan in this scenario, you’d wind up paying more than $20,000 in premiums. That’s pricey but allows you to maintain your coverage temporarily.

Pros: Allows you to keep your previous employer’s plan.

Cons: Costly, only available for 18 months after employment.


Original Medicare

Medicare Parts A & B are often called original Medicare. It’s the program that has covered seniors since the 1960s.

Part A covers hospitalizations; Part B deals with physicians and outpatient care. Nearly all seniors can sign up for Part A without any premiums when they turn 65.

Annual Part B premiums average $1,600 in 2019, but that could be higher depending on your income.

Pros: Accepted by most physicians and hospitals, Part A doesn’t charge premiums for most people, Part B can be a better alternative than employer plans or individual insurance.

Cons: You may have trouble finding a physician that accepts Medicare, you’ll need to get a Part D prescription plan and Part B coverage can be more expensive than Medicare Advantage.


Medicare Advantage

Medicare Advantage is a plan that’s offered by a private insurance company. It’s an alternative to original Medicare.

Many Medicare Advantage plans have prescription drug benefits. The plans also have supplemental benefits, such as home health care, transportation to appointments and population health initiatives.

The average annual Medicare Advantage premium for 2019 is $336, though nearly half of enrollees have a plan with no premiums.

Pros: Less expensive than employer-sponsored plans.

Cons: You might have trouble finding a Medicare Advantage plan that accepts doctors in your area if you live a rural region.



Once viewed as a safety-net health insurance program that covered the poorest people, Medicaid has grown into an even more substantial way Americans get health insurance.

Medicaid, which is a federal/state program, covers nearly 70 million Americans. The ACA allowed states to expand Medicaid. What this did was let people up to 138 percent of the federal poverty level get coverage.

Three dozen states expanded Medicaid. Other states are also showing interest in the possibility, which is the primary reason why 15 million more Americans have health insurance since the ACA.

The costs of a Medicaid plan varies depending on your state and income. That said, Medicaid costs are much cheaper than most plans.

Pros: Low-cost plans that provide all the coverage found in regular health insurance.

Cons: Not all doctors accept Medicaid.


Individual market/Affordable Care exchange plans

The individual market could be an expensive option for uninsured Americans before the ACA. The health law made the market more affordable — though it’s usually still more costly than employer-sponsored plans.

The average annual individual premium is about $7,200. That’s quite higher than other health insurance and the premiums could be much higher depending on your state and plan.

However, the ACA helps people pay for their insurance. The IRS provides tax cuts on health insurance premiums for people at 400 percent of the federal poverty with an ACA plan.

Check out the Health Insurance Advisor to help you find an individual plan.

Pros: Cheaper alternative to COBRA.

Cons: More expensive than other plans.


Short-term health plans

Before the ACA, short-term health plans were a low-cost alternative to regular health insurance. The short-term plan market took a significant hit with the ACA, which required the plans provide the same level of coverage as regular health insurance. That coverage includes the 10 essential health benefits, including hospitalization, emergency, maternity, prescription drug, mental health and preventative coverage.

The Trump administration made a change to those plans for 2019, which allow the plans to sidestep coverage requirements once again. Most Americans are now eligible for short-term coverage. Another difference is that people can now have short-term plans for a year and renew twice. So, in effect, you could have a short-term plan for three years.

The result is lower-cost plans that can offer little coverage with hefty out-of-pocket costs. So, you may pay low premiums but will have to pay more for health care services.

Pros: Low premiums.

Cons: Fewer consumer and patient protections and potentially high out-of-pocket costs.


Association health plans

Association health plans allow small businesses and sole proprietors to band together to buy health insurance.

AHPs no longer must provide the 10 essential health benefits. Also, the Trump administration lessened restrictions on companies banding together.

These plans offer low-cost solutions but may offer limited coverage.

Pros: Low-cost alternative to individual insurance.

Cons: Fewer protections, you must meet AHP requirements.


Children’s Health Insurance Program

The Children’s Health Insurance Program (CHIP) is a state/federal program initiative that provides coverage for children whose families meet income requirements. Income requirements vary by state.

More than 9 million children are covered by CHIP, which is sometimes rolled into with a state’s Medicaid program.

Pros: Low-cost coverage and peace of mind that your children are covered.

Cons: Fewer physicians accept CHIP than employer-sponsored insurance.



How to choose a health plan

Once you figure out your options, you may find that you have multiple alternatives. For instance, your employer may offer different types of plans, including a preferred provider organization (PPO) plan and a high-deductible health plan (HDHP). Or you might have multiple Medicare Advantage options in your state.

When choosing between health plans, look at the costs associated with the plans. That includes:

  • Out-of-pocket maximums
  • Deductibles
  • Copays
  • Co-insurance

Think about how often you needed to use health care services over the past year and what you expect for the next year. You can’t predict exactly how much you’ll require, but you may be able to figure out approximately what you need. For instance, you might be starting a family or you may need to finally get help with your back or knee. Figure out what you might need and that can help guide through which plan to choose.

Then, make sure your physicians are part of the plan’s network of providers. If not, you may not be able to see the provider or will have to pay more for those office visits.

Also, think about what you want from your plan. Do you want to see any doctor and don’t mind paying higher premiums, a PPO might be a good choice. If you want to pay low premiums and don’t mind paying more for actual services, then an HDHP could be a wise decision. If you don’t care about getting a referral to see a specialist and don’t find a restricted network of providers, a health maintenance organization (HMO) plan could be right for you.

Before making your decision, check out the Best Health Insurance Companies page on Insure to read reviews of health insurance companies.

No matter which type of health insurance plan for you, make sure you go through the process to find the right health plan for you.

Healthcare, Insurance

Guide to Short-term Health Insurance

Originally published on

Most Americans have an additional health plan option in 2019. Short-term health plans are a low-cost plan. Don’t confuse them with standard health insurance plans though.

Yes, they provide health coverage, but they fall well short of what’s considered health insurance under the Affordable Care Act (ACA).

The ACA restricted short-term plans to young people and Americans who couldn’t afford any type of insurance. However, the Trump administration implemented a new policy for 2019 that will now allow anyone to apply for a short-term plan.

These are not catastrophic health plans. Catastrophic health plans are more commonly referred to as high-deductible health plans. Those plans as the name suggests have high deductibles.

High-deductible plans have low premiums and high out-of-pocket costs, but they provide all the protections of a health insurance plan. Short-term health plans aren’t considered an insurance plan because of their limited protections. They are now yearlong options with a chance to extend two more years. Short-term plans previously only lasted three months and let people renew up to a year.

Ryan McCostlin, a healthcare advisor at Bernard Health, said short-term plans aren’t for everyone, but some Americans may want to consider the plans.

“More and more Americans are saying that figuring out health insurance is more like filing taxes than buying car insurance, and the resurgence of short-term plans for 2019 is a signal that there’s just another healthcare financial planning strategy to be considered by savvy consumers,” McCostlin said.

Let’s take a look at what’s a short-term plan, what it covers and what it costs.

What’s a short-term health plan?

Short-term health plans are low-cost, low-coverage plans. Starting in 2019, these plans are available for most people up to one year with the option to extend the plans twice. In effect, you could have a short-term plan for three years. That’s unlike regular health insurance, which doesn’t have time limits.

Not all states allow short-term plans. States that forbid the sale of short-term plans include:

  • California
  • Hawaii
  • Massachusetts
  • New Jersey
  • New York

Other states have regulations that restrict short-term plans beyond the federal rules. For instance, Maryland only allows short-term plans for three months with no renewals.

What does a short-term health plan cover?

What short-term plans cover varies widely. Federal regulations allow short-term plans to create their own coverage plans without any required mandates like a regular health insurance plan. So, you may find substance abuse treatment coverage in one short-term plan, while another might cover barely anything.

The Kaiser Family Foundation analyzed short-term plans available in 2018 and found that:

  • 43 percent don’t cover mental health services
  • 62 percent don’t cover substance abuse treatment
  • 71 percent don’t cover outpatient prescription drugs
  • None of the plans cover maternity care

“They have a lot of fine print exclusions,” cautioned Betsy Imholz, special projects director at Consumers Union. “It’s worth noting that 40 percent of pregnancies in the U.S. are accidental. So, women of childbearing age need to be mindful of that excluded coverage in short-term plans.”

The ACA requires health insurance plans cover the 10 essential health benefits:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder
  • Prescription drugs
  • Rehabilitation services
  • Laboratory services
  • Preventive and wellness services
  • Pediatric services, including oral and vision care

Those are now standard parts of health insurance. Not so for short-term plans. In fact, you might have trouble finding a short-term health plan that covers most of those services.

Short-term plans vary, so you might find one that covers prescription drugs, while others don’t.

Short-term plans with more benefits will cost more than ones that provide little protection.

There’s also the issue of being denied coverage. While ACA plans require that insurers approve everyone regardless of health status, short-term plans can reject you. Some states may require “guaranteed issue,” which means a plan must cover you, but the federal law doesn’t demand that for short-term plans.

A short-term plan may reject you if you have a pre-existing condition. Or that plan may charge you exorbitant premiums. That’s not allowed in ACA plans.

More than half of Americans who aren’t in Medicare or Medicaid have some type of pre-existing condition. A short-term plan is likely not a good choice for those Americans.

Imholz said short-term plans can also cap the amount they pay to cover you annually and can limit how much it will spend on specific services, such as hospitalizations.

So, if your short-term plan covers hospitalizations, but only up to $5,000, you’ll be the hook for any amount above $5,000. That’s one reason why it’s critical to dig into what a specific short-term plan covers before signing up.

Plus, short-term plans can bring hefty out-of-pocket costs. Many short-term plans have lifetime limits on what they’ll cover. If you have a short-term plan and you’re diagnosed with a costly illness, the plan may stop paying for care after a limit is reached, such as at $100,000.

Short-term plans can also limit what they pay for specific treatments and hospitalizations.

How much does a short-term health plan cost?

You can find a short-term health plan for less than $100 a month. Compare that with the average of nearly $400 for ACA-compliant health plans. Short-term health plan premiums are 80% less on average than ACA plans.

However, Imholz said premiums are just one piece of a financial puzzle. You must also look at a plan’s deductibles, copays, coinsurance and dollar limits and exclusions of services that aren’t covered in short-term plans.

You may find that a low-cost, short-term plan may actually cost you more in the long run than an individual health insurance plan.

“There are all sort of pitfalls in these skinny plans that may not be evident at first blush and aggressive marketing emphasizing their lower premiums may make them sound tempting. But short-term plans cost less in premiums because they cover less. If you fall into one of the many gaps these plans have, it will end up costing you a lot more in the longer run,” Imholz said.

Who should get a short-term plan?

Healthy people might benefit from a short-term plan’s low premiums as long you don’t need health services.

These plans can provide you with some coverage but can lead to substantial out-of-pocket costs. A short-term plan is likely not a good idea if you plan to start a family.

“Short-term plans are not a panacea. They’re not a good fit for everyone, but they should be included in any serious analysis of healthcare financial planning,” McCostlin said.

Some major health insurers, such as UnitedHealthcare, offer short-term plans. Don’t confuse that coverage with regular health insurance. Just because a big-name insurer offers a short-term plan doesn’t mean that plan will provide you with full health insurance coverage. It’s not always easy to distinguish between plans, so it’s critical to read the fine print.

“One thing consumers can do is to ask the agent or company for a Summary of Benefits and Coverage, which is a standardized form required for ACA plans to help people compare plans. If there is not one available, that’s an indicator that it’s not an ACA-protected plan,” Imholz said.

People with any illness and pre-existing condition like asthma or diabetes should avoid short-term plans. Even if a short-term plan covers you, your pre-existing condition will likely lead to significant premiums. The plan also won’t likely provide enough coverage to make it worth your while.

However, if you’re healthy and don’t plan on using healthcare services often, a short-term plan can be a wise choice. Just hope for a year full of healthy days and little time spent at the doctor’s office or in a hospital.

Of course, you can’t predict your health for the next year. Imholz gave the example of one woman who bought a short-term plan. She was healthy so thought it was a good fit. Then, she was diagnosed with diverticulitis. The plan covered that ailment, but not the infection that arose from the condition. The plan declined to cover the treatment and deemed it a pre-existing condition. That decision left her with thousands of dollars of medical bills.

“Accidents and illness often come unexpectedly, so while you may be healthy today, life can change in an instant. If you can swing a marketplace policy, it’s a much safer, better deal,” Imholz said.

Short-term plans are also an option if you need to bridge the gap between employer plans. You can buy COBRA insurance and keep your previous employer’s insurance plan temporarily. That’s expensive though.

A short-term plan is a lower-cost alternative to COBRA or an individual plan. It’s also better than not having any coverage at all.

“There are many Americans who are choosing between short-term plans and no coverage at all. For these consumers, short-term plans can be a good fit to protect against emergencies and unexpected accidents,” McCostlin said.

Healthcare, Insurance

What is Medicare: How Do You Get Covered?

Originally published on

Medicare is a federal health insurance program that covers about 44 million Americans. That’s about 15 percent of the population.

It’s the single largest payer of health insurance in the country. People become eligible when they turn 65. It’s also available for people under 65 with disabilities or those with end-stage renal disease.

You’re automatically enrolled in Medicare when you turn 65. As you approach 65, you’ll receive information about choosing a Medicare plan. This should come three months before you turn 65. You have until three months after your 65th birthday month to pick a plan. That gives you seven months to review your options before making a decision.

The effective date is the first day of the month when you’re eligible for Medicare if you sign up in the months before becoming eligible. If you wait to sign up for Medicare on the month when you’re eligible or the following month, the effective date is the first day of the next month.

What are the different types of Medicare?

There are four types of Medicare. These plans cover specific services:

Most Medicare beneficiaries have original Medicare (Parts A & B), but Medicare Advantage plans have gained popularity over the past decade.

Now, about one-third of Medicare beneficiaries have Medicare Advantage and that’s expected to grow in the coming years.

How do you find a doctor who takes Medicare?

One of your biggest concerns with switching health insurance might be: Will I get to keep my doctor?

An easy way to find a doctor or to see if your current doctor accepts Medicare is to check CMS’ Physician Compare. The tool lets you search by the provider’s name or the group practice name. You can also look by specialty, medical condition, body part or organ system. That will help you find specialists.

Once you provide the information, the site will give you a list of local providers with profiles and specialties.

Lindsay Engle, a healthcare expert with MedicareFAQ, said doctors who accept original Medicare (Parts A & B) might not take Medicare Advantage plans. About 96% of physicians accept Medicare, but you may find doctors who aren’t in Medicare Advantage networks.

“Your plan information will tell you what type of plan you’re currently enrolled in and what providers or networks you have to use. Your best option is to contact your doctor or physician’s office to see what type of Medicare plans they accept,” Engle said.

Do I need a Medicare plan if I turn 65?

Let’s say you’re 65 and you plan to work for a few more years. You’re happy with your employer-sponsored health plan and don’t want to give it up. Do you have to get Medicare?

You could go with only a Part A policy, which is free for most Americans.

That way you won’t have to pay premiums and still have your private health plan to help you with coverage, including doctor visits.

“Your Medicare benefits will work with your employer coverage,” Engle said.

Medicare and other insurers have something called coordination of benefits (COB). COB figures out which plan pays first for coverage if you have more than one plan.

For instance, if your employer has more than 20 employees, the COB will consider Medicare coverage a secondary payer. If your company has fewer employees, your Medicare coverage is primary and the employer is secondary.

The primary insurer pays initially and then the secondary payer covers its portion up to 100% of the total cost.

Having more than one type of health insurance is called “dual insurance.” Having dual insurance can help reduce out-of-pocket costs, but also means you may have to play two premiums. Plus, you could face two separate deductibles.

“Medicare as secondary insurance will cost you money. Part B is not premium free. Some beneficiaries choose to delay their Part B coverage if they have group coverage as their primary since it covers outpatient benefits usually. Since employer coverage is considered credible coverage, you won’t be penalized for delaying your Part B enrollment,” Engle said.

You’ll want to run all of those numbers to see whether keeping other coverage makes sense for you when you become eligible for Medicare.

How do I find a Medicare plan?

Not too long ago, people turned 65 and enrolled in original Medicare (Parts A and B). Now, seniors have multiple options, including Medicare Advantage.

You can go with Parts A and B, you can add on a Part D plan or you can choose one of many Medicare Advantage offerings.

You’re able to compare plans each year and pick the best one for you. Medicare recommends members consider:

  • Costs
  • Coverage
  • Your other coverage
  • Prescription drugs
  • Doctor and hospital choice
  • Quality of care
  • Travel

You also want to make sure your doctors or hospital are considered in-network. You might even want unrestricted access and not need doctor referrals. In that case, you might want to get a PPO, which is more expensive than an HMO but gives you more flexibility.

One way to figure out the plan for you is to check out CMS’ star ratings for the different plans. CMS rates plans between one and five stars with five stars being the highest mark. The ratings take into account membership surveys, quality and performance.

Besides the prestige of earning five stars, health insurance companies get a higher reimbursement from the government when they have a five-star plan.

Medicare Plan Finder lets you compare both traditional and Medicare Advantage plans in your area. The site will ask you a series of questions that will help you narrow the number of sites that interest. It will reveal each plan that may make sense for you, including premiums, deductibles, estimated annual health and drug costs and overall rating.

Once you find the plan for you, you can choose it on the site and fill out the necessary paperwork.

Should you choose traditional Medicare or Medicare Advantage?

Which Medicare works best depends on your situation, your area and what plans are available.

Engle suggests sticking with original Medicare (Parts A & B) if you want to keep your current doctor who doesn’t accept Medicare Advantage and the plan has better overall coverage than Medicare Advantage.

“You should consider a Medicare Advantage plan if you want medical and drug coverage combined into one plan, limit annual out-of-pocket costs and extra benefits like dental, vision and hearing,” Engle said.

You may find a plan with low premiums, but remember you get what you pay for. Plans with low rates may have high deductibles and out-of-pocket costs.

If it’s your first time choosing a Medicare plan, Engle suggests speaking to a licensed agent who works with multiple carriers. The expert will consider all of your options. Don’t rely on a friend or family member.

“Medicare is always changing, part of an agent’s job is to stay up to date with the most recent changes. Also, what works for your friend or family member may not work for you. Everyone has different healthcare needs,” Engle said.

When can I change Medicare plans?

Don’t worry about getting stuck in a Medicare plan you don’t like.

All Medicare beneficiaries can switch plans once a year. This happens during the annual open enrollment. Medicare’s open enrollment runs between Oct. 15 and Dec. 7. Any changes will take effect on Jan. 1.

However, Medicare beneficiaries can make changes during any time of the year if they go through certain life events. That can include if you move or you lose other health insurance coverage.

Here are some events that trigger a special enrollment:

  • Loss of coverage
  • Changes in household, such as a death
  • Changes in residence, such as moving to another state
  • Changes to your income

If you go through an eligible life event, you can make changes during a Special Enrollment Period. Changes made during a Special Enrollment Period usually kicks in the first day of the next month.

What is Medigap?

Medicare, just like any health insurance, can get pricey. Medigap is one way to help you pay for healthcare costs.

Medigap is a supplemental insurance. Original Medicare pays for 80% of your medical needs. Medigap covers the remaining 20% and out-of-pocket costs.

This is not a health insurance plan. Instead, the policy assists you to pay for services in Medicare Parts A & B. Those costs include copays, coinsurance and deductibles.

Medigap kicks in after Medicare pays its amount for covered healthcare services.

Some Medigap plans offer coverage not available in regular Medicare. For instance, you can get Medigap coverage for when you travel outside the country.

Private companies sell Medigap policies to individuals and not couples or families. So, if you and your spouse both want Medigap coverage, you each need to buy a policy.

“If you want all of your healthcare costs covered, a Medigap plan is your best option,” Engle said.

Healthcare, Insurance

5 Takeaways From Payer Q2 Earnings Reports

Originally published on Healthcare Dive.

Second-quarter numbers for payers showed a steady engine that has withstood the strain of the past two years, most notably (the failed) Republican efforts to tear up the Affordable Care Act and other big moves from the Trump administration.

Insurers appear to have found stability and responded by expanding offerings, pulling back on others, moving into new subsectors and partnering with or gobbling up other companies.

Payer underwriting margins were strong overall with no apparent ramp up in underlying medical consumption, David Windley, managing director for healthcare equity research at Jefferies in Nashville, told Healthcare Dive.

“2Q is a critical quarter for (managed care organizations) because it is the point at which management has seen enough actual data on claims payments to assess product pricing and any unusual trends,” he said.

Here are five trends and highlights from payers’ earnings reports in the past few weeks.

1. Payers love Medicare Advantage

Payers remain bullish on Medicare Advantage. Not only are traditionally strong MA payers growing their offerings, but more minor players are also expanding in the market.

UnitedHealth Group and Humana continue to have the two largest MA member populations. UnitedHealth’s MA population increased 10.4% year-over-year after picking up 450,000 new members. UnitedHealth views MA as a significant growth area and company officials said its long-term group rate is about 8%.

Meanwhile, MA drove Humana’s second-quarter earnings, which included a 5% increase in quarterly consolidated revenues. In a move to boost its MA plans, Humana recently purchased a 40% share of Kindred at Home with the right to buy the remaining interest over time. The payer expects that adding Kindred will help with end-of-life costs.

Another insurer growing its MA footprint is WellCare Health Plans. Medicare premium revenue grew more than 17% for WellCare, which offers managed Medicaid, Medicare and Medicare pharmacy drug plans.

The company said the increase was related to buying Universal Americanand organic growth. The Tampa-based payer ended the quarter at about 510,000 Medicare members, which was a 5% increase year-over-year.

WellCare’s pending acquisition of Meridian Health Plan for $2.5 billion is also expected to grow membership in Illinois and Michigan, as well as pick up MeridianRX, its pharmacy benefit manager business. “It will position us for future growth opportunities in government-sponsored programs, and we expect the transaction to be accretive,” Kenneth Burdick, WellCare’s CEO, said during the company’s Q2 call.

Anthem also spoke positively about its MA business, reporting a 14% operating revenue increase in its government business for the quarter. That was thanks to purchasing Health Sun and America’s 1st Choice as well as growing its Medicare membership organically.

Medicare enrollment grew by 254,000 year-over-year and membership in Medicare Advantage Part D plans skyrocketed by 37%. Anthem finished the quarter with 933,000 Medicare Advantage Part D members.

Anthem CEO Gail Boudreaux said the company plans to build its membership further by increasing its county footprint while finding organic growth where it already operates. She added that the Blues payer has found that members in their commercial plans want to transition to its MA plans once they reach retirement age.

“We have a strong pipeline of commercial customers who want to stay Blue,” Boudreaux said.

2. The individual market isn’t so bad after all

The days of widespread double-digit premium increases and payers fleeing the ACA exchanges appear to be over — or at least on hold.

During second-quarter earnings calls, multiple payers spoke of the ACA exchanges positively. Centene, which expanded its ACA footprint to 16 states this year, pointed to the exchanges as a major reason for its quarterly revenue growth. The payer, which has a large managed Medicaid population, has found success in ACA plans.

Centene is also looking to add new states next and grow further in the states where it’s already located.

Another payer that focuses on at-risk populations traditionally, Molina Healthcare, said it has seen better-than-expected ACA plan membership and risk-adjusted revenue.

Molina CEO Joseph Zubretsky said the risk profile of its reduced membership is also better. Last year, Molina pulled out of Wisconsin and Utah. Now, the payer is contemplating a return to those states and expanding to North Carolina.

“The issues we had in Utah and Wisconsin were mostly related to a network that was too wide and too highly priced. And the team is working at developing a network that will support the prices that we file … We’re going to watch every bit of data emerge on 2018 to make sure we have this right and then we’ll make the call at that point,” Zubretsky said during the call.

Even Anthem, which pulled back on the ACA exchanges along with other big-name payers last year, is looking at potential minor county expansions for 2019. Boudreaux said the insurer isn’t considering significant expansion, but it may move to abutting counties while focusing on areas with current Anthem individual plans.

“I think you’ll see some county expansions, but I think more focused on the areas that we’ve been this year, so not a major rescaling, but we are pleased with the performance. And again, it is all about stability and more certainty around that marketplace. But again, this year was solid,” she said.

Despite the better-than-anticipated ACA numbers, not all payers are interested in returning to the exchanges. UnitedHealth Group ended the quarter with 60,000 fewer individual plan members than a year ago.

UnitedHealth Group CEO David Wichmann said the nation’s largest private payer, which has 480,000 individual plan members, will continue a “modest presence” in that market. “Nothing has fundamentally changed since we made our decision,” he said about the exchanges. “It was the right decision for us.”

3. Commercial market results fell for some big players

Multiple payers have seen a drop in their commercial membership over the past year. UnitedHealth Group, Anthem, Humana and Aetna all reported decreases.

UnitedHealth Group said more commercial plans are moving to risk-based contracting.

The payer’s risk-based offerings increased by 50,000 members, while fee-based products decreased by 60,000. That’s part of a trend that Wichmann predicted during the first-quarter call in April. Wichmann said half of Americans will get care from a physician with a value-based contract within a decade.

Meanwhile, two payers, Humana and Aetna, reported that what companies want from payers is changing, especially small businesses. They’re seeing small group companies moving to contracts to perform administrative duties only.

Humana’s administrative services only plans increased by 3% to 458,800 members. The payer said small group membership made up just 7% of group ASO membership a year ago and 12% at the end of 2017. It was 18% at the end of the second quarter.

Humana’s commercial membership dropped 5% to slightly more than 1 million members as it lost large group accounts in self-funded accounts, but more ASO plans partially offset the loss.

Not all payers are seeing commercial plan decreases. Cigna picked up 329,000 customers year-over-year and ended the quarter with 16.2 million enrollees. “All the indicators we’re seeing … continue to reinforce [that] we see a very attractive growth outlook in the commercial space in 2019,” Cigna CEO David Cordani said.

Cigna has focused more on commercial plans after CMS temporarily suspended the payer from offering MA plans. Cigna got the OK to sell those plans again last summer.

4. Payers are looking at public plan opportunities

While payers are seeing sagging commercial plan membership, they’re finding growth potential in managed Medicaid.

Centene recently purchased Fidelis Care for $3.75 billion, which gives the payer the fastest growing Medicaid managed care company in New York and second fastest in MA. Fidelis’ 1.6 million members are spread across the ACA, MA and Medicaid markets. Centene expects to see more than $11 billion in revenue from Fidelis.

WellCare’s purchase of Meridian will make it the largest Medicaid payer in membership in Michigan and Illinois, where it has 508,000 and 565,000 members, respectively. WellCare said the deal will put it in the leading market position for six states.

WellCare will also grow Medicaid membership after being the sole winner for Florida’s Children’s Medical Services contract. The company expects the contract will increase its Florida Medicaid annual revenue stream by $1.5 billion.

Molina picked up nearly 70,000 members in the second quarter after a recent statewide Illinois contract.

There are other Medicaid opportunities for payers too, as more states show an interest in expanding Medicaid. Boudreaux said Virginia’s upcoming Medicaid expansion brings 400,000 possible members. Maine voters also approved Medicaid expansion last year and a growing number of states are putting expansion on the ballot this fall.

However, it is not all positive news for Medicaid payers. Humana’s state-based contracts membership, which includes dual-eligibles, decreased by 13% year-over-year. The decrease came after the payer didn’t participate in Illinois’ Integrated Care program and a Medicaid membership drop in Florida. That said, Humana expects improved Medicaid membership next year after a new Florida contract.

5. Industry is in good financial shape

The second-quarter reports show that payers (and most healthcare companies, actually) are doing well financially. Axios reported that publicly-traded healthcare companies enjoyed billions of dollars of profits in the second quarter. In fact, they’re making more than in Q1, especially pharmaceutical companies. Those numbers don’t include nonprofit hospitals, which face their own challenges.

Two financial numbers that stand out are the revenue results for Aetna and Molina. Aetna stayed stagnant, but it’s also in the middle of the CVS Health merger. Plus, it enjoyed a nearly 8% profit margin in the quarter.

Molina, meanwhile, went through upheaval over the past year when it ousted CEO Mario Molina and CFO John Molina, the sons of the company’s founder. The payer also pulled back on the exchanges. Hence, the revenue drop.

Looking ahead to Q3, Windley expects more of the same for payers. He said insurance companies will begin to publicly discuss their 2019 plans during the third-quarter calls, including potential MA growth.

Here’s a breakdown of important metrics to show how payers did in the second quarter:


Revenues: $15.6 billion

Compared to 2Q 2017: No change

Profit: $1.2 billion

Net profit margin: 7.8%

Membership: 22 million



Revenues: $22.7 billion

Compared to 2Q 2017: Up 2.3%

Profit: $2.4 billion

Net profit margin: 5.2%

Membership: 39.5 million



Revenues: $14.2 billion

Compared to 2Q 2017: Up 19%

Profit: $300 million

Net profit margin: 2.1%

Membership: 12.8 million



Revenues: $11.5 billion

Compared to 2Q 2017: Up 10%

Profit: $193 million

Net profit margin: 1.4%

Membership: 16.2 million



Revenues: $14.3 billion

Compared to 2Q 2017: Up 5%

Profit: $193 million

Net profit margin: 1.4%

Membership: 16.6 million


Molina Healthcare

Revenues: $4.9 billion

Compared to 2Q 2017: Down 2.3%

Profit: $202 million

Net profit margin: 4.1%

Membership: 4.1 million


UnitedHealth Group

Revenues: $56.1 billion

Compared to 2Q 2017: Up 12.1%

Profit: $2.9 billion

Net profit margin: 5.2%

Membership: 48.8 million



Revenues: $4.61 billion

Compared to 2Q 2017: Up 7.4%

Profit: $172 million

Net profit margin: 3.9%

Membership: 4.4 million



Return of the House Call

Originally published in Healthcare Dive. 

The days of the kindly, silver-haired doctor with a small medical bag going house-to-house appeared dead and buried, but a new movement is taking shape to return the practice.

The resurgence has a key twist, however, with a heavy dose of 21-century technology.

Healthcare startups have cropped up to provide in-home medical services, including mobile urgent care and doctor appointments. But they’re not the only ones trying house calls. Established providers such as Johns Hopkins are getting into the act and Medicare is testing a home-based primary care model for high-cost chronically ill beneficiaries.

“We see (our house calls) as old-fashioned care with state-of-the-art technology,” Nick Desai, co-founder and CEO at Los Angeles-based Heal, a company that offers the service, told Healthcare Dive.

Mobile urgent care startups now dot the healthcare landscape and big-name private payers like UnitedHealthcare and Anthem, as well as Medicare and Medicaid, are contracting with mobile care companies.

Investors see potential and have put millions into mobile urgent care startup companies. Heal, which offers services in California, Washington, D.C. and northern Virginia, recently announced $20 million in additional funding to raise its total capital collected to more than $69 million.

Mobile care advocates like Desai say providing care in a person’s home is a better alternative than telemedicine or urgent care centers. Both of these avenues are an attempt to offer lower cost settings, but Desai said they are getting in the way of the direct primary care physician-patient connection.

Desai said the healthcare system isn’t going to be helped by “cramming more people into waiting rooms or further distancing doctors from patients.”

Healthcare companies that offer mobile care differ by where they see themselves in the system and who’s making the house calls.

Denver-based mobile urgent care provider DispatchHealth sees itself as supplementing care and as a partner for primary and specialty care. Meanwhile, Heal provides regular care, including primary care, prevention and pediatrics, as well as urgent care.

Johns Hopkins’ Hospital at Home treats patients with pneumonia, heart failure, chronic obstructive pulmonary disease and other conditions.

Home-based models “can be a versatile platform for creating an alternative to skilled-nursing-facility care after hospital discharge, a complement to early-discharge programs, and an option for post-surgical care. And technological advances, such as biometrically enhanced telehealth modalities, will make [them] more viable,”  Bruce Leff, professor of medicine at Johns Hopkins University School of Medicine, wrote in the New England Journal of Medicine.

Leff predicted that the move to value-based care will be a catalyst to “challenge the traditional, facility-based model.”

Longer, but fewer, patient visits

What house calls offer is convenience for the patient, and a potentially longer time with the doctor.   Heal said its average visit is 28 minutes, compared to the national average of 13 minutes.

However, the drawback for a mobile urgent care company is that a clinician sees fewer patients than in an office setting. That means fewer reimbursements. Lower overhead costs is one way to offset that.

Mapping out myriad appointments would be difficult for a human, but mobile care companies have technology that does the work for them. DispatchHealth screens patient appointment requests by using a risk stratification tool that analyzes a person’s age and chief complaint. The proprietary technology maps out the stops based on distance, traffic and a patient’s sickness.

CEO Mark Prather told Healthcare Dive its first market, Denver, has eight vehicles on the road and they can get to most calls within 20 to 25 minutes. “The computer does all that and optimizes all visits to get more visits out of calls per day,” he said.

Heal said it has also removed office-related healthcare costs from the equation. Desai said Heal’s technology platform automates the booking and billing process, which lowers healthcare operating costs and bureaucracy by 65%.

Dispatch expects to care for 55,000 patients this year, which it said would save about $80.8 million in medical costs, such as avoidable 911 transports, emergency room visits and hospitalizations. Heal has delivered more than 60,000 house calls since it launched in March 2015.

Mobile care models vary

Prather said DispatchHealth is designed as a “mobile ER to intervene on acute illnesses” that communicates with the patient’s regular care team. Founded in 2013, DispatchHealth operates in markets in Colorado, Virginia, Arizona, Nevada, Oklahoma and Texas and plans to expand to 10 markets by the end of the year.

A two-person medical team, which includes a medical technician and an ER-trained and board-certified nurse practitioner or physician assistant, go to homes and businesses. They usually arrive within an hour in a vehicle equipped with a certified lab, advanced formulary of medications, IVs and fluids.

Meanwhile, Heal sends a doctor and medical assistant to calls.

Desai said 80% of Heal’s calls are to patient homes. The company also provides employee healthcare. That’s about 15% of its business. The remaining visits are done in senior facilities.

Mobile urgent care is how Heal often acquires patients. Desai said 80% of its users first enter the system through mobile urgent care and then transition to Heal’s primary care, chronic disease management, wellness and pediatrics services.

Social determinants of health

Another potential benefit of mobile urgent care companies: helping providers find potential social determinants of health issues. Payers and providers increasingly see a link between SDOH and overall health outcomes. If a person doesn’t have a car, stable housing or regular nutrition, there’s a good chance they will wind up with health problems.

DispatchHealth includes a SDOH section of its patient report that reviews concerns with primary physicians.

By being in patient homes, mobile urgent care clinicians can spot potential issues, such as smoking, unsafe living conditions and medication issues. For instance, Desai said two-thirds of senior falls are related to medication-related dehydration. Being in the home allows the clinician to review all the medications and make sure they don’t conflict. Conflicting medication can lead to dizziness, falls and hospitalization.

Growth opportunities in senior population

The aging population may be one factor driving the trend.

A majority (60%) of DispatchHealth’s business is in the senior population, which may be redefining on-demand care. “We have a tremendous opportunity to address the healthcare needs in the aging population in a much smarter way,” Prather said.

The U.S. Census Bureau estimates that the country’s senior population will grow to 83.7 million by 2050, nearly doubling. An older population means more chronic illnesses and healthcare needs, leading to more hospitalizations and ER visits.

CMS also sees opportunities with house calls. It is testing primary care services at home through its Independence at Home demonstration. The second year of the program saved Medicare more than $10 million, an average of $1,010 per beneficiary.

Though mobile urgent care is becoming more common, Prather said hospitals shouldn’t worry that it will replace them. Mobile care will be supplemental. There will always be a place for hospitals, but they will increasingly focus on caring for the very ill. Healthcare will need to provide other types of care in lower cost settings, such as the home, he said.

“If you’re a hospital system, you’ve got to look at the landscape and see where it’s headed. It’s not more bricks and mortar,” Prather said.

Personal Finance, Real estate

How Much Money Do You Need in Your Emergency Home Repair Fund?

Originally published on

A home repair emergency fund can save you from financial disaster. While it’s easy to believe your house is in great shape, you never know when you’ll have to deal with an expensive plumbing bill or a flooded basement.

If you don’t have money set aside for repairs, you might be tempted to use your credit card. However, unless you’re able to pay them off immediately, charging costly home repairs is never a wise financial idea — it’ll accrue interest and leave you with an even larger bill later.

The better solution is to think ahead and create a home repair emergency fund.

What’s a home repair emergency fund?

A home repair emergency fund is money set aside to pay for unexpected home repairs—the cash you can grab at a moment’s notice. In other words, you don’t want to put that money into a long-term savings portfolio where you’ll face massive fees if you pull money out early.

Homeowners don’t need to get too creative with an emergency fund, says Byron Ellis, managing director of United Capital Financial Advisers in The Woodlands, TX. A savings account in a local bank will suffice.

How much money should you save in your emergency fund?

Ellis suggests homeowners create a cash reserve of three to six months of living expenses. You cash reserve target should be about 1% to 3% of your home value. So, if your home is worth $500,000, Ellis suggests setting aside $5,000 to $15,000.

Of course, each situation is different. A homeowner with a new home with all new systems and appliances might not need to tap into a home repair emergency fund. Fixer-uppers and old homes, of course, will likely require that money sooner.

General emergency funds

In addition to a home repair emergency fund, it’s also wise to create two general emergency funds: an everyday emergency fund and a dire emergency fund. Everyday emergencies—such as needing a new boiler in your home—can cut into your monthly budget, so having some cash stowed away will allow you to still pay your rent or mortgage. Shoot for having about 10% of your annual wage in your everyday emergency savings account, says Robert Reed, a partner at Partnership Financial in Columbus, OH. If you’re self-employed, Reed says to put aside 20% of your yearly salary since the income is variable.

The second emergency fund — the dire emergency fund — is for life’s calamities that interrupt your income. It could be losing your job, falling ill and needing to take time off work, or dealing with a death in the family.

“Our concern when something catastrophic happens is that people could risk losing their home because all of a sudden they can’t make their mortgage payment,” Reed says.

Reed recommends working toward saving 20% of your mortgage balance for the dire emergency fund. Put aside money from each check and you’ll quickly begin to get closer to your goal. For instance, putting aside $25 every week will get you $1,300 in a year.

Use a savings or money market account for your emergency fund. You shouldn’t use a brokerage account since that fluctuates.

What to do if you don’t have an emergency fund

Let’s say your central air-conditioning system dies in the middle of summer and you desperately need to replace it, but you don’t have a home repair emergency fund. Where do you turn? Two options are a home equity loan and a home equity line of credit, or HELOC.

Both of these let you tap into the value of your home to cover costs. A major difference is that the home equity loan is a lump sum and you often have a fixed interest rate. HELOC is a line of credit that you can borrow. A HELOC lets you draw money from the account as much as you need up to the available maximum amount. Also, a HELOC usually has an adjustable interest rate.

You can think of a home equity loan as a way to pay for a significant renovation project, while a HELOC is more likely going to help you with smaller projects that crop up over time. You tap into the HELOC only if you need it.


Value-based Pay a Factor Pushing Docs to Hospital Work

Originally published on Healthcare Dive.

More physicians, especially young doctors, are turning to hospitals for employment rather than running their own practice, spurred by the rise of value-based payments and population health.

The trend can have the effect of raising costs, however, and there are signs it may be slowing.

A recent report from Avalere conducted for the Physician Advocacy Institute found a 100% increase in hospital-owned physician practices, as well as a 63% increase in the total number of physicians employed by hospitals between July 2012 and July 2016. There were 72,000 physician practices employed by hospitals in July 2016.

PAI CEO Robert Seligson said payment policies favor large systems and the current payer environment “stacks the deck against independent physicians” through “administrative and regulatory burdens.”

Patrick Padgett, executive vice president of the Kentucky Medical Association (KMA), has seen the trend in his state over the past decade. Most employment is through hospitals and hospital systems in Kentucky, especially in rural areas. He’s seen a similar trend of more physician-led practices employing doctors, such as multi-specialty practices, Padgett told Healthcare Dive.

Times have changed so much in Kentucky that the KMA stopped providing an annual seminar to new doctors on starting your own practice. Now, because nearly every new doctor is employed, the seminar focuses on employment contracting and personal finance education.

What’s causing more hospital-employed physicians?

Multiple factors are driving the trend. Payment policies are a major factor.

Population health and value-based care models are driving “more coordinated, integrated and consumer-centric healthcare delivery systems,” Katie Gilfillan, director of Healthcare Financial Management Association’s finance policy, physician and clinical practice, told Healthcare Dive.

As payers move to risk-based payments, reimbursements that reward value, quality and lowering costs are replacing fee-for-service payments.

However, hospitals have limited influence on costs and patient outcomes once the person leaves the facility. So, instead, hospitals are looking to scoop up physician practices as a way to stay connected to those patients when they’re not in the hospital.

Caroline Pearson, senior vice president at Avalere, told Healthcare Dive that this gives hospitals a better chance to manage care and reduce costs.

Another factor is connected to market share and payer negotiation leverage.

Physician groups are feeling the economic pressures of rising costs to deliver care, Gilfillan said. Smaller practices are increasingly looking to hospitals and larger physician-led practices, which they feel can influence care and share the burden of risk more than going it alone. Being part of a larger system can make former small practices more competitive with the ability to negotiate better rates.

Being part of an integrated system also reduces risk. Plus, it can lessen regulatory burdens put on medical practices, such as prior authorizations.

A recent American Medical Association survey found that medical practices average 29.1 prior authorization requests per week. Processing takes an average of 14.6 hours per week. About 34% of physicians said they rely on staff to work solely on data entry and other manual tasks connected to prior authorization. Instead, being part of a larger system brings with it a bigger staff to take over or at least spread around those types of tasks.

Costs associated with EHRs also play a role. “Many small practices simply could not afford installing and then maintaining such systems,” Padgett said.

And then there’s just personal preference. Going the employee route reduces operational and financial risks, which can be appealing to physicians, especially those new to the profession. Employment can also bring with it a more predictable schedule. The downsides, though, can be a lower salary and less control over practice designs and office management.

Many younger physicians are interested in practicing medicine and don’t want the hassle of running a practice or a small business.

In its Physician Practice Benchmark Survey in 2016, the AMA found that two-thirds of physicians under 40 were employees in 2016. That’s compared to about half in 2012. The share of employees among physicians 40 and older also increased in that time, but the increase was more modest.

What does the hospital-employed physician trend mean for costs?

A potential downside to the trend: rising costs.

Pearson said that’s because physicians employed by hospitals are more likely to perform procedures within the hospital setting, which are more expensive than at a lower-cost setting. “This can drive up costs,” she said.

An Avalere study in 2017 showed hospital-employed physicians increased Medicare costs for four services by $3.1 billion between 2012 and 2015. That study, also for the PAI, revealed that Medicare paid $2.7 billion more for four specific cardiology, orthopedic and gastroenterology services in hospital outpatient settings rather than in an independent physician’s office. Medicare beneficiaries spent $411 million more in out-of-pocket costs for those services compared to what they would have spent in an independent physician’s office, according to the report.

Given the trend toward hospital-employed physicians, Pearson expects payers will make changes. One way they may address these issues is through care payment site neutralization. For instance, insurers may pay more for complicated procedures and less for less complicated procedures rather than pay by care setting.

Is the hospital-employed physician trend slowing?

Though Avalere shows a doubling of hospital-employed physicians, the AMA said its numbers show that the trend is actually slowing. Physicians working for a hospital or in a practice with some ownership remained steady in 2014 and 2016 at 32.8%, according to the AMA.

Nevertheless, the group’s Physician Practice Benchmark Survey in 2016 marked the first time physician practice owners were not a majority portion of physicians since the organization began documenting practice arrangements. It found that more than half of physicians continue providing care in smaller practices (10 or fewer physicians). However, there is a gradual shifting toward larger practices.

Though the AMA said there is movement away from physician-led practices, Pearson wonders whether that will change. Physicians have increasingly led accountable care organizations and multi-specialty practices are willing to accept risk.

Physicians not affiliated with hospitals may see long-term savings if they assume risk and manage population health in the same way as a hospital in an ACO, she said.

“I think the pendulum may swing back to physician-led models,” Pearson said.

Gilfillan said there’s also a growing need for physicians in leadership positions, especially those who can “connect the clinical goals to the financial goals of the health system,” as well as running a “financially sustainable healthcare system.”

Future of hospital-employed physicians

More physicians are employed by hospitals than a decade ago, but is this a short-term trend or now a healthcare industry norm?

“I think it will continue to increase because there are a lot of drivers supporting that trend,” Pearson said.

That said, Pearson expects payers will change policies, such as payment incentives, which now push doctors into hospital-employed situations. Those changes will slow the trend curve. Also, eventually hospitals will run out of physicians interested in a hospital-employed situation, though new doctors prefer employment arrangements.

Something else to watch are proposed megamergers, which Padgett said seem to go against the hospital-employed physician trend.

“Recently proposed mergers, such as Humana/Walmart and CVS/Aetna, seem to be counting on more people getting their healthcare at store-based clinics. But the trend toward integrated care through a health system/clinic, along with technology changes, seem to be working against that trend. Unless they align with organizations that can provide different kinds of care through different specialists, I’m not sure how that will work out for them,” he said.

Real estate

4 Most Common Reasons Why Your Home Insurance Company Will Drop Your Coverage

Originally posted on

Homeowners usually see their payment to their home insurance company as a necessary evil. The coverage they offer helps protect your home, belongings, and investment, but those payments can hit your wallet hard.

Shelling out thousands of dollars on an insurance policy may feel like a large financial burden, but did you know that your insurance company can choose to drop or not renew your policy? Circumstances like not paying your premiums, violating the terms of the policy, or committing fraud will obviously jeopardize your coverage, but your company can also drop coverage if it believes you and your property are too risky to insure. In these cases, an insurer may cancel, and you could have a hard time finding another company to protect your property.

Insurers may also decide to not renew your policy for many reasons that don’t ever cross your mind. Consider these common yet unapparent circumstances that could threaten your policy.

Real estate

Common Reasons Why Property Taxes Increase

Originally published on

Homeownership is one of life’s great highlights, but ask homeowners about paying property tax and they’ll tell you it’s one of their least favorite responsibilities. But as much of a downer as they are, property taxes are vital for funding schools, libraries, police departments, fire departments, and public works like roads and parks.

Savvy homeowners and prudent buyers are probably aware of the property tax rates in their area, but they may not understand the factors that can drive their property tax rates up. We’re here to help! (With the understanding part, that is.)

So when tax season rolls around, if you find yourself having to shell out more than you did last year, one of these five reasons might be to blame.

1. Home improvements

Renovating a bathroom or kitchen can revitalize a home and add to its worth, but it’s also the most common reason why your property taxes rise, says David Rae, a certified financial planner and president and founder of DRM Wealth Management in Los Angeles. Why? Improving your home makes it more valuable. That, in turn, increases your property taxes.

Converting a walk-up attic or basement into a livable space is also likely to trigger an automatic reassessment, says Rita Patriarca, a Realtor® with Re/Max Encore in Wilmington, MA.

Rae suggests that homeowners run the numbers first. Calculate how much the work will cost you, how much the renovation can add to your property’s value, and whether you can afford a higher tax bill. If you find that the cost of the work is likely to leave you with too little money to pay your higher taxes, Rae recommends holding off and saving more money before you do the work.

Although your tax bill will go up when you renovate, the good news is that you will directly benefit from the update in the form of a brand-new amenity in your home. That’s not the case in some of the scenarios that we describe below.

2. Revaluation

Communities and counties periodically reevaluate properties. During these revaluations, government officials or hired appraisers review all real property to figure out its current assessed value. Revaluations are needed to make sure that the tax burden is spread equitably and accurately among the area’s homeowners.

Lorrie Beaumont, appraiser and owner of LB Appraisal Associates in Westwood, MA, says revaluations are the second most common reason that property tax bills increase.

During the evaluation, an expert will take into account a home’s location, size, and type, and any changes since the last evaluation. The expert will also review home sales and valuations in the neighborhood, changes in the economy and housing market, and any changes in the area that may have improved or reduced a home’s value. Even if the assessor doesn’t enter your home, he or she will review permits to see whether you have undertaken any improvements. So, if you’ve renovated or expanded your kitchen, you can expect higher taxes.

A revaluation doesn’t automatically mean that your taxes will go up, though. For instance, let’s say there’s been a lot of building in your community lately. Having more taxpayers in your community may help offset a tax bill increase.

3. Nearby home sales

If your neighbors sell their homes for more than the asking price, your property taxes may rise. That’s the unfortunate fact, but it’s out of your hands.

Home sales affect what other houses in a neighborhood are worth. While that’s great for your property’s value when you decide to sell, it means a higher tax bill in the meantime.

Rae points out that, for you, this is the least advantageous way your tax bill can increase, because you’re not actually benefiting from living in a nicer home. Instead, you will be paying higher taxes because your neighbors made out like bandits!

4. New schools

Building a new school is great for students and teachers, and for the community overall. However, it will come with a hefty price tag that is likely to entail higher property taxes.

There are two reasons why property taxes can increase after the construction of new schools:

  • Communities and counties often increase taxes to help pay for school projects.
  • A new school will bring new families to town, which will make your community a more desirable location. The hotter market and the greater competition for homes are likely to lead to bidding wars and higher property values. And, of course, higher property values mean higher taxes.

5. Higher government budgets

One of the main reserves on which cities and counties draw to fund their budgets is the property tax. If government employees are owed a raise, or other budgetary needs increase, the residents’ taxes may need to be increased to help foot the bill.

But rest assured that a community can’t raise taxes at whim: There are limits that require voters’ approval. For instance, Proposition 13 in California and Proposition 2½ in Massachusetts limit how much property taxes can increase.

Still, that doesn’t mean your property taxes won’t go up each year. These limits just put a cap on the increases unless the community votes to raise taxes even higher that year.

Ways to protect yourself against property tax increases

So how can you, as a homeowner, push back and lower your rates (or, at the very least, make sure they don’t reach stratospheric heights)?

One way is to appeal your home’s property assessment, Rae says. Research home sales around you and look for similar homes that are selling for less. “Most municipalities have a process to contest your property tax bill,” says Rae. “I’ve contested the value of my home in the past, and the assessor shaved $150,000 off the taxable value of the home. Definitely worth the effort.”

You should also make sure your property records reflect the property’s amenities accurately, Beaumont notes. “I have seen many instances where records say you have more bedrooms or bathrooms than you actually have, or additional living area that doesn’t exist,” she says. If you do find mistakes, notify the assessor’s office and have the record corrected.

Real estate

Supreme Court Decision Creates More Housing Benefits for Same-Sex Couples

Originally published on

The Supreme Court’s decision in Obergefell v. Hodges in June 2015 opened the way for same-sex marriage in the remaining states that did not allow it.

The ruling has been met with enthusiasm by not only same-sex couples and supporters, but real estate experts who believe the decision will help spark newly married same-sex couples to enter the housing market.

One reason for this optimism came in a recent joint survey by Better Homes and Gardens Real Estate and the National Association of Gay and Lesbian Real Estate Professions. The survey found that:

  • 90 percent of LGBT homeowners already see homeownership as a good investment
  • 81 percent of LGBT non-homeowners believed the ruling will make them feel more financially protected and confident

Same-sex marriage legalization will especially help couples in the areas of VA mortgages and property-ownership status.

The VA recognizes same-sex marriage of all veterans

Chris Birk, director of education at Veterans United Home Loans in Columbia, Missouri, says the VA loan process has been “more onerous and expensive” for same-sex couples.

Before the recent ruling, the VA has allowed veterans and service members to have a co-borrower who isn’t a spouse or qualified veteran, but the joint loans for same-sex couples covered only the qualified veteran’s portion of the loan amount.

“That left applicants on a joint VA loan – who were not considered spouses – with the need for a 12.5 percent down payment. Most VA buyers make no down payments, which is a significant benefit of this historic home loan program,” says Birk.

After the Supreme Court struck down the Defense of Marriage Act in June 2013, the Department of Veterans Affairs announced it would begin reviewing applications on a case-by-case basis “to determine whether same-sex married couples could proceed in the same manner as opposite-sex couples.”

In the wake of the Supreme Court’s decision in June, the VA announced that it will “recognize the same-sex marriage of all veterans, where the veteran or the veteran’s spouse resided anywhere in the United States or its territories at the time of the marriage or at the time of application for benefits,” says Birk.

“Given that, I think we’ll see more same-sex married veterans and service members look into the VA loan, which is arguably the most powerful loan product on the market,” he says.

Same-sex couples granted full ownership status

Another benefit of the Supreme Court decision will be the way married borrowers typically take title of property, says David Brennan, senior vice president at Cape Cod Five Cents Savings Bank in Barnstable, Massachusetts.

Same-sex couples will now be able to both have “tenancy by entirety” ownership status. This is the strongest form of ownership and means that a spouse automatically takes ownership in the event of the other spouse’s death.

“In many states where same-sex marriages were not allowed or recognized, there were limitations as to the legal types of property ownership status afforded to married couples. The ownership status of ‘tenancy by entirety’ is the most common way married couples take ownership of their property due to its legal advantages and protection for both owners. This form of title ownership, where offered, will now be available to same-sex married couples in all states,” says Brennan.

What will it mean to home buying?

For some real estate experts, the Supreme Court’s decision was deeply personal. Thom Schoepfer, a senior broker-associate and top agent in closed sales at William Raveis in Chatham, Massachusetts, and his partner bought their first home in New York in the early-1980s for $10,000.

“Seeing equality reign in 50 states is a dream,” says Thom Schoepfer, a senior broker-associate and top agent in closed sales at William Raveis in Chatham, Massachusetts, on Cape Cod. “I’m so thankful. Home is part of the American dream and continues to be for people of all stripes,”

Schoepfer and his partner – who have been together all of their adult lives and first bought a home together in New York in the early-1980s – have witnessed gay and lesbian couples go from the fringes of society into the mainstream.

So while Schoepfer doesn’t expect the Supreme Court’s decision to have much of an impact on his area, where same-gender couples have been buying homes Cape-wide, especially in communities with top school districts and low property taxes, he does expect a greater impact “nationally and regionally.”

Teresa Boardman, Realtor at Boardman Realty in St. Paul, Minnesota, isn’t so sure that legalization will flood the housing market with same-sex couples. Boardman says unmarried couples (same-sex and otherwise) have been able to buy homes before the Supreme Court’s decision.

“There are several groups in our society that have always been allowed to marry, but have low homeownership rates. The lack of a good job and a good credit rating holds people back from homeownership as does piles of student debt. Homeownership is lower in Minnesota today than it was in 2005 because of the crash of the housing market and the great recession. The ability to marry just doesn’t seem to have an impact on homeownership,” says Boardman.

Tough to gauge the impact

It’s difficult to gauge how same-sex marriage has affected home sales in the states that had already legalized same-sex marriage. Massachusetts was the first state to legalize same-sex marriage in 2004, for instance, but the Massachusetts Association of Realtors has not collected data concerning sexual preference of homebuyers.

Yes, there was a spike in home sales in Massachusetts that year, but it also coincided with the height of the housing bubble so you can’t say for sure whether same-sex marriage played a large part in the spike.

We’ll have a better idea next year. Adam DeSanctis, economic issues media manager at the National Association of Realtors in Washington, D.C., says the NAR will begin collecting data about same-sex married couples in its 2015 Profile of Home Buyers and Sellers.