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ICHRA Plan and EBHRA Plan: Comparing Your Options

Are you currently deciding between an EBHRA plan or an ICHRA plan? 

Whether you work as part of a group, are self-employed, or are retired, you may have questions about health insurance.

There are hundreds of options that accompany health insurance. You want to be sure you’re getting the best deal; however, plans change depending on your employment status, age, and several other factors.

Moreover, you may have heard about either EBHRA or ICHRA plans but don’t know where to start. Even with the opinions of friends and family, choosing between the two can be confusing. If you’re an employer, you have extra pressure to do right by your employees and save your business money.

We’ll walk you through the different types of EBHRA or ICHRA plans to help you decide what works for you.

Determined not to go at it alone? Get the expert help you need by contacting Diana Reeves.

ICHRA Plan vs EBHRA Plan

Learn more about which Health Reimbursement Arrangements (HRA) fits your needs better. We’ll begin by defining the two plans and getting into the details of what makes them different.

What Is ICHRA?

ICHRA stands for Individual Coverage Health Reimbursement Arrangement. It’s an HRA plan for organizations of any size that allows tax-free reimbursements for employees. HRAs, in general, began in 1974 to help minimize the costs of medical care.

Today, HRA plans allow reimbursement funds to be used for medical care and even premiums. An ICHRA plan offers these same benefits but must combine it with the Affordable Care Act (ACA). An employee can also use Premium Tax Credits if it’s a more affordable option than HRA dollars.

An ICHRA plan allows employers and employees to have more flexibility when choosing a health plan that works for them. 

Employees can:

  • Choose their own coverage within the local market
  • Use allowances on a ton of benefits like premiums, co-pays, and more

Employers can:

  • Set a budget
  • Delegate an ICHRA plan for full-time or part-time only employees
  • Design a plan around an employee’s location

An ICHRA plan comes down to four basic steps:

  1. The employer designs the benefits by setting a budget for allowances and choosing which employees can participate, and then employees…
  2. Choose their own health insurance plan
  3. Submit receipts to employer
  4. Finally, employers review and reimburse their employees, and the employer keeps any unused allowance

What’s A Premium Tax Credit?

A Premium Tax Credit is money taken away from taxes when filed. You can then use that money to pay a health insurance provider to lower the cost of a premium. You can also use it to save until the next tax filing is due. Eligibility for a Premium Tax Credit depends on a few factors, including:

  • Family size
  • Income
  • Benchmark health plan value eligibility

What Is EBHRA?

EBHRA means Excepted Benefit Health Reimbursement Arrangement. It works similarly to an ICHRA plan and includes the following steps:

  1. The employer chooses an EBHRA account for their employees, then those employees
  2. Sign up for all eligible benefits
  3. Pay their premium for their healthcare provider
  4. Submit a reimbursement request

There are a few differences with an EBHRA plan. Employers must also offer a group health plan to the same group of employees as well. In addition, enrollment in both is not necessary. There is also a benefit limit of $1,800 per person annually. 

Additionally, an EBHRA plan can reimburse employees for medical expenses. However, it can’t reimburse premiums for Medicare, IMC, or non-COBRA group coverage. An employer may only offer either an ICHRA or EBHRA plan, not both. 

ACA Options And HRA Plans

Better known as “Obamacare,” the ACA stands for the Affordable Care Act. Signed into law by President Barack Obama in March of 2010, its main goals are to:

  • Make health insurance affordable for more people
  • Have states expand Medicaid to adults living below the poverty line
  • Back innovative medical care delivery solutions

With the Affordable Care Act (ACA) came about many changes to HRA plans. One of those changes became another HRA aside from an ICHRA and EBHRA called QSEHRA. It means Qualified Small Employer Health Reimbursement Arrangement. QSEHRA is for small businesses rather than companies of any size. Because smaller businesses typically do not offer group coverage for their employees. This type of plan can cover medical expenses as well as premiums.

In general, businesses with more than 50 full-time employees must provide health insurance to employees. Or they’re subject to pay a tax penalty for not offering affordable health coverage.

What Is A Qualified Plan For An ICHRA And EBHRA?

According to, the definition of a qualified health plan is one that is:

  • Certified by the Health Insurance Marketplace®
  • Offers essential health benefits while following established limits on cost-sharing 
  • Meets other requirements under the Affordable Care Act

When looking at an ICHRA plan, the following plans are considered qualified:

  • Catastrophic plans 
    • Limits for this include those under age 30 who qualify for a hardship exemption
  • Part A+B or part C Medicare
  • Student health insurance
  • Bronze, Silver, and Gold labeled major medical plans purchased

If you’re considering an EBHRA plan, the following are typically covered:

  • Long-term care coverage
  • COBRA continuation coverage
  • Dental and vision insurance (limited)
  • Short-term limited-duration insurance (STDLI)
  • Cost-sharing (copays and deductible)

Therefore, an EBHRA plan does not include qualified coverage for:

  • Group plan premiums aside from COBRA
  • Part A, B, C, or D Medicare
  • Individual health insurance

Have an idea of what you’re interested in but still need help? Contact Diana Reeves.

EBHRA And ICHRA Plans: Can You Use Insurance Premiums?

Whether you can use your plan to cover the cost of insurance premiums depends on a few things.

Self Employed

Typically, the answer for this one is no. HRAs of any kind are only for employees and not self-employed individuals.

There are two exclusions to this rule. One is if your business is a C-Corp. The second is if you own a company that is a sole proprietorship. You must also not have a spouse that is a W-2 employee.

Small Business

ICHRA Plan: Yes, small businesses and companies of any size can use an ICHRA plan for insurance premiums.

EBHRA Plan: Small businesses can use EBHRA plans for employees. However, employers cannot reimburse employees for certain health insurance premiums.


ICHRA Plan: If you’re retired, you have the same benefits of using an ICHRA plan. This is true as long as you would have had those same benefits at the job and role you were at before retirement.

EBHRA Plan: No. If you plan on using an EBHRA plan and are retired, you no longer have an employer to reimburse you for insurance premiums. Only individual medical expenses will apply.

Diana Reeves Can Help

There are a multitude of options to choose from when it comes to health insurance plans. It can get confusing when you’re attempting to navigate all of the choices on your own. What you need is an insurance agent who’s an expert at knowing what you need, no matter your level of employment. Diana Reeves serves Americans by helping them find their optimal plan and getting them better coverage every day. 

Are you feeling stuck in your search for a health plan that works for you?

Contact Diana today to find or customize a plan that’s right for you.

How The Small Business Labor Shortage Affects Health Insurance

How The Small Business Labor Shortage Affects Health Insurance

It’s no secret that the recent supply chain disruption has impacted companies across the world. Even more so, the small business labor shortage affects health insurance unlike never before. 

While it may be surprising to hear, there are some solutions to finding health insurance that fit the way current small businesses operate – even with fewer employees on hand.

The pandemic has made things more difficult for small businesses across the nation. As many as 200,000 small businesses closed within the first year of the pandemic alone. Surviving companies may be facing new challenges as the ongoing small business labor shortage affects health insurance costs and expectations from future hires.

Recent studies are telling us what we need to know. As a small business owner, are you prepared to take on the impact of changes to health insurance for your employees?

Don’t want to go it alone? If you need detailed help navigating health insurance needs for your business, contact Diana Reeves.

How The Pandemic Labor Shortage Affects Health Insurance For Small Businesses

The nationwide labor shortage is taking a toll on small business owners. Employers everywhere have made changes to aspects like:

  • Minimum wage
  • Overtime pay
  • Hours
  • Bonuses
  • Time off

However, 15% of small businesses have opted to improve health insurance benefits to get applicants through the door. But for many businesses, it simply is not enough. Let’s take a look at some of the most common reasons for the labor shortage taking place at the moment.

  • The Pandemic. A number of potential employees have continuing health concerns because of COVID-19. In addition to these health concerns, you’ll often find those who are worried about others not being vaccinated if they were to return to the office. 
  • Lack Of Support At Home. Other employees may be the sole to elderly family members, children, or those with health concerns. As a result, those roles have taken precedence over working.
  • Industry Shifts. The pandemic has either forced or freed employees to leave certain industries for others. And those who have left industries, such as foodservice, healthcare, supply chain, and manufacturing, may not have any plans to return.
  • Unemployment Benefits. An increase in unemployment benefits and stimulus packages offer more incentive to stay home and wait out the pandemic in hopes of an improved economy. Many who are on unemployment benefits may also be waiting for better working conditions or the ability to work and maintain household responsibilities.
  • Retirement. About 28.6 million Baby Boomers (born between 1946 and 1964) stated they were retired in the third quarter of 2020. This number of retirees is up 3.2 million more than last year during the same period. An increase in retirees means fewer people going back to those same industries they once worked in.

Why Improving Benefits Matters

Health insurance costs for small businesses vary. However, if other small businesses are improving benefits, those small businesses are likely shelling out more money to keep up with the demand for better jobs and benefits.

An eHealth research report said, “The average per-person premium for small group health insurance was $409 per month in 2018.”

As employers take a look at the current labor shortage, they are likely analyzing how much more can be spent to keep employees satisfied with the health benefits being offered to them. Increasing the quality of health insurance is no simple undertaking, but could have additional benefits for employees returning to the workforce post-pandemic.  

Mental Health Support

What has long gone as taboo in the U.S., support for individual mental health is now on the rise. The pandemic has and will have a lasting effect on people’s mental health.

Even before the pandemic hit, nearly 20% of adults experienced a mental illness. As that number continues to grow, mental health is on everyone’s mind lately. This means individuals are on the hunt for jobs with better mental health support through added benefits.

Preventive Care

Many people missed out on what would have been regular doctor, dental, and vision appointments in the past year. However, they’re looking forward to employment opportunities that will allow them to return to those health check-ins without having to spend too much money to do so.

Preventive care is critical for both employees and employers. Adequate upkeep of preventative health means fewer sick days and less time spent away from work visiting healthcare facilities.

Furthermore, having health concerns addressed faster, with more efficiency, and set at a more affordable price point through better benefits means less stress, anxiety, and depression for employees.

What You Can Do As A Small Business Owner

As a small business owner, it’s understandable that adjusting your budget for health insurance benefits sounds stressful. The available options seem endless and confusing, and every other business owner you know says something different. But you do have options.

You can go about browsing for health insurance on your own or partner with an agent who’s familiar with small business health insurance. An agent can help you search for a plan that fits your budget and business size. They can use their network of providers to compare and build a plan that fits your needs.

Find an agent with comprehensive health insurance services who offers the following:

  • Medical
  • Vision
  • Critical Illness
  • Dental
  • Accident
  • Income Protection

Diana Reeves Helps Small Businesses Know Their Health Insurance Options

Deciding to make changes to your health insurance plan as a business owner can feel overwhelming. That’s why choosing an experienced agent like Diana Reeves is an important step when it comes to knowing your options. You don’t want to end up selecting the wrong plan or paying way too much for a plan that simply isn’t right for you. If studies have shown that the small business labor shortage affects health insurance, it’s likely going to impact your small business. 

Contact Diana today to get started on a customizable plan that works for your small business.

New Trends in Health Insurance Options For Small Business Owners and Self-Employed Individuals

New Trends in Health Insurance Options For Small Business Owners and Self-Employed Individuals

Now more than ever before, our health is at the forefront of our minds. And this makes sense, considering the year we just had. 

As a result, new trends in health insurance options (especially for self-employed individuals) are rising. 

From an increase of telehealth services to an expansion of mental health options, insurance plans are adapting to meet Americans’ needs. 

Self-employed individuals and small business owners can find suitable plans for themselves and their employees. 

But with these new trends in health insurance options comes questions about what plans are best for your situation. 

To help you navigate through the process, know what options are available and how to determine if you qualify. 

Health Insurance Options For Small Business Owners

Let’s look at the different health insurance options for small business owners first. 

There are a lot of options – especially for small business owners. If you can’t afford these expensive health options, you can access more flexible solutions (especially with Diana’s network).

To have a group plan, you need at least 2 full-time employees. With Diana, you can access custom plans in the form of a group. 

BlueCross Blue Shield

Providers like BlueCross Blue Shield offer a wide range of plans depending on the size of your business. Their BlueCard PPO option is in-network with 96% of U.S. hospitals and 95% of American physicians. They have also received high ratings from organizations like J.D. Power. 

This option – depending on the number of employees and type of coverage – may be out of your budget. 


Humana plans are an excellent choice for your employees if customer service is one of your top priorities. In 2020, the insurance company was ranked Number One for customer service by Newsweek. 

In addition to an expansive network, Humana has tailored plans for business owners that takes into account your goals, scale, and desired services. Some of their plans offer lower premiums, while others eliminate copays and deductibles. 

However, it’s important to keep in mind that Humana is not available in every state in the US. To qualify for their options, you would have to be in a state they service. 


UnitedHealthcare differs from other health insurance companies in the emphasis they place on technology. They offer telehealthcare so your employees can check in with a physician and receive prescriptions through their mobile device or PC. 

Once you choose a plan, your employees can often modify their coverage to fit their budget and healthcare needs.  

Something to consider is whether you or an employee has pre-existing conditions. If so, you may have to look elsewhere for coverage to ensure everyone can access health insurance options. 

So to ensure that you and your team are receiving the best options available, schedule some time to talk with Diana to explore your unique situation. Start to compare options with a specialist today. 

Health Insurance Options For Self-Employed Individuals

If you’re self-employed, Diana offers great and affordable plans that can either sustain your self-employment or get you through temporary unemployment. 

What Is The Affordable Care Act & Why Does It Matter To Self-Employed Individuals? 

The Affordable Care Act is a government-sponsored healthcare program. 

Recently, President Biden signed the American Rescue Plan Act into effect that opened enrollment into ACA health insurance options to more individuals.

Typically, there is a window of time where individuals can enroll in government health insurance plans. The American Rescue Plan Act extends the enrollment time frame and qualifies more individuals for health insurance. 

Depending on your circumstances, you may also qualify for tax credits through ACA plans – regardless of pre-existing health conditions. 

You Can Now Access Affordable Care Act Subsidies

The American Rescue Plan bill provides tax subsidies for those with health insurance plans from the ACA. 

Before 2021, only individuals who met certain income criteria were given these premium tax credits, or what’s also called PTC, but now you may qualify for these subsidies as well. 

PTCs are refundable credits that help individuals and families pay for the premiums of their ACA health insurance plan. 

What About Government Health Insurance And Pre-Existing Conditions?

If you have a chronic health condition such as asthma or diabetes, health insurance plans on state enrollment programs can’t deny you coverage because of any pre-existing health condition. 

If you want to take advantage of the Special Enrollment Period into ACA plans and find an option that suits your needs, contact Diana Reeves. An agent who understands how to navigate the enrollment process and considers your unique circumstances to help you find or customize a plan for quality coverage. 

If you own a small business, recent health insurance trends are making it easier to find custom plans for you and your employees. 

Health Insurance Tax Benefits For Self-Employed Individuals

If you’re self-employed, you may qualify for deductions on premiums you pay for your medical and dental insurance coverage. 

On the first page of your 1040 Form, you can write off taxes you pay on health insurance expenses even if you choose not to itemize your deductions. 

Deducting your insurance premiums this way will actually lower your adjusted gross income. Consequently, it will help you remain eligible for additional tax breaks. 

However, to claim these deductions, you nor your spouse can be eligible for an employer-subsidized health plan for the month’s taxes you’re writing off. If you’re operating as a sole proprietor and experience a tax loss for the year, or your business doesn’t generate positive income, your deductions must not exceed the income you earn from your business.  

If you use long-term care, your deductions depend on your age. But every self-employed individual from their 20’s all the way up to over 70 years of age qualifies for a tax deduction on long-term care. 

Talk To Diana Reeves About Your Health Insurance Options

Although exploring all the health insurance options available can feel like a daunting task, Diana Reeves is here to help you decide which option would best suit your circumstances. Every self-employed individual can find a viable solution to their healthcare needs. And small business owners can provide their employees with quality options while new health insurance trends are taking place. Contact Diana today to get started.

A Breakdown Of Health Insurance Costs, Definitions, And Other Realities

A Breakdown Of Health Insurance Costs, Definitions, And Other Realities

Congratulations! You’ve graduated college and now have your first job. However, your 26th birthday is coming up in a few years, and you aren’t at all sure what it means to be “kicked off” of your parent’s insurance. 

Are you wondering, “what will health insurance costs look like for me on my own?” 

And if you’ve never had health insurance through a parent, here is your time to soak in the knowledge you need to make a smart decision for yourself.

Maybe you’ve re-entered the workforce after some time but need updated information on today’s health insurance terminology. No matter the situation you’re in, something we hear most often is that understanding health insurance costs can be confusing. We get it. 

There are a myriad of options out there with little to no education available, which is especially crucial for younger people. As a result, those young people grow up and find themselves facing the need for health insurance. 

Whether it’s something you can get through a job, agency, or other parties available, it’s important to understand what you’re paying for – especially when it comes to coverage regarding your health.

On top of the number of options available, there are a ton of terms you may have heard over the years that don’t make any sense to you. Our hope is that we can offer a more clear understanding of what various health insurance costs mean and what plans consist of.

A Brief History Of Health Insurance Costs And Plans In America

First, let’s take a super quick look at the history of health insurance in the United States.

Health insurance is by no means a new concept and has been in development since the 1930s. During the construction of several major railroad tracks, employees doing the building were often injured and needed medical care close to or on-site. For a while, employees would go to nearby hospitals, receive their care, and have deductions taken from their pay over time to cover the costs.

One of the earliest examples of a health insurance plan was conducted by Blue Cross Blue Shield for teachers of Baylor University Hospital in Texas in 1929. This plan said, “…each teacher would be eligible for 3 weeks of hospital care in return for a payment of $3 a semester or $6 a year.”1

Through the 1930s and 1940s, coverage included additional factors such as dependents and surgical needs. Dental institutions also hopped on the health insurance trend at the time. 

Today, there are a number of group and individual policies available through a wide array of insurance providers and agencies.

Health Insurance Costs And What They Truly Mean

A health insurance cost is also known as a premium and is the amount you pay every month to maintain having health insurance, also known as coverage. But that is likely not the only thing you will be expected to pay. You may also see the words deductible, co-pay, and coinsurance come up. But we’ll get to those in a minute.

To get an idea of how much your premium should be, first take a look at your medical uses. Do you…?

  • Visit the doctor often? 
  • Take regular prescriptions? 
  • Have a spouse or children who may need coverage as well?

It’s crucial to gauge how much medical coverage you’ll need before you dive in. If you are young and fairly healthy, you may be better off paying a lower premium each month. However, regardless of age, if you see a doctor often and require medications, you may need to consider paying a higher premium for more frequent coverage.

Understanding Premiums

You’ve probably heard that there are “good” and “bad” premiums. But what does that mean? Let’s take a closer look at what paying a higher or lower premium determines.

High Versus Low Premium

Having a lower premium does mean you’ll owe less every month. However, if you ever do need care, you may owe more out-of-pocket in order to receive that care. That’s why lower premiums are often suggested for young and healthy individuals.

A higher premium means you will owe a lot more each month. But in the case of required healthcare, you may find that a fair chunk of your future medical expenses is low. If you can afford a high premium each month, it’s an ideal plan for those who need consistent medical care throughout the year.

15 Popular Health Insurance Terms Or Phrases

As mentioned before, we’ll take a look at some common words or phrases used when talking about health insurance.

1. Benefits

Your benefits include what is covered under your plan and for how long you are covered. Typically, employers require you to re-enroll for health insurance each year as everyone’s circumstances can change throughout the year.

2. Coinsurance 

Your coinsurance amount is the amount left that is owed after you’ve received a medical service. For example, if you had a doctor’s appointment but your plan only covers 80% of the visit, you still owe 20%. If the doctor’s visit costs $200, your insurance covers $160. This means you owe $40.

3. Co-Pay

If your plan and its providers allow co-pays, you’ll be required to pay a certain amount at the time of your visit. For example, you may need to see a dermatologist and their co-pay is $50. That $50 is how much you will owe at your visit.

4. Deductible

Your deductible is how much you will need to pay before your health insurance will cover their coinsurance portion. As an example, if you have chosen a plan with a $1,000 deductible, you are expected to pay $1,000 of your own money before your health insurance will begin paying their 80% coinsurance. Health insurance companies often call this “meeting your deductible”.

5. FSA (Flexible Spending Account)

This type of account consists of money set aside by you and your employer to use before the end of the year. An FSA plan can help fund doctor’s visits, dental work, vaccines, and more. 

6. HMO (Health Maintenance Organization)

This specific type of plan will ask you to choose a primary doctor that you will see during the duration of your plan period. If you have this type of plan, be sure anywhere you go accepts individuals with HMO coverage.

7. HRA (Health Reimbursement Account) 

Similar to an FSA account, an HRA sets money aside for your healthcare needs. This money is then used to reimburse you for covered services only. By using this plan, you can access tax benefits for both yourself and your employer.

8. HSA (Health Savings Account)

Also like an FSA account, you set aside money for potential medical care needed in the future. However, with this plan, you do not need to spend your nest egg within the year. Keep in mind that this type of plan often is paired with a high deductible health plan.

9. In Or Out-Of-Network Provider

An in-network provider is someone who is approved to use within your specific chosen healthcare plan.

Someone who is out-of-network means your plan has not approved to cover that provider. You may still see this person if you wish, but you will likely need to pay for all costs of services, visits, testing, and beyond on your own with no additional help.

10. Medicare

This program is for those 65 years or older to help cover certain medical expenses.

11. Open Enrollment

Open enrollment is the period of time in which you can switch, stay with, change, or update your medical coverage plan. This is the perfect time to evaluate your coverage and consider what kind of coverage you’d like more or less of.

12. Outpatient Or Inpatient Services

An outpatient service is one that does not require a hospital stay. An inpatient service may include room and board fees, which may or may not be covered by your plan. Double-check to make sure.

13. Out-Of-Pocket Cost

Any out-of-pocket expenses are those you need to make yourself without the help of insurance. For example, your doctor’s visit may be covered with a $20 copay, but there was a test they did during your visit that was not covered. The test cost $80 and the copay cost is $20. So in total, your out-of-pocket total cost for that visit is $100.

14. PPO (Preferred Provider Organization)

A PPO is a great plan to have and offers more flexibility when it comes to providers and services covered. 

Ready to explore your PPO options? Give Diana Reeves a call at 713-806-5966 today.

15. Provider

Lastly, a provider is anyone you may see when you seek medical services. This includes doctors, dentists, surgeons, and so on.

Why You Should Call Diana Reeves To Help You Choose A Plan

Diana Reeves works around the clock assisting those with nationwide PPO network health, dental, vision, term life, critical illness, accident, and income protection. Through her vast network, she can find the best plan for you with optimal coverage in mind. Ask any questions you have about health insurance costs, coverage, and more. 

Whether you’re searching for coverage for yourself or your entire family, there’s no better time than now to see what Diana Reeves can do for you.

Contact Diana Reeves today for a free quote!  (713) 806-5966!

How To Save Money When Choosing Your Health Insurance

How To Save Money When Choosing Your Health Insurance

On top of health insurance consisting of many options, it can also get expensive to have and maintain for yourself and your family. Yet, it is still critical now more than ever to be covered under a plan you trust that won’t break the bank. As your health insurance expert advisor, I want to share how to save money when choosing your health insurance plan (without sacrificing your coverage).

How To Save Money When Choosing Your Health Insurance

Want to save money on your health plan? Take a look at my five tips to follow when choosing the right health insurance plan for you (and your family).

1. Explore Your Employer’s Options

Whether you are on the hunt for yourself or your entire family, you should know what options your employer offers when it comes to coverage. According to recent information provided by the Kaiser Family Foundation (KFF), “about 156,199,800 Americans (about 49%) rely on health insurance offered by their employer.”

Health insurance is seen as a significant benefit, but it can also be tricky to navigate when selecting the best plan for your money. An employer will typically offer three forms of coverage, including health, vision, and dental.

Health coverage can include full or partial coverage for hospital, emergency, or urgent care visits. It can also include doctor or specialty appointments and visits, prescription drugs, and preventive care.

Vision usually includes full or partial coverage for visits to the optometrist or ophthalmologist, eyewear care (i.e. glasses or contacts), testing, and other preventive maintenance forms related to vision.

Dental usually includes full or partial coverage for preventive care, routine exams, cleanings, and testing.

Analyze These Numbers On Your Employer’s Plan

To help break it down further, you should analyze the following:

  • Monthly payments made to keep your health insurance
  • Co-Insurance Plan. Percentage of payment after your deductible
  • Co-Payment Option. A fixed amount that you pay at the time of your visit
  • Dual Coverage. Coverage provided by more than one provider (like health and dental)

You should also be aware of the Affordable Care Act (ACA). Signed into law and amended in two parts in 2010, the ACA intends to make healthcare available to more people, cover more adults with Medicaid, and support new health initiatives that lower coverage costs.

It may also help to know the significance of balance billing. This term refers to the amount you are directly billed after your health insurance has covered their allowed amount. For example, if a visit costs a total of $120 and your insurance covers $80, you may be billed the remaining $40. This is considered an out-of-pocket expense. However, an in-network provider may not balance bill you after a visit as the amount projected by your provider should be the accepted amount expected from your doctor.

Keep in mind that balance billing laws vary from state to state. Be sure to talk to a health insurance professional like me if you have questions about balance billing in your state.

2. Understand Different Plan Options Before Choosing A Plan

Planning for coverage can be confusing. But what you need to know is that you are likely to be looking at a few key plan options available to you at different levels of coverage, including:

  • Exclusive Provider Organization (EPO)
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)

Exclusive Provider Organization (EPO)

Exclusive Provider Organization (EPO) offers coverage for services done on an in-network basis. You do not need a primary care physician for this plan. In the case of a real emergency, an EPO plan might cover a portion of your out-of-network emergency visit.

EPO’s focus on preventive care to help make future care more affordable in the long run. However, if you are someone who sees specialists often, this may not be the plan for you as EPOs require prior authorization for specialist services.

EPOs tend to lean on the cheaper side than PPOs when it comes to sharing the cost of your visits (co-sharing), but it’s important to keep in mind that you may be limited in your choices of healthcare providers.

Health Maintenance Organization (HMO)

Health Maintenance Organization (HMO) plans cover doctors’ services working with HMO, usually in a specific area. With an HMO, you do need a primary care physician. But similar to an EPO, your HMO plan may cover all or part of a true emergency visit.

HMOs also focus on preventive care and tend to offer low out-of-pocket costs. Be aware that your HMO plan may offer cheaper premiums upfront, but cost more in the long run when paired with a low deductible.

Preferred Provider Organization (PPO)

Point of Service (POS) and Preferred Provider Organization (PPO) provides coverage for doctor visits within the plan’s network. You must receive a referral for specialists using POS to remain covered.

While you do not need a referral for a PPO plan, it may cost extra to see a specialist. You do get some added flexibility when it comes to searching for doctors or hospitals within a PPO network. And you may even be able to receive a small amount of coverage for out-of-network visits. However, it’s important to note that you will face higher premiums and annual deductible with a PPO. Depending on the plan, you will likely have the advantage of lower monthly payments.

3. Take Advantage of a Health Savings Account (HSA)

Life is unexpected. You are often better off preparing for what’s possible by taking advantage of an HSA if you have a High Deductible Health Plan (HDHP). The purpose of this type of account is to allow you to put pre-taxed money away for a variety of qualified medical expenses when you need it most. You can use this money to help pay for copayments, deductibles, and other costs that might otherwise be expensive. While you cannot use an HSA to pay for premiums, other benefits are available, such as rolling over any unspent amount year-to-year. Be sure to ask your employer or health insurance agent about your options for an HSA.

4. Choose Your Doctors Wisely (In-Network vs. Out of Network)

If you have a plan that provides full or partial coverage for healthcare services performed in-network, it is vital to stay in the network. Of course, emergencies should take precedence over choosing in-network providers.

When you select a provider within your network, you opt for services that you know your healthcare provider works with to give you some form of coverage. By choosing healthcare services outside of your network, it means those healthcare workers do not have a pre-negotiated contract with your provider – meaning you will be subject to paying the full cost of any services done.

5. Head to the Expert 

If you don’t have the time or would like someone to walk you through your options, contact me, Diana Reeves, for your health coverage needs to get started. Whether you’re self-employed, searching for family coverage, or requesting individual coverage, I can take you step-by-step to find the coverage that works best for your budget.

As an expert in the field, we provide free quotes with year-round availability to address all of your questions and concerns. Call me today to learn how to save money when choosing your health insurance plan at (713) 806-5966!