Top t ips. for Buying Individual Health Insurance. Your Guide to Saving Money and Getting the Protection You Need

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1 Top t ips for Buying Individual Health Insurance From the experts at Your Guide to Saving Money and Getting the Protection You Need

2 Top t ips for Buying Individual Health Insurance Who needs health insurance? Everyone does! Without a good health plan, most people are just one serious illness or accident away from bankruptcy. It s true: more than 60 % of bankruptcies in the U.S. are the result of medical bills. 1 So having health insurance is essential. But not just any plan will do. Most people who file for bankruptcy due to medical bills actually have health insurance, but gaps in their coverage such as copayments, deductibles, and uncovered services leave them open to unexpected costs. Which leads us to our first tip, and the most important of all: 1 Tip #1: If you don t have health insurance now, don t put it off another day. If you already have a plan, make sure it s a good fit for your needs. At WPS, we know that buying health insurance is no picnic. That s why we ve tapped our team of individual plan experts to bring you some of the industry s top tips for choosing an individual health plan that offers the protection you need at a price you can afford. Without a good health plan, most people are just one serious illness or accident away from bankruptcy. 2 1 American Journal of Medicine, August Top Tips for Buying Individual Health Insurance

3 Meet Our Experts With more than 250 years of combined experience, WPS team of individual plan experts has the knowledge and expertise you need to choose a health plan wisely. Meet four members of our team Chris, Catherine, Steve, and Chastiny whose insights contributed to this guide. Chris Kleisner With 12 years of industry experience, Chris has seen nearly every plan and situation the market has to offer. He understands the challenges faced by people who are selfemployed, and he takes the time to match his clients with the right plan for their needs. In his spare time, Chris enjoys golfing, fishing, and camping. Steve Freitag A health insurance veteran of 20 years, Steve has been a WPS consultant since One of Steve s most valuable skills is his ability to answer questions in simple language that anyone can understand. When he s not helping WPS customers, Steve likes golfing, SCUBA diving, and listening to live music. Catherine Thomas For 25 years, Catherine has worked in health insurance from many different angles: customer service, claims processing, enrollment, sales, and more. A WPS individual plan consultant since 2002, Catherine enjoys the outdoors, swimming, going for walks, and reading. Chastiny Ellingworth With 11 years of health insurance experience that includes customer service, claims processing, provider certification, and individual sales, Chastiny employs her in-depth knowledge and unique perspectives to help clients find the right plans for them. In her spare time, Chastiny enjoys walking, jogging, reading, and watching movies. If you have a question about your health insurance options, call or send us an . Chris, Catherine, Steve, Chastiny, and our other friendly consultants are dedicated to helping you find the health plan that s right for you, and they ll spend as much time with you as necessary to make sure you re happy with your decision a.m. to 5 p.m. Monday Friday WPSIndividualSales@wpsic.com 3

4 First Things First: Answers to common questions Before we get started with our top tips, let s answer some common questions about individual health insurance. Q. What s the difference between individual health insurance and a group health plan? A. An individual health plan is purchased directly from a private health insurance company; a group plan is provided by a company as part of an employee benefits package. Although the word individual may suggest coverage for a single person, these plans also cover spouses and legal dependents. 4

5 Q. Is individual health insurance more expensive than group health insurance? A. Not necessarily. Oftentimes, individual health plans only seem more expensive because the planholder is responsible for paying the entire premium. In a group health plan, the employer pays a sizable portion of the cost (often 50% to 90%) as part of an employee s compensation. Q. Can I be turned down for individual health insurance? A. Yes. There is no guarantee that your application will be accepted. Health insurance companies may reject your application or attach exclusions if you have health problems. The process of reviewing applications and determining coverage is called underwriting. Insurance companies underwrite applicants based upon risks and projections and decide whether to extend coverage, as well as how much the policy s premium will be. In this way, individual health insurance is like other insurance you buy for your home, car, or life. In each case, the insurance company evaluates how much risk it will assume by issuing you a policy. An insurer that miscalculates risk in the underwriting process on a large pool of policyholders can later be forced to dramatically increase rates or even go out of business. Q. What kinds of people buy individual health insurance? A. Individual health insurance plans are common among the self-employed, small business employees without group coverage, early retirees, and people looking for an affordable alternative to COBRA. Today s market for individual health insurance is growing as more and more companies cut expenses by dropping employersponsored health coverage. WPS Health Insurance

6 And Now... Our Top Tips for Buying Individual Health Insurance We ve already covered Tip #1 in our introduction, but because it s so important, let s say it again: Tip #1: If you don t have health insurance now, don t put it off another day. If you already have a 1plan, make sure it s a good fit for your needs. A good health plan is more than protection for your health and financial security. It s precious peace of mind! It also helps you stay healthy by promoting regular checkups, screenings, and immunizations. Once you ve made the decision to move ahead, the next question is, how do you choose a plan that s a good fit for your needs and budget? That s what the rest of our tips will cover. A good health plan is more than protection for your health and financial security. It s precious peace of mind. Decoding the Language of Health Insurance Benefit the amount payable by the insurance company to a plan member for medical costs. Claim a request by a plan member, or a plan member s health care provider, for the insurance company to pay for medical services. Coinsurance the amount you pay to share the cost of covered services after your deductible has been paid. This is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%. Copayments (copays) the flat fee you pay for certain medical expenses (e.g., $25 for every doctor visit), while the insurance company pays the rest. Deductible the amount you pay each year to cover eligible medical expenses before your insurance plan starts paying. Premium the amount you pay each month in exchange for insurance coverage. Visit the Learning Center on the WPS website ( for a comprehensive glossary of health insurance terms and other helpful information. 6 Top Tips for Buying Individual Health Insurance

7 Tip #2: Choose a plan based on your expected health care costs. 2How old are you? Are you healthy? Do you have children, or are you planning any? What kinds of health problems run in your family? The answers to these questions will help you determine how much coverage you need. Some people simply want protection against catastrophic injury or illness, and these folks are more likely to choose a high-deductible health plan with a lower monthly premium. Others are willing to pay more for greater protection. What type of person are you? If you are young and healthy and you rarely see the doctor, your best value may be in a high-deductible plan with a low monthly premium. If you have young children, consider a plan with a higher premium that will reduce your out-of-pocket expenses (deductibles and coinsurance). Older people and those with health problems should consider a comprehensive health plan with a higher premium. If you end up in the hospital, the out-of-pocket deductible and coinsurance you ll pay could well exceed any premium savings a lower-cost plan would have provided. (Continued on next page.) First-Dollar Coverage of Preventive Care Steve says: I talk with people all the time who miss the value of high-deductible plans. What s the point? they ask. I don t want to pay a lot out-of-pocket to see the doctor. What many don t realize is that high-deductible plans pay benefits at 100% for the most common preventive care services, such as routine physical exams and screenings. So in addition to protecting you from catastrophic injury and illness, a high-deductible plan can help you stay healthy by keeping up with your preventive care visits. And healthy people spend less money at the doctor s office. WPS Health Insurance

8 Tip #2, continued: Choose a plan based on your 2expected health care costs. By now, you ve probably gathered that health plans with higher deductibles generally have lower premiums. If it makes sense for you, raising your deductible is an easy way to reduce your premium significantly by as much as 50%. Despite this, some people are afraid of high deductibles because they can t bear the thought of paying $2,000 or more out of their own pockets each year for health care. What they don t consider is that even high-deductible plans offer 100% coverage for preventive care services so they won t pay a penny toward their deductible for common expenses like annual physical exams and screenings. And if the worst happens and they do get sick or injured, even a $5,000 deductible is a lot better than a $75,000 medical bill. The trick is to find the most cost-effective balance between how much you pay versus the potential cost if you need medical care. Take, for example, a plan with a low ($500) deductible and a premium of $205 a month. $205 x 12 months = $2,460 a year that you can count on paying for health expenses, even if you never once visit the doctor. On the other hand, a plan with a high deductible (say, $5,000) will save you money each month with its lower premium (for example, $71). If you stay healthy, you could spend less than $900 for the year instead of $2,460. And if you do get sick or injured, you can draw from that $1,500 you saved in premiums to help pay for your higher deductible. And that s not the only way you save. Keep in mind that most insurance companies negotiate with health care providers to pay discounted rates for their services. Without a health plan, you ll pay the provider s nondiscounted retail rate and you ll be responsible for the entire cost yourself. Bonus Tip Chris says: If you choose a high-deductible plan, put the money you save on premiums in the bank. That way, you ll have extra cash available in case you need it to cover your out-of-pocket expenses. You could also consider a highdeductible plan featuring a Health Savings Account see Tip #7 to learn more. 8 Top Tips for Buying Individual Health Insurance

9 Tip #3: Make sure the plan provides coverage for the services you need. 3What specific services does the plan cover? This is the other major factor to consider when selecting a plan. For example, do you take prescription medications? Review the policy to make sure it covers your current prescriptions, and find out how much the plan will pay. Other services to consider include well-child care, X-rays, immunizations, hospitalizations, emergency visits, and specialized preventive care such as vision and dental. Don t forget about specialists. If you want to see an acupuncturist or chiropractor, know for sure that your plan will cover them. Tip #4: Be wary of plans with too-good-to-be-true low premiums. 4Price is an important consideration, but ultimately, it s the coverage that matters. When evaluating plans, make sure you re comparing apples to apples with respect to deductibles, coinsurance, annual out-of-pocket maximums, and the doctors and hospitals that are considered participating network providers. Read the details so you can recognize plans that offer lower premiums but limit the number of times you may see a doctor or the number of hospital or lab-related services you are allowed. By the same token, find out if the plan you re interested in has limits on how often its rates can increase. Too often, people are attracted by a low premium only to find that the plan s rates rise quickly in the first year. You Get What You Pay For Chris says: I know a fellow, 58 years old, who retired early. For him, the price of the plan was his biggest concern. So he chose a cheap health plan without giving much thought to what it actually covered. Well, you get what you pay for. His rates rose quickly, and all of a sudden, that affordable plan wasn t so affordable anymore. It spoiled his retirement he wound up having to take a part-time job just to pay his health insurance premiums. WPS Health Insurance

10 Tip #5: Choose the network that lets 5you see the doctors you want. When choosing an individual plan, another important consideration is the doctors and medical facilities you can access when you need care. That s where provider networks come in. A provider network is the group of doctors, hospitals, and other health care professionals that an insurance company contracts with to provide highquality, cost-effective services to members. Generally speaking, the more extensive the network, the higher the monthly premium you will pay. If you value freedom of physician choice, then a preferred provider organization (PPO) plan may be for you. While PPO plans contract with 10 Top Tips for Buying Individual Health Insurance

11 a network of preferred or in-network providers, they allow you to see outof-network providers as well. You ll receive richer benefits (the plan will pay more of your costs) when you visit health care providers within the network, but the option to see other providers can be important if you travel, if you need to see a specialist, or if your kids attend college in another city or state. Health maintenance organization (HMO) plans offer a slimmer choice of doctors and generally require members to receive all of their care from a provider who is either employed by or under contract with the HMO. If you receive care from a provider outside the network, the HMO typically will not pay for that care unless you received prior authorization from the HMO or your condition was judged an emergency. The upside is that HMO plans generally have lower premiums than PPO plans. So if your preferred doctor is already part of a smaller, more affordable network and you don t anticipate needing medical care beyond your geographic area, then choosing an HMO can be an effective way to save. Another type of network is a regional or focused PPO network think of it as a middle ground between a broad PPO and an HMO. A regional PPO offers a local subset of the providers in the broader PPO network, but allows you to access out-of-network providers at a reduced level of coverage. In this way, you enjoy PPO plan choice at near-hmo rates. Point of Service (POS) plans, yet another type of network, offer a similar advantage. Wider Networks, Greater Peace of Mind Chastiny says: I work with a family that has two kids in college, and they chose a PPO for its wider provider networks. They find it reassuring to know that both kids can see local doctors. For example, their son had a snowboarding accident and their daughter, an appendectomy. In situations like these, you don t want to have to ask permission to see a doctor outside your network. You just want to get the care you need, fast. WPS Health Insurance

12 Tip #6: 6Pay attention to the type of deductible. Most health plans contain a deductible the amount of money you pay out-of-pocket each year to cover eligible medical expenses before your plan starts to pay benefits. There are two types of deductibles: embedded and aggregate. Health plans with embedded deductibles are advantageous because they contain two separate deductibles: an individual deductible and a family deductible. The individual deductible allows each member of a family to receive benefits from the insurance company before the family deductible is met. Let s imagine a family of three on a health plan with a family deductible of $3,000 and an embedded individual deductible of $1,000. If one family member reaches $1,000 in medical expenses, that member s individual deductible is satisfied and the plan will start to pay benefits for that person for the rest of the year, even though the family deductible has not been met. Other members of the family are eligible to receive benefits once the entire family s combined expenses meet the family deductible. In contrast, if this same family had a health plan with an aggregate deductible, then the family would have to satisfy the entire amount of the family deductible ($3,000) before any members of the family would receive benefits. The deductible may be satisfied by one family member or by a combination of family members, but the plan will only pay benefits once the family deductible is satisfied. The bottom line? A health plan with an embedded deductible could save you thousands of dollars each year. A health plan with an embedded deductible could save you thousands of dollars each year. 12 Top Tips for Buying Individual Health Insurance

13 Tip #7: Consider an HSA-qualified high-deductible health plan (HDHP). 7A Health Savings Account, or HSA, is a personal savings account that allows you to pay for medical expenses with tax-free dollars. HSAs are designed to complement a special type of health insurance called an HSA-qualified high-deductible health plan (HDHP). With an HSA-qualified HDHP, you can take the money you save on premiums and invest it in the HSA. While you are responsible for your initial health care costs until the deductible is met, the advantage is that the money saved on premiums is ready and waiting to pay for qualified medical expenses. In addition, HDHPs provide first-dollar coverage for preventive care services such as annual physicals and certain health screenings. HSA-qualified HDHPs can be a good choice for: People interested in trading higher out-of-pocket costs for lower premiums. People who want more control over their health care spending. Those interested in the tax benefits of an HSA. Anyone interested in using a personal savings account to pay for qualified medical expenses. A Health Savings Account is a personal savings account that allows you to pay for medical expenses with tax-free dollars. WPS Health Insurance

14 Tip #8: 8Choose an individual health plan instead of COBRA. If you find yourself suddenly unemployed without health coverage, or your current employer no longer offers group health insurance, consider an individual health plan from a private insurance company before you elect for coverage under COBRA (the Consolidated Omnibus Budget Reconciliation Act). An individual plan that covers the services you need, or expect to need, may well save you money compared to COBRA. COBRA allows people who have lost their health insurance as a result of certain qualifying events to buy coverage through their former health plan for up to 18 months (36 in some cases). But the premiums can be high, and unlike a group health plan, the employer contributes nothing. (By law, you can be charged 100% of the plan s premiums, plus an administrative fee of up to 2%.) For example: A COBRA plan with a $2,000 deductible may cost an individual $600 a month in premiums, or $1,200 for a family. In comparison, a private plan with the same deductible may have a monthly premium of $400 to $500 for an individual, and $650 for a family. But there s another advantage to choosing an individual health plan instead of COBRA. If you are injured or you develop a health condition while on COBRA, you may find it difficult to purchase an individual plan from a private insurance company when your coverage expires. Once you ve developed a condition, you may be turned down for coverage, charged a higher rate, or have your condition excluded from the policy. If you are injured or you develop a health condition while on COBRA, you may find it difficult to purchase an individual plan. 14 Top Tips for Buying Individual Health Insurance

15 Tip #9: Separate policies could save you money. 9As we covered in Tip #2, it pays to consider your estimated health care costs when choosing a plan. But what happens when members of the same family have different needs and different expected costs? Sometimes purchasing separate health plans is a smart way to save. For example, let s take a family of four that includes a healthy adult male, a healthy adult female, and two children. Dad rarely visits the doctor except for his annual physical. The kids often bring home whatever bug is going around at school and need to see the doctor more often. Scenario 1: The same plan for everyone. In this example, the family chose a plan with a $1,000 deductible. They pay $513 in monthly premium. The plan includes first-dollar coverage for preventive care visits such as annual physical exams and certain screenings. And once the deductible is satisfied, the plan pays benefits for all covered services. Scenario 2: A separate plan for Dad. Mom and kids have the same $1,000-deductible plan as above, but their monthly premium is now $380. Again, the plan includes first-dollar coverage for preventive care visits, and pays benefits for all covered services once the deductible is satisfied. Meanwhile, Dad chose a plan with a higher deductible of $5,000. Like his wife and kids, his annual exams are covered at 100% without the need to satisfy the deductible. His monthly premium is $65. In this example, the family together pays just $445 in monthly premiums (compared to $513), resulting in savings of $816 for the year. Granted, this approach is not for everyone. If Dad gets sick, for example, his expenses will be subject to his higher deductible. Depending on your situation, you may decide that it s worth the additional monthly premium to limit your potential out-of-pocket costs. WPS Health Insurance

16 Tip #10: If you need health insurance but Medicare is a few years away, the last thing you want to worry about is whether your health insurance premium will go up every year between now and Medicare. A fixedrate individual health plan allows you to lock in your rate until you become eligible for Medicare protecting you from unexpected rate increases and allowing you to plan more accurately for your future. 10Are you age 60 to 64? Look for a fixed-rate plan. Tip #11: healthy. 11Stay When buying health insurance, your current health is a key factor in whether you will qualify for a plan and how much you ll pay in premiums. Health insurance companies use a process called underwriting to determine your risk and decide whether to extend you coverage. At minimum, most companies require you to complete a health questionnaire, and many also require a physical exam. One way to keep your premium low is to maintain a healthy weight. If you smoke, quit. In addition, people who drink heavily, who are involved in dangerous jobs or high-risk hobbies, and those who otherwise place themselves at additional risk will also pay higher premiums. Beyond saving you on premiums, maintaining a healthy lifestyle can also help you cut down on medical costs as you age. It pays to stay healthy. Preventive Care is Key Catherine says: It s easier to get a comprehensive health plan with affordable rates when you re healthy. Once you do have a plan, be sure to take advantage of the preventive care services it covers. See your doctor for regular screenings and checkups. Preventive care is key to finding and fixing serious health problems early. And that can save you a lot more than just your life savings it could save your life. 16 Top Tips for Buying Individual Health Insurance

17 Tip #12: Be honest on your application. 12When completing your application for insurance, be sure to provide full and accurate answers to the questions that are asked. Any dishonesty or failure to disclose requested information could result in denied claims. What s more, a health insurer can rescind and cancel your coverage entirely if it discovers that you provided false information on the application. When completing your application for insurance, be sure to provide full and accurate answers to the questions that are asked. WPS Health Insurance

18 Stop Procrastinating Start Protecting Yourself Today! We know you re busy, and right now, there are probably things you d rather do than research and buy a health plan. That s why WPS makes it easy to get started. The WPS website ( is a great resource whether you re still in the tire-kicking stage or you re ready to enroll. With just a few clicks, you can compare rates on a variety of plans and no, you won t have to share any personal information. Take your time and learn about your options at your own pace. If you have any questions about your options, just call one of our friendly WPS representatives we ll be happy to help! Once you ve chosen a plan and you re ready to enroll, our electronic form makes it easy to do. There s no money down and no medical exam. No need to provide medical records. You can apply online or through the mail, and again, our representatives are here if you need them. Plus, we can protect you fast. Once we receive your completed application, you could have the essential coverage you need in as little as one week! a.m. to 5 p.m. Monday Friday WPSIndividualSales@wpsic.com Visit our online Learning Center for more tips and tools. Visit our online Learning Center (go to and click on Learning Center in the Resources area at left) for a collection of helpful articles, references, and interactive tools. From decoding complicated insurance jargon and finding an in-network doctor to controlling health care costs, our Learning Center will connect you to the information you need to more effectively manage your family s health and wellness. 18 Top Tips for Buying Individual Health Insurance

19 Strength and Stability Close to Home Wisconsin s leading not-for-profit health insurer, WPS has served the state s residents and businesses with quality health plans at competitive rates for more than 65 years. Everything we offer our customers, from plan designs, to provider networks, to member services, ascends from our heritage as a Wisconsin-based health insurance company. Our commitment to ethical service has earned us recognition worldwide. In 2010 and 2011, WPS was named one of the world s most ethical companies by the international Ethisphere Institute, and we are TM the only health insurance company to earn this distinction. We invite you to learn how the strength and experience of WPS Health Insurance can benefit you. For more information, call or visit

20 Buying Your Own Health Insurance? Find the Right Plan with Tips from the Experts Buying your own health insurance can be a daunting task. That s why we talked with four members of the WPS individual plan team to bring you 12 of the industry s top insider tips for finding the right coverage for you. Look inside to see them all! From left to right: Chris Kleisner, Chastiny Ellingworth, Catherine Thomas, and Steve Freitag Wisconsin Physicians Service Insurance Corporation. All rights reserved

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