The end of the individual mandate opens new doors for individuals

The individual mandate has been a burden for some. But with its demise, non-traditional coverage, such as Cost Sharing and Direct Primary Care Programs, may be viable options for those looking to reduce costs. Here is a look at these two insurance alternatives. 

​As we enter into the open enrollment season for individual medical coverage, this year will be a little different for one primary reason. As of 1/1/2019, individuals will no longer be penalized for going without health coverage. While premiums are not rising substantially this year (for most carriers), we all know individuals who may take the risk and go without insurance. Some clients may choose to go a non-traditional route through a Cost Share plan or a Direct Primary Care provider. While not full coverage by any means, they may be non-insurance alternatives for clients who are not able to afford traditional insurance.

---

Cost Share Programs
“Cost Share” plans, sometimes referred to as “Health Ministry” or “Health Share” plans, can be almost half of the premium of an individual policy, but of course, there are reasons for this. The coverage is lower, there’s health screening required for entry, and the plans have lifetime limitations (and in some cases annual limitations). 

​Let’s look at one popular program, Altrua HealthShare. They offer 4 plan levels. For a 45 year old, monthly premiums are $296 Gold / $269 Silver / $202 Bronze / $100 Copper. While they give different names to benefits, the “Bronze” plan basically looks like a $1500 deductible plan, then 25% coverage of the next $10,000, then 50% coverage for the next $10,000. Therefore, the “out of pocket maximum” would be $11,500 for covered services. Plus this Bronze plan has a $250,000 annual maximum benefit limitation. One other hurdle to enrollment is that you will need to “agree” that you will live a clean and healthy lifestyle and share the “ethical or religious beliefs” outlined on their website.    

Things to consider about Cost Share Programs
Cost Share Programs can be a viable option, especially if your client is healthy and clean living. If they have a pre-existing condition, they may not be approved for the program, and if they are, they‘ll want to consider whether the program accommodates that condition and/or assesses additional premiums. Also, keep in mind that coverage in one year does not guarantee coverage in subsequent years. These programs are voluntary on both sides and a program can elect to discontinue coverage. Finally, the survival of a specific program is dependent on its financial strength. Clients should do their research to ensure the program is well managed and solvent.

---

Direct Primary Care Programs
“Direct Primary Care” refers to an agreement between a physician and a patient where the patient pays a monthly fee to be a part of the physician’s practice. The typical monthly fees range from $60 to $150 per month, depending on the age of the patient – each physician sets their own membership fees.  Typical services provided at no charge include office visits, office-based procedures, medical management, writing of prescriptions, coordination of care, and some urgent care. For an additional cost, patients are also able to obtain vaccines and lab testing, or home/facility visits from the physician. 

In the state of Washington, there are over 40 Direct Primary Care physician practices. They must register with the Office of the Insurance Commissioner, which makes it easy for a consumer to find a DPC physician near them.  Here’s the direct link to the OIC’s list, which provides addresses and links to each provider’s practice. 

​Things to consider about Direct Primary Care Programs
Again, if your client is generally healthy, Direct Primary Care will definitely save them money. But, while Cost Sharing Programs may cover medical needs beyond those provided in a primary doctor’s office, a client utilizing a Direct Primary Care Program should consider also enrolling under a catastrophic health plan to cover, say, a cancer diagnosis or severe injury.

---

Other Programs
If you have clients who are looking to go without insurance this coming year, whether or not they enroll in a Cost Share Program and/or a Direct Primary Care relationship, they may benefit from some of these other programs:

• 24/7/365 telephone access to a doctor – one program we recommend is AllyHealth/MDLive, which can be purchased on an individual basis
• Rx Discounts – have your clients check out GoodRx any time they are going to fill a script, so they can find the least expensive place near them
• Healthcare Benchmarking – even patients without insurance can negotiate with their providers using Healthcare Bluebook - they have about 250 procedures’ costs available, plus a printable “agreement” that can serve as a document in their negotiations.
• Individual Aflac policies – Aflac provides their Accident, Cancer, Critical Illness, Dental and Life products on an individual basis – if you need a representative, contact Shawna Scott Hayes at trishawna_scotthayes@us.aflac.com (or 253-988-5900).

---

Agents understand the need for insurance, after all, we see the astronomical cost of cancer treatment, specialty drugs, and even a one-day hospital stay for an appendectomy. I’ll continue to pay my $500+ premium every month because I know all too well how a single medical event could cost so much more than my $6000 premium and $7,000 out of pocket maximum. But as we all know, some people don’t have the luxury of slapping down $500 a month, and it looks less and less appealing the healthier you feel you are.

​At least having some options in your back pocket to provide some “backup” for these clients can help you feel like you have done all you can to cover them as best as they can afford.  Plus you’ll be able to replace a little bit of lost individual commissions. AllyHealth/MDLive and Aflac both have commissions built in, and some Cost Share programs provide commissions (Altrua HealthShare is one of these).