As the health insurance market continues to grow, navigating the options and choosing the right plan can be a difficult task for some.
The Lambert Agency, located in the Westlake area and run by insurance broker Jeff Lambert, helps guide families and small businesses in purchasing health and life insurance options. Community Impact spoke with Lambert to learn more about the health insurance process and nuances.
What is the biggest misconception people have about health insurance?
I would say the biggest misconception is that you can get health insurance on your own as an individual that’s just as good as you imagine it to be, but people are definitely not happy with their options that they end up with. If somebody works somewhere where they make a decent wage and their household income is high, there’s almost no reason not to accept the coverage from their employer. It’s going to be much better in most cases.
How has the health insurance industry changed in recent years?
Premiums have gone crazy for everybody. For small groups, as well as for individuals in the marketplace. For example, a family of four on the Affordable Care Act, who makes $150,000 a year, their cost could be as much as $5,000 a month. The change is the subsidies have decreased. There were always subsidies available to people with the Affordable Care Act and there still are, but they have gone back down to pre-COVID subsidies. When COVID came through, they added more and more subsidies, which made it free for a lot of people and affordable for a lot of people. Once they stripped that away, we’re now looking at this particular family of four [and] $2,200 is their minimum cost for a very high deductible, high maximum amount out of pocket and not a very good plan. That’s the biggest thing that has changed so much. If you’re making $150,000 a year for a family of four, you cannot afford $2,289 plus a $10,000 deductible.
What are your first steps when working with a new client?
I would ask them if they currently have any expensive medications or preexisting conditions that they need treatment for and what their income is. This lets me know what might be the right direction for them. I would also ask how they ended up calling me. “How did you end up with no health insurance?” “Did you not have it before?” “What changed?” That information will tell me if they qualify for the Affordable Care Act because they will be in a special enrollment period.
Many people who don’t have health insurance who want health insurance are self-employed. I may guide that person, depending on the scenarios, to start a corporation or a company and have another W-2. Now this person may qualify for small group health insurance and have access to small group PPO health insurance ... so there are some ways to navigate through that system.
What should people look for when comparing health insurance plans?
First of all, people should look at what network that plan is using. “Are my doctors and hospitals in that network,” would be the first question I would ask. I would also ask, “Is going to a specialist without getting a referral important to you?” I think a lot of people are starting to just self-pay so they can go to the doctors they want to.
People should also understand the benefits of that plan and any limitations or exclusions that it has. Does it cover preexisting conditions? Look at what the actual cost is. Even if you pick the cheapest plan, you still have to calculate, “what is my deductible?” “What is my max amount out of pocket on top of that?”
What are some common mistakes you see people make when selecting a health insurance plan?
I’d say the biggest problem people have is that they bought coverage that their doctors don’t accept. For those with the Affordable Care Act, they need to upload their income to the system so they can receive the subsidies. If they lapse on providing that information, they could end up with no health insurance because the subsidies will be canceled.
One thing you wish clients understood before buying insurance
I think it’s important for them to understand that it isn’t necessarily what the insurance does for you now or in a day-to-day. But if you’re trying to be affordable, even the worst [coverage] that has a $10,000 maximum out of pocket—if you need a $100,000 surgery, you only need to pay $10,000. These plans are still protecting that individual and the credit of that individual. Having some health insurance, even if it’s not exactly what they wanted, is better than none at all.
What advice would you give to someone currently seeking health insurance?
Understand all the options and call a broker. A good broker will have more options than what you will find just looking online. We can tailor something specific for the individual as opposed to just getting what is out there. What I want people to know is there are now options out there that did not exist a few months ago. They have fixed indemnity plans that are much more affordable. There are also healthcare sharing plans from primarily organizations. It can be a lot, but that's what I help guide people through when they call me.
