Private Plans (Alternatives To ACA Plans)

Private plans are health insurance plans sold outside the ACA Marketplace. They're designed mainly for people who earn too much to qualify for an ACA subsidy, or whose subsidy is small, and who would otherwise pay full price for an ACA plan.

Unlike ACA plans, private plans are medically underwritten. Applicants answer health questions and, based on those answers, they're either approved or not approved. Once approved, the plans don't exclude or limit coverage for pre-existing conditions, but applicants who don't pass underwriting aren't eligible. Because of underwriting, premiums are often significantly lower than unsubsidized ACA premiums, particularly for healthy individuals and families.

Many private plans are PPOs that use large national networks, such as Cigna's largest PPO network, the PHCS Extended PPO network, or First Health (owned by Aetna). Others are limited benefit plans that provide less extensive benefits than PPO plans but can be attractive to those who are seeking even less costly alternatives than those provided by the PPO plans.

All these plans provide the ACA-required preventive care benefits,

The lowest-cost options are group plans available to self-employed people and small business owners with a business EIN, even a business of one.

Many private plans can also be purchased any time of year, not just during open enrollment.

Private plans aren't the right fit for everyone. People who receive a sizable subsidy, have significant health conditions, or are pregnant or planning to be are usually better served by an ACA plan, which can't turn anyone down because of their health and is the only type of plan eligible for subsidies. Anyone considering a private plan should apply well before the ACA open enrollment deadline, so they can still enroll in an ACA plan if they aren't approved.

Plans Available To Self-Employed/Sole Proprietors With an EIN Number Or W-2 Employees Sponsored By An Employer

We offer a set of seven different group plans to those who fit this category. Prospective members must be able to answer NO to the first ten health questions and yes to the last three questions to qualify.

The subscriber must be age 18 to 64 ½ to qualify but the employer can permit the employee to stay in the plan past 65, These plans use composite rates (one flat premium regardless of age), and premiums are significantly less than for other available private plan PPOs. For example, the HSA 9000 plan has a single premium of $426, and the premium for a couple is $528. There are no membership or application fees. The premium for the highest cost plan (Platinum) is $1003 for single and $1,632 for a couple, but the in-network deductible is only $250 individual/$500 family and the in-network out-of-pocket maximum is $1250 individual/$2500 couple.

These are true PPO plans that use Cigna’s largest network (Choice Fund PPO) and are the only private plans where the third-party network has a contract that requires Cigna to adjudicate the claims. This means that claims are sent by providers directly to Cigna for adjudication (this is the process in which the carrier reviews a claim and decides what’s owed. The carrier confirms coverage, applies network discounts, and calculates what the plan pays and what the member owes. Cigna then tells the third-party administrator how much to pay, and the administrator then pays the provider.)

With all other private plans claims are sent to the third-party administrator for adjudication and not to the carrier. Hence, this makes for much more efficient and timely claim processing and eliminates the long delays that are sometimes experienced with third party administrators.

Here is an overview of the seven plans and here are Summaries of Benefits and Coverage for each of the plans:

• HSA 9000
• HSA 6000
• Bronze
• Silver
• Gold
• Diamond
• Platinum

Enrollment must occur by the 20th of the month to be effective the first of the following month, and the prospective member can enroll either for the following or the succeeding month. Payment can either be made through ACH (electronic funds transfer) or by credit/debit card (there is a 2% service charge).

Please call us on 786-970-0740 for additional information and for help in enrolling.

AFI-PHCS Plans

These plans use the PHCS “Extended PPO” network, do not ask height and weight, and have one-year look back periods. Here is information about each of the four plans:

• 8300 HSA Here is the brochure for this plan
• 3500 HSA Here is the brochure for this plan
• 4500 Copay Here is the brochure for this plan
• 3500 Copay Here is the brochure for this plan

Prospective clients must be able to answer all these health questions NO to qualify for one of these plans.

These plans are not available in Washington state. MBA TPA is the plan administrator for these plans. These are association plans, and prospective clients must become members of the Americans for Financial Independence (AFI) to enroll in a plan.

These plans use the PHCS Extended PPO network. Click here for instructions on fading providers. Here is the link to the formulary used by these plans.

All plans include $20,000 of life insurance from Humana Life.

Enrollment should occur by the 20th of the month. Although enrollment is permitted through the 25th of the month, it may take up to 10 days for benefits to be fully activated by the third-party administrator; accordingly, we recommend that all applicants apply no later than the 20th of the month.

Smart Health Plans (AKA HC Data Consulting)

The plans described in this section are offered by Smart Health Plans (also known as HC Data Plans); administered by Securus, which is a third-party administrator; and are written on a group chassis to individuals and families who qualify. Prospective members must acknowledge a Joinder Agreement. Prospective members must also agree to enroll in the Association Affinity Health Plan (AAHP).

All plans are age-banded (age bands are different between the Med Performance and the limited benefits plans described below). They use national networks but are NOT plans of the carriers offering these networks. Providers must send claims to the address that is provided to applicants when they enroll. Claims sent directly to the network provider will not be paid unless they are sent to the address provided.

These programs are meant for very healthy individuals who have a Body Mass Index of under 30. Height and weight questions are now included in the application. They previously used a “Yes” or “No” application with a simplified questionnaire. The questions now allow the plan to evaluate each prospective participant individually and can approve individuals who answered No to a question if appropriate documentation is included.

The health questions are the same for each of the three sets (i.e., the Med Performance PPO and the two sets of limited benefits plans). There is a five-year look-back period for all plans.

Med Performance PPO Plans

Click here to learn more about the four different Med Performance plans (3500 Classic, 5000 Classic, 5000 HSA, and 7350 Value. Premiums are age-banded based on the age of the primary enrollee (for spouses this can be the younger spouse). There are five age bands (18-29; 30-39; 40-49; 50-59; and 60-64) and four premium tiers [single; couple; subscriber and child(ren); and family]. There is a $75 application fee to join one of the plans.

These are major medical PPO plans that utilize Cigna’s largest PPO Network. Healthy non- and lowly-subsidized individuals who qualify will find they’ll save significantly by purchasing one of these plans instead of an ACA plan with similar benefits and networks. Click the Info tab under the name listing each of the four plans to see the plan brochure (the brochure includes information on premiums), the Schedule of Benefits, and the plan’s list of covered medications. Click here for instructions to look up in-network providers.

Enrollment must occur before age 65, but members may retain their plan past 65. These plans are not available for residents of Washington state, but enrollees can utilize the plans anywhere in the U.S.

Med Access-MVP and MedMax-DVP Limited Benefit Plans

All versions of these plans utilize the First Health Network (which is owned by Aetna). These are EPO plans that don’t require referrals but also don’t provide out-of-network coverage. These plans don’t offer the coverage offered by a major medical plan, but they meet the needs of some of those who are looking for lower-priced coverage.

These are limited benefits plans; less comprehensive (many of the copay benefits have daily limits and fewer items are covered) than in the Med Performance PPO plans; and are meant as alternatives only if the premiums for the Med Performance PPO plans are unaffordable or a healthy applicant is seeking a less costly plan.

Click here to learn more about the Med Access plans. Monthly premiums are age-banded (18-45 and 46-64) and vary by family size and whether the enrollee chooses the Basic or Pro version. The Pro version includes maternity benefits (no maternity benefits are available in the Basic version), and there is a 12-month waiting period to be eligible for maternity benefits under that plan. Click on the Info button for each version of the plan to learn more about that plan. The Info tab for each version of the plan contains the Brochure, Rx formulary, Summary of Benefits, and shows how to find a First Health Network provider.

The five Med Max plans are all the same except each has a different deductible ranging from $250 to $1500, and all these plans include maternity. There is a 12-month waiting period to qualify for maternity benefits. Premiums are banded into four different age bands: 18-29; 30-44; 45-54; and 55-64 and vary by family size. Click here to learn more about each of the Med Max plans. The Info tab for each version of the plan contains the Brochure, Rx formulary, Summary of Benefits, and shows how to find a First Health Network provider.

Required Authorization

All prospective applicants for any of the Smart Health Plans (i.e., Med Performance PPO, Med Access-MVP or MedMax-DVP plans are required to read and accept authorization agreement. We suggest you read this agreement before enrolling and print it out for your records. If you have any questions, please contact us when we help you with your application.

Please contact us at 786-970-0740 (Cell) for more information, pricing, and/or enrollment in any of these plans or any other individual group health plans that we may be able to offer to individuals or families.