Individual and family health insurance coverage is not that different than the health insurance you get from your employer. There are two main differences in the plans that are important to understand. The first is the exclusion of maternity coverage (see separate maternity FAQ question) and the second is the ability for the insurance carriers to underwrite you when applying for an individual/family policy. This means that they are not obligated to offer you coverage. Once you apply, they will look over your application and determine your overall risk. Once they’ve completed that step they may offer you coverage exactly at the premium that we quote. They also have the right to increase your premium if they believe you’re a higher-risk client (height/weight ratio, hypertension, etc). They may also exclude certain conditions from being covered (knees as a result of knee surgery) or if they believe you’re too high of a risk they can decline to extend an offer of coverage to you.

Virtually all of the individual/family plans available are PPO plans. The PPO plans break down to either a Co-Pay(ment) option or an HSA Compatible Plan option.

A Health Savings Account (HSA) is a bank account that works in conjunction with an HSA-compatible health plan. This allows you to contribute pre-tax money into the HSA to be used for qualified medical expenses as well as another means of long-term savings or retirement. The account bears interest and many banks allow for mutual funds and other investments to be purchased with the funds contributed. All interest and earnings are tax-deferred and all funds utilized for qualified medical expenses are penalty free and tax free. For a list of qualified expenses visit the IRS website.

A Co-pay(ment) plan is what most people consider traditional PPO health insurance. You’ll pay a “Co-Pay” for office visits, specialists, and prescriptions. How much depends on your health plan but can range a great deal. The amount of money you pay does not go towards your deductible and it’s not reduced from what you owe, rather it’s just the fixed amount you pay regardless of the provider’s charges.

A deductible is the set amount of money you must pay before an insurance company is required to pay.

? Coinsurance is the percentage of money paid by the insurance company after the deductible has been met. There is virtually always a coinsurance limit, after which the insurance company pays 100% of your medical care for the remainder of the calendar year.

Doctors and other providers have the opportunity to partner with insurance companies which would make them “in-network” with that particular carrier. When choosing an insurance company you will want to make sure that the doctors you use on in that carrier’s network. You can find this out online or simply by calling the provider directly.

In most cases your coverage can being immediately after getting approved by the carrier. You can also request to start on a certain date, thus making it easier to leave one carrier for another and not having any gaps in coverage.

Unlike group health insurance (through your employer), carriers offering individual/family health insurance are not obligated to extend an offer of coverage to you. Every applicant, spouse, and dependent is underwritten by the carrier based on medical history you provide in your application. Getting approved will be based primarily on the outcome of their underwriting.

This will depend upon your situation. Younger and/or healthier families tend to gravitate towards HSA compatible plans. People who frequent the doctor or take costly medications on a regular basis may find a co-pay plan more to their liking. Both plans have pros and cons and there’s not one plan that’s perfect for every situation.

Some carriers still charge for paper applications; however when you complete an application online through Alkali, LLC, the application fee is waived on virtually every carrier.

There is no obligation to buy the insurance, either before applying or after getting approved or anywhere in-between.

Due to heavy insurance regulations all carriers must sell their health plans at the same price whether through their own website or through an independent broker. This guarantees that you will never have to pay more money for our service. It’s like getting good advice for free!

Consultants at Alkali have the heart of a teacher. We begin by assessing your needs to determine which products would be in your best interest. We then educate our clients, walk them through the different types of products we have available, and then guide them through the application process and beyond. Our service does not end there though! We’re also here to assist you anytime you need to make changes to your policy (i.e. adding or removing a dependent) or if/when you ever decide you’d like to look at other carriers or other plans. Being a broker, we are independent and are appointed with many different insurance carriers. This allows us more options to shop on your behalf. To top it off we are endorsed by Dave Ramsey as an Endorsed Local Provider for the Dallas/Fort Worth metroplex.

While it is certainly possible for a health insurance carrier to decline to extend an offer of coverage to you, we can review alternate options that might work for you.

Can you help me? There is a good chance! One of the services we pride ourselves on is trying our best to pair you up with the carrier that best fits your needs and your medical history. Sometimes the carriers will decline to extend an offer of coverage to you. If so, there may still be options left for you. We can also “pre-screen” your medical history and send it to the carriers anonymously to try and see how receptive they would be to specific conditions.

The Texas High Risk Pool is a state-run insurance option for people who have no other health insurance option. The Texas High Risk Pool will not decline you based on medical history or pre-existing conditions. Their prices are all listed on their website and are higher than most other policies but they offer several plans and can be a great alternative to people who have exhausted all other avenues. For more information please visit their website

Once you apply the carrier will receive your submitted application and notify us. They will begin underwriting your health history and application and determine, based on their findings, if they are going to extend you an offer of coverage. Part of their process could include calling you for a medical interview to get clarification on information submitted to them. The entire process typically takes 1-3 weeks. We will keep tabs on your application throughout the process and let you know of any updates we receive.

There are two primary differences between group health insurance (through your employer) and individual/family coverage: The first is that as a rule maternity is not covered on individual/family plans. Not only is maternity not covered, an expectant parent (even fathers) can not get an individual/family plan as well. The second primary difference is in terms of how one gets approved for coverage. On a group plan you usually complete an enrollment form and pay your premiums. Previous medical history or pre-existing conditions are usually irrelevant. On an individual/family plan the carrier will underwrite your medical history and evaluate your level of risk before deciding whether they will offer you coverage. They may also increase the premiums or exclude coverage of specific conditions based on their findings.

One primary difference between group and individual/family plans is that maternity is not covered on most individual/family plans. Right now there are two carriers that we work with who offer maternity but many times the additional cost of adding this benefit outweighs the benefit itself. It’s also important to note that expectant fathers cannot get an individual/family policy either. The reason is that newborns can be automatically added to an insurance plan (without underwriting) when they’re born even if they’re unhealthy. Insurance carriers know this and aren’t willing to add the risk. If you’re currently pregnant your best bet is to try and get on a group health insurance plan until the baby is born.

Currently there are two carriers that we work with who offer maternity; however often times the additional cost of adding this benefit outweighs the benefit itself.

Many factors play a role in determining the rate of your premium. The biggest are your age and health history. Zip codes also play a role as people in the same geographic regions often have similar healthcare patterns.

Maternity and Mental Health are two of the biggest exclusions that may be included. Some carriers will cover one or both but these are important things to mention to your Consultant if they’re a condition you decide you definitely want covered. Some plans may have waiting periods for particular plan features such as Preventive Care. Other plans may not cover any preventive care until the deductible has been met. Always be sure to read your health insurance contract carefully and to ask us if you have specific concerns or needs.

Coinsurance is the percentage (split) paid by the insurance carrier and you once the deductible has been met. Many people are familiar with the traditional 80/20 split after a deductible is met on a co-pay plan. The coinsurance limit will range anywhere from $0 to several thousand dollars. Copayments simply refer to the fixed cost charged for office visits, prescriptions, etc. It does not go towards the deductible and are generally unlimited in nature, unless notated otherwise.

The “Total (or Max) out of Pocket” usually refers to the amount of deductible and the amount of coinsurance combined. This is the worst-case scenario financially for a member or family. This is an important number to notice since a deductible itself can be deceiving. For example, you may have a $500 deductible but a Max out of Pocket of $5000. This may mean paying $5000 for a claim even though you only have a $500 deductible.

Sometimes if you truly just need an insurance policy to fill a short gap, in employment for example, or you’ve just started a new job and you have a 90-day waiting period than a Short-Term medical plan might work well for you. They cost less than a fully insured plan and have very fast approvals but have plenty of drawbacks as well. They do not cover pre-existing conditions, they have no co-pays, they are only valid for a short period of time (usually months) and they generally have higher deductibles. They’re designed really well for short periods of time in the unlikely event of a true major medical/catastrophic event.

There is no contract and you are free to cancel at any time. We always encourage you to speak with a Consultant before canceling in case there are other options or carriers that might work better for your situation.

Currently we work with Aetna, Assurant, Blue Cross Blue Shield, Celtic, Cigna, Humana, and United Healthcare. We’re open to working with other carriers if we see they’re competitive and are requested by a client. We also worked with Unicare but they have since pulled out of the state of Texas and transitioned their remaining members over to Blue Cross Blue Shield.