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SHORT TERM MEDICAL INSURANCE
OVERVIEW
In Oregon you can purchase Short-Term Medical (STM) insurance for up to 90 days per contract. Short Term medical plans are a type of limited-benefit health insurance and are not subject to the Affordable Care Act/Obamacare regulations, and is not guaranteed-issue.
Generally, STM plans were designed for someone needing medical insurance for a limited amount of time while waiting for other coverage to begin. Most plans do not cover you for a pre-existing condition, prescription drugs, or preventative services. Take time to read the brochure plan limitations and exclusions prior to enrolling in coverage to see if the coverage is right for you.
DEDUCTIBLE AND OUT OF POCKET MAXIMUM:
It's important to note with Short Term that the plan deductible does NOT go towards meeting the plans out of pocket maximum: This is an important distinction compared with most traditional health insurance plans.
For example, if you purchase a $5000 deductible plan with a $3750 out of pocket maximum, should you have a $30,000 covered medical expense, your out of pocket maximum for covered services would be $8750. Different plans will have different out of pocket maximum options.
WHEN DOES COVERAGE BEGIN AND HOW DO I QUALIFY?
Coverage can begin as early as next-day, or you can select a future day for the plan to start. To qualify you have to answer NO to the 6 or 7 qualifying questions. I always recommend if possible to have the coverage end the last day of a month. For example, if your plan starts effective September 15, have your end November 30 or December 31. This will benefit you should you transition to a new plan on the Marketplace or buy another STM plan with a 1st of the month start-date.
Overview of the plans
Here is a brief overview of the 3 plans I represent currently.
1. Flex Term: The Flex Term plan is my first-choice of the 3 plans: Unlimited primary care visits are covered with $50 copay before your deductible needs to be met. You can pay month to month, or select the single-pay option and save about 20%. The plan also covers a preventative exam (though not the tests or diagnostics) before the deductible.
2. Pivot Health: The Pivot Health Plan is my least expensive plan offering a variety of plan options. You can pay monthly or select the single-pay and save about 20%. The Deluxe & Choice plans include 3 Primary Care, Specialist, or Urgent Care visits with a copay before the deductible needs to be met.
3. Allstate Health Solutions: Allstate Health Solutions, (underwritten by National General) offers 1 primary care visit with a $50 copay prior to your deductible, and $50 Urgent Care visits.
Plan 1: Flex Term STM Plan
The Flex Term STM plan is underwritten by the Everest Reinsurance Company and has an A+ financial rating. The plan offers unlimited Primary Care visits with a $50 copay. In addition, a routine Physical Exam is covered with a $50 copay before the deductible is met (but not the diagnostics or labs, mammogram/pap that accompany the exam).
CLICK HERE to quote and enroll in Flex Term Plan
Please review the plan coverage plan limitations and exclusions section of the brochure prior to enrolling. The qualifying enrollment questions are also included in the brochure below.
PROVIDER DIRECTORY OF CONTRACTED PROVIDERS:
The Flex Term plan is contracted with a national network of providers called the PHCS Practitioner and Ancillary network. You have freedom to see any provider, but if you choose someone in this nationwide network you will pay a lower, contracted rate.
https://www.multiplan.com/webcenter/portal/ProviderSearch
Quick Links for Flex Term Customer Service
Customer service can be reached at 800-279-2290 to cancel your plan or ask questions of the coverage or claims, or to prematurely cancel your coverage . Policy administration is through TPA Administrators.
Plan 2: PIVOT HEALTH STM PLAN
Pivot Health Plan is underwritten by Companion Life. The brochure outlines side-by-side the different plans and benefit options. Pivot Health has no contracted provider network: so you can see an doctor that agrees to bill the plan. The Deluxe plan offers the lowest out of pocket maximum.
CLICK HERE to quote and enroll in Pivot Health
Please review the plan coverage plan limitations and exclusions section of the brochure prior to enrolling. The qualifying enrollment questions are also included in the brochure below. All the plans include free Telehealth services.
CLICK HERE to view the Pivot Health Brochure
The Choice and Deluxe plans both offer a combined 3 visits to an Urgent Care, Primary Care, or Specialist visit before your deductible needs to be met. The Deluxe plan has a lower out of pocket maximum.
Application Notes for Pivot Health:
When you get to the payment section of the application you will see a 'pre-pay' option. If you single-pay for the 3 months of coverage, you save about 20% in premiums. However, by pre-paying you are not allowed to cancel early with a refund if you only need a month of coverage.
Quick Links for Pivot Health Customer Service
Customer service can be reached at 844-630-7500 to cancel your plan.
To cancel your plan prematurely you can call customer service or email clientservices@insurancebenefitadministrators.com
Plan 3: ALLSTATE HEALTH SOLUTIONS
Allstate Health, (underwritten by National Health Insurance Company) offers a solid plan with a good benefit and large, national network called the Aetna Open PPO Network. The contract can be taken out for 3 months and offers 1 Primary Care doctor visit with a $50 copay prior to your deductible and unlimited Urgent Care visits with a $50 copay. You save about 20% if you select the single-pay option.
CLICK HERE to get a quote and enroll
Before making application please review the plan brochure, especially the plan limitations and exclusion section.
CLICK HERE to view Allstate Health brochure
Search for In-Network providers in the Aetna Open Choice PPO Network:
CLICK HERE to search Providers contracted network.
Application Notes for Allstate :
Select the 'Monthly' option when quoting. You can keep coverage from 1-3 months and cancel any month by calling Customer Service in advance. You can save about 20% of you choose the single-pay option. The contract maximum is 90 days.
Allstate Health Solutions Quick Links to Customer Service:
Allstate Health Solutions: 888-781-0585 You can call and cancel your plan early if you want. Email memberservices@nhicadmin.com with general requests like another ID card or billing question.
SINCE THE PLANS DO NOT COVER PRESCRIPTION DRUGS,
WHAT SHOULD I DO IF I TAKE A MEDICATION?
I recommend going to http://www.goodrx.com and looking up your drugs. You will find the best cash pricing at local pharmacies. It's a great tool!
WHAT ARE MY OPTIONS WHEN THE STM CONTRACT ENDS?
When the contract ends you have a few choices:
1. APPLY FOR ANOTHER STM PLAN WITH MY OTHER STM COMPANY:
Before your STM contract ends, you can apply for up to 90 days of coverage with my other STM insurance carrier. Oregon requires a 60 day gap before you can reapply with the same carrier. I recommend the Flex Term plan first, then either Pivot Health or the Allstate Health Plan. For example, you can do the Flex Term plan for 3 months, then the Pivot Health plan for 3 months, then back to the Flex Term. The risk you face is having to pay more than one deductible per year if your health is poor.
2. BUY COVERAGE THROUGH THE MARKETPLACE:
The Marketplace accepts a Short Term Medical contract ending as a 'qualified event' to purchase coverage. I can help you apply for a 'fully qualified' plan (such as Kaiser or Providence) through the Marketplace when your STM plan ends. You have 60 days from the end of your STM plan ending to qualify for a Marketplace plan as a 'Special Enrollment' situation. Example, if your Pivot health plan ended November 30, I could write you a Marketplace plan that began on December 1.
WHAT IF I WANT TO DO A VIDEO-VISIT FROM HOME?
I believe the Pivot Health and National General plans offer at no cost telehealth video visits with a doctor. If not, Providence Express Care Virtual visits are available to anyone. You can do a video visit with a doctor or nurse for a flat $79.00 per visit.
Download the Express Care Virtual app for your phone, or from a laptop start at the link below:
https://virtual.providence.org/
MONEY IS TIGHT, BUT I STILL NEED TO DO AN ANNUAL EXAM AND WOULD LIKE THE TESTS COVERED.
Some of my clients sign up for a traditional plan like Kaiser or Providence and have their preventative exams, then switch to Short Term Medical for the rest of the year. The Flex Term plans will pay for a preventative exam with a $50 copay, but not the tests that go with it like a routine colonoscopy, mammogram or pap.
I want to be very clear that Short Term Medical insurance is not the same as a creditable health plan under the Affordable Care Act and has many more plan limitations.
Short Term Medical Disclosure
This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your Policy/Certificate carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health. For example, the Pivot Health plan limits treatment for Kidney Stones to a $1500 maximum and an Appendix surgery to a $2500 maximum.
Benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your Policy/Certificate might also have lifetime and/or annual dollar limits on health benefits.
If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage. Also, this coverage is not “minimum essential coverage.” This plan has a pre-existing limitation provision that may prevent coverage from applying to medical conditions that existed prior to this plan effective date.
TO MAKE SURE I DON'T MISPRESENT SHORT TERM MEDICAL PLANS, here is the definition of the coverage from the Flex Term brochure
"What is Short-term medical insurance? Short-term medical (STM) insurance policies are designed to provide temporary coverage during life’s transitions until you can secure an Affordable Care Act (ACA) insurance plan. STM insurance policies are not required to comply with the requirements of the ACA and may have exclusions and limitations not permitted in ACA plans. ACA plans are guaranteed issue, must cover certain “essential health benefits” (EHBs), and you cannot be denied coverage based on pre-existing medical conditions. In contrast, STM insurance requires that you answer a series of medical questions to determine your eligibility, may not cover all EHBs, and does not cover pre-existing conditions. The limitations on benefits and exclusions, including the pre-existing conditions exclusion, likely will result in STM policies having lower insurance premiums than ACA plans and make them a viable option for your health insurance needs. If you have had medical conditions in the past or have current or chronic conditions, you should seek an ACA or other comprehensive insurance plan as soon as you are eligible for enrollment.
Allstate Health STM brochure 2023
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Flex Term Brochure & PHCS 2023
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Pivot Health Brochure 2023
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