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Ohio Medicaid Health Insurance Information – Applications And Qualifications

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Ohio Medicaid Health Insurance is available to many Buckeye State residents. Medical plans are currently provided to more than three million individuals and families, with pre-existing conditions covered, and premiums either free or extremely inexpensive. Comprehensive benefits  are provided after a short application is submitted and approved. Food and cash assistance, help with housing and utilities, and mental health and addiction services are also offered through other Agencies.

The two public assistance cards are  “Direction” and “EPPIC.” If you currently utilize either of the cards, an additional application is not needed. Veterans or persons serving in the Military may have additional options. WIC (women, infants, and children)  offers supplementary nutrition assistance to breastfeeding and pregnant women, and children less than five years old. Nutrition and breastfeeding education, and specific foods (eggs, vegetables, fruits, whole grains) are provided to eligible persons. Infant mortality has been greatly reduced, while birth weight and length of pregnancy have increased, due to WIC and other similar  programs.


Applicants that can qualify for benefits include individuals with low income, persons with disabilities, older adults, infants, small children, and pregnant women.  Additional requirements are US citizenship, legally reside in Ohio, and be able to meet specific income guidelines. Applications can be submitted online or through the mail. A personal visit is not required. Non US citizens that are ineligible for coverage can apply for alien emergency medical assistance or refugee medical assistance. Refugees who have been in the US less than eight months, and are ineligible for Medicaid, may be able to receive benefits if their household income is less than 100% of the poverty level.

CHIP and Medicaid eligibility is largely determined by the MAGI (Modified Adjusted Gross Income). Of course, the more money the household earns, the less federal or state funds are provided. You can view specific information regarding the calculation here.  Expansion has taken place in many states (including Ohio), so more applicants are now eligible.  “Healthy Start” and “Healthy Families” are available to state residents that have a social security number and meet certain financial requirements.

Healthy Start

“Healthy Start” (also known as “SCHIP”) is available to uninsured children (19 and under) with household income up to 206% of the Federal Poverty Level (FPL). Applicants must  be a US citizen, permanent resident, or legal alien. Any person that has illegally entered the United States will not be eligible for benefits.

Pregnant women in families with income up to 200% of the FPL and covered children (19 and under) with household income up to 156% of the FPL also qualify.  There is no pre-existing condition clause, or waiting period for treatment, once enrolled in the program.  After becoming eligible for Medicaid, each child will have access to Healthchek, Ohio’s early and periodic screening, diagnosis and treatment program.

Comprehensive coverage is provided (including preventative benefits) along with other coverage, including  dental, ER, alcohol and drug addiction, family planning, hospitalization, Healthchek (see below), vision, transportation, mental health, pregnancy, transportation, prescriptions, and medical equipment.

Healthy Start Oho medical coverage

Affordable Quality Ohio Healthcare Is Available

Healthy Families

“Healthy Families” is offered to families, with a child under age 19,  that have income no higher than 90% of the Federal Poverty Level. Coverage is available to the adults, but not children. Applicants must be a US citizen and a legal resident of Ohio. There is no cost to enroll or secure coverage. Once approved for Medicaid, fee-for-service benefits begin, although you are required to re-apply every six months. Proof of US citizenship and income will be required.

Household income will be re-calculated every six months to ensure continued eligibility. Case workers should always be informed of changes that impact income or eligibility. Once approved, there is no waiting period before using services. A case worker will be assigned to provide assistance, and record changes that may impact eligibility.

Applying for coverage can be completed online by completing a CPA (Combined Programs Application). Phone assistance is also available. Covered benefits include Preventative healthcare, dental, vision,  ER, outpatient and inpatient hospital expenses, prescription drugs, pregnancy and prenatal care, drug and alcohol addiction, and HealthChek. Typically, a “managed care” plan must be chosen.  The four available options in Ohio are:

UnitedHealthcare Community Plan

Molina Healthcare


Buckeye Health Plan

Paramount Advantage


Healthchek” provides newborns, children, and young adults (through age 20) preventative, diagnosis and treatment services. Ten  checkups in the first two years along with follow-up annual checkups provide comprehensive healthcare. If additional treatment is required, Medicaid will pay for the expenses. NOTE: The program is also known as EPSDT (Early Periodic Screening, Diagnosis, and Treatment).

Each physical examination includes a medical history review, complete unclothed exam, vision and dental screening and other screenings and services, if recommended by the attending physician. Physical therapy benefits are actually more comprehensive than similar coverage offered to adults. Dental coverage is also more comprehensive than many plans offered to adults.

Other  services include hearing and immunization assessments and additional diagnosis and treatment if a potential health problem is discovered. Any necessary lab tests  and nutritional advice will also be provided. Additional  information can be found here. Note: Newborns should utilize all 10 exams before their third birthday. By age three, only one exam is generally required each year. Physicians that accept Medicaid for insurance reimbursement, can also be used for Healthchek exams. If you move to a different county, a Healthchek Coordinator should be notified.

How to apply for Medicaid in Ohio

Preventive Benefits Are Covered By Ohio Medicaid

Medicaid Covered Benefits

The list is long and comprehensive, but we have highlighted the major coverage below:

Mental Health And Illness – Crisis intervention, partial hospitalization, psychological testing, group and individual counseling, psychiatric diagnostic interview,  and pharmacological management.

Preventative Health – Immunization, mammogram,  OBGYN visit, routine annual physical, annual flu and pneumonia shots, chest x-ray, and prostate and cancer screenings.

Drug And Alcohol Addiction – Case management, methadone administration, intensive outpatient, crisis intervention, drug/alcohol screening and lab urinalyses, and Naltrexone injection.

Pregnancy, Maternity, And Delivery – Covered females can receive benefits on all deliveries, including C-Sections. Generally, a $0 copay applies. Common benefit services include preconception and prenatal care, amniocentesis, physical examinations, blood tests and urinalyses, medical history assessment, counseling, high-risk monitoring, transportation of mother, ultrasound, pain medication, and of course, the delivery.

ER Visits – Benefits are included although a low $3 copay may apply if treatment is not considered an emergency.

Medical Equipment – Approved durable equipment includes (but is not limited to) walkers, wheelchairs, speech-generating devices, hospital beds, crutches, canes, prosthetic devices, breast pumps, diabetic supplies, and oxygen supplies.

Dental – Checkups and cleanings are provided every six months for persons under age 21 and annually for adults. A $3 copay applies to adult visits. Braces and orthodontia often require prior approval. Dentures and partial plates also must be approved. Fillings, extractions, root canals, and crowns are often covered. level of benefits are often determined based on medical necessity.

Vision – Medical and surgical benefits are provided along with annual vision checkup with one pair of glasses (every two years for adults). Screenings for Glaucoma are also covered.

Additional  resources and initiatives include:

Balancing Incentive Program – Increased federal funding is utilized  to improve long-term care services. Disabled persons and Seniors can live in non-conventional residences, and learn more about available services.

Electronic Visit Verification – Provides verification  of services and the length of time they were performed. Private duty and home health nursing are included.

Payment Innovation – Quality of services rendered should be rewarded, as opposed to the volume of services provided.

MyCare Ohio  – See below.

Disability Determination Changes – Several administrative procedures that determine eligibility were combined into one process. Persons impacted include the blind, aged, or disabled. “Spending down” is not required, and more lower-income individuals can qualify for benefits.

Budget Cost-Containment – Limiting per-member cost increases to less than 3% is the ultimate goal.

Transition Of Home And Community-Based Services – HCBS must meet specific guidelines and provide protections to persons receiving benefits.

Persons Receiving Both Medicaid And Medicare Benefits

Managed care benefits are available through MyCare Ohio, who provides long-term, medical, and behavioral coverage. Enrollment is required if you live in a “demonstration” county, are 18 or older, and currently are receiving Medicare and Medicaid benefits. A plan will be chosen for you, if you do not select a choice. Written confirmation will be sent, with the your deadline for enrollment. Behavioral support and long-term care is also provided. Note: You can compare Medicare Supplement plans in Ohio, and customize benefits and cost. Many levels of prescription drug coverage can also be chosen.

MyCare began in 2014 and provides benefits in 29 counties for more than 100,000 persons. Medicare-eligible applicants can retain their existing coverage. A “care team” helps coordinate your treatment. Members of the team include your primary-care physician, specialists, family members, case managers, and other medical personnel. Generally, reviews of your overall health are conducted regularly, and all treatment (if needed) is discussed. This system simplifies and organizes your benefits, since you have one main point of contact, instead of several persons in different cities.

Long-Term Care

Disabled and older adults often need assistance with routine daily activities, such as eating, getting mail, taking baths or showers,  and preparing meals. LTC services help individuals and families enjoy a more routine and comfortable life, with Medicaid’s help. Specific services offered include private duty nursing (PDN), if the need is between 4 and 12 hours of continuous assistance. The personal-care physician (pcp) can help coordinate nurse’s care. Hospice services are also available for the terminally ill, and they can discontinue the benefits at any time.

Ohio State Student Health Insurance Plan Options – Compare OSU Rates

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As a condition for enrollment at Ohio State University (OSU), students are required to be covered under a qualified health insurance plan. This requirement applies to undergraduate students enrolled for six or more eligible credit hours (four or more eligible credit hours for graduate and professional students and three hours for post-candidacy students). You may choose to purchase private on and off-Marketplace coverage or the OSU option.

You can also be covered under a parent’s private or employer-provided plan until age 26. At that time, a “Special Enrollment” will allow you to select a Marketplace plan, regardless if the Open Enrollment period has ended.

All international students must also meet these requirements, and are automatically enrolled in the “comprehensive” plan. Also, auto-enrolled are students that study overseas, interns, and persons working on dissertations or a thesis. However, if alternative qualified coverage is in-force, a waiver will be granted. If no selection is made, the comprehensive plan will automatically be selected. Generally, you must select a choice about seven days before August Semester classes begin.

When registering for classes for the first calendar year term, the Buckeye Link will indicate the cost of coverage for the comprehensive plan option. That coverage can be kept, or waived, with proof of another qualified policy. If waived, a supplementary WilceCare policy (discussed in detail later) also becomes available. NOTE: The annual period of coverage is August to August as opposed to using the calendar year.

Qualifying Events

If you miss the Enrollment/Select/Waive period for changes to the comprehensive plan, a 31-day period is granted if you qualify for a “qualifying event,” and submit the appropriate form to SHI. However, any form received after that period will not be considered. Coverage can be requested to be added or terminated. Examples are listed below:

Death of spouse, child, or dependent

Dependent no longer eligible for other coverage because of age restriction

Adding a spouse because of marriage

Deleting a dependent because of divorce

Dependent becomes US citizen

Adding a newborn from legal adoption or delivery

Dependent leaves country to return home

Employment change leads to new healthcare eligibility

Domestic partnership is terminated


2018 Rates

OSU student health insurance rates for 2018 are listed below. These rates are “per semester” with the plan offered and underwritten by UnitedHealthcare, one of the nation’s largest healthcare providers. Details of the OSU student health insurance plan can be viewed through the provided link. NOTE: Although UHC has greatly reduced their presence on state and federal Exchanges, it does not impact the specific plans offered at OSU. All of the options below satisfy ACA (Affordable Care Act) requirements and regulations, and include “minimum essential requirements.”

(Paid TWICE per year)

Student –   $1,497

Student And Spouse –   $2,994

Student And Child – $2,994

Student And Spouse And  Child –   $4,491

Student And Two Or More Children –   $4,491

Student And Spouse And Two Or More Children –   $5,988

OSU Medical Center Serves Ohio State Students

Ohio State University Hospital Is One Of The Finest In The Midwest

Plan Overview

The policy provides comprehensive healthcare benefits, including coverage for office visits, prescriptions, Urgent Care and ER visits, major medical, mental illness, dental, and vision. If network facilities are utilized, maximum out-of-pocket expenses will be minimized. However, the UnitedHealthcare network is also available for off-campus treatment. Within the Franklin County PPO Network area, there are many available facilities. If purchased through the Federal Marketplace, the policy would closely resemble a Platinum-tier plan.  NOTE: Picture above is property of OSU.

Additional specific network highlights include a low $150 deductible and $2,700 maximum out-of-pocket costs (in-network treatment). Both primary-care physician (PCP) and specialist office visits  are subject to only a $20 copay with no limit on the number of covered visits. Also, no referrals are required. Vision and dental exams also feature the $15 copay.

“Tier 1” services are provided at the Wilce Student Health Center. By utilizing the facility, office visits, diagnostic lab tests and x-rays, allergy testing, treatment and injections, surgery, and outpatient procedures are covered at 100%. Also covered without any out-of-pocket expenses are durable medical equipment, and prosthetic devices.

The benefit package was recommended by the Student Health Insurance Advisory Committee and approved by the Board of Trustees.  Additional benefits include:

100% qualified preventative benefits with no out-of-pocket costs.

10% coinsurance for diagnostic tests (blood work and x-rays), MRIs, and PET/CT scans.

10% coinsurance for generic drugs, 20% for preferred brand drugs, and 50% for non-preferred brand drugs.

10% coinsurance for physician/surgeon and facility fees.

10% coinsurance and $100 copay for Emergency-Room visits.

10% coinsurance for hospice and rehabilitation services, skilled nursing care, and durable medical equipment.



Not all medical expenses are covered, regardless if treatment is performed in the Columbus area, or outside of Ohio. A partial listing of exclusions is listed below:

Experimental or unapproved surgery

Bariatric surgery

Cosmetic surgery

Hearing aids

Infertility treatment

Adult dental care

Weight loss programs

Long-term care

Foot care

If you receive treatment at the Wilce Student Health Center, usually there will be very little (or no) out-of-pocket cost. Qualified preventative expenses are covered with no out-of-pocket cost. This also applies to the UnitedHealthcare-provided benefits (Tiers 2 and 3). Common examples include: routine annual physicals, prostrate and testicular screening, breast cancer screening, well-visits, OBGYN exams, and colorectal cancer screening.

Ohio State University Student Health Insurance Options

The WilceCare Supplement covers diagnostic lab tests and X-rays.

WilceCare Supplement Plan Option

If you opt out of the “comprehensive” option, and choose to utilize your own private plan, depending on your deductible and network benefits, higher out-of-pocket expenses could result, depending on the number of submitted claims. The WilceCare option is a pre-paid coverage that provides benefits for common ailments (and injuries).  It is not a qualified insurance plan, and covered treatment must be provided at the Wilce Student Health Center during normal operating hours.

The two main components of the contract are prescription drugs and outpatient treatment. In-hospital expenses, or any services provided away from the Wilce Center are not covered.  The Buck ID is the only identification needed for treatment. Major highlights of the rider are listed below:

Annual cost is $225. Spouses and dependents are not eligible for coverage.

$2,000 is the maximum amount of benefits paid for the contract year. Prescription drugs have a separate maximum of $225.

Outpatient services include office visits, physical therapy, allergy injections, diagnostic services, including x-rays, lab tests, and electrocardiograms, and needed supplies.

Prescription drugs for conditions that are covered under the program. Coinsurance is 10% for generic drugs, 20% for brand name drugs (no possible generic substitute offered), and 50% for brand name drugs with generic substitute available. A $10 copay also applies, unless the cost of the prescription is less.


The following conditions and expenses are excluded:

Dental and vision treatment, including glasses, contact lenses, and hearing aids.

Non-prescribed medications (over-the counter) and contraceptives.

Preventative treatment. NOTE: These types of expenses are 100% covered under private and group plans.

Psychotherapy and psychiatry.

OSU Ohio Healthcare Plans

It’s Important To Properly Compare All Ohio Student Health Insurance Plan Options

Comparison Of OSU Student Plan To Available Private Plans

For our comparison, we are assuming the insured is a healthy 20 year-old  who lives in the Columbus area. It should be noted that rates vary, depending on where you live, your smoking status, and age. For this comparison, we did NOT include a federal subsidy, which can substantially lower premiums if you meet eligibility requirements. Listed below are some of the best plans to consider for student health coverage in Ohio. Rates are monthly:

$112 – CareSource Just4Me Bronze – $6,650 deductible with $40 and $80 copays on pcp (Primary-Care Physician) and specialist office visits respectively.

$132 – UnitedHealthcare Compass HSA 5500 – HSA-eligible plan with $5,500 deductible and $6,500 maximum out-of-pocket expenses.

$136 – Molina Marketplace Silver – $2,000 deductible with $20 and $55 office visit copays. The generic drug copay is $10.

$148 – Anthem Bronze Pathway X PPO 5000 30 – $5,000 deductible with pcp office visit of $55.

$173 – Molina Marketplace Gold – $500 deductible with $15 and $35 office visit copays. Maximum out-of-pocket expenses are $6,850.

$179 – UnitedHealthcare Gold Compass 0 – $0 deductible with $30 and $60 office visit copays. $6,850 maximum out-of-pocket expenses.

$185 – Anthem Silver Pathway X PPO 2000 20 – $2,000 deductible with $45 copay on pcp office visits.

$197 – Anthem Gold Pathway X HMO 1450 20 – $1,450 deductible with $30 and $50 office visit copays. )nly $3,100 for maximum out-of-pocket expenses.

$201 – Medical Mutual Market 1750 – $1,750 deductible with $30 and $60 office visit copays (with 25% coinsurance).

$245 – Market 1000 – $1,000 deductible with $25 and $50 office visit copays. Maximum out-of-pocket expenses are $6,500.

There are many affordable student health insurance options and it’s very possible one of the plans listed above may be worth considering. Our contact information is listed at the top of the page and we are always available to discuss the best choices.


We continue to be recognized as the premier resource for all student medical coverage. You can view additional details here and view quotes live online. Often, purchasing your own private coverage is much less expensive and many benefits will be much more comprehensive. However, each situation is different so we’ll be happy to provide our unbiased advice and input.

It is also important to note that we are not affiliated with the OSU student health insurance program. However, optional  coverage from many top-rated companies is very comprehensive, and rates are quite attractive. Specific questions regarding OSU student plan rates, coverage, eligibility requirements and enrollment details should be directed to this website.  However, we also encourage comparing rates from all of the available carriers, not just one. Our quote section at the top of the page will help.

Some Answers Questioned – Some Questions Answered

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I have many answers to questions, and many questions to answers. Here are a few of them and my apologies for straying off-topic for the first time. I think I’m allowed to do this once.

Kathleen Sebelius (Health & Human Services Secretary) said she was talking with the National Football League (NFL) about helping them promote the new healthcare legislation? Of course, we all knew the NFL would have no part of it. And why would they? Obamacare badly need the help of young healthy men, which happen to make up a large portion of NFL viewership.

Not surprisingly, the NFL released a statement directly contradicting Sebelius, saying they had no interest in promoting the legislation, and were never had any discussions regarding the matter.


Corn on the cob  is ridiculously cheap. At about 10-15 cents per ear, it has to be one of the great bargains in food. If it were healthy enough to eat all of the time…imagine your grocery bill. About $1 per day. Then again, I love Chinese food too much to try the corn experiment. I could easily eat Garlic Chicken every day.


Kings Island, Hershey Park, Disney World and Disneyland. I have been to all of them. Guess which one I prefer? OK, it is true that Kings Island is only 25 minutes away, but if you live within five hours of Mason (Ohio), start planning your trip there.

Some of the newer attractions include the world’s largest animatronic dinosaur, Reds Hall Of Fame Restaurant, and Charlie Brown’s Jungle Journey. Admittedly, our teenagers enjoy the park more than we do, but you could easily spend a few days between the main park and the water park. And, you’re just 25 minutes from Cincinnati, where there are many other activities that the entire family could enjoy.


Best Rides In Ohio

What A Beast!

Fantasy Football season is almost here. NFL training camp begins in July, the first pre-season games are in August, and the regular-season games begin in September. Drafts are typically held in late August so the research and information-gathering will shortly begin.

For many males, it’s the time of the year, where nothing else matters. Work, eating, vacation and other daily necessities suddenly no longer matter. For non-playing family members, it’s a time to put up with random questions, such as “Honey…Do you think the Broncos will have a running back by committee this year?”

And when the three-hour draft begins…Don’t bother us, unless the house is on fire. Of course, we will still make our selection and grab our laptop before we exit the house.


Ohio State University is a phenomenal college. I never admitted it until we visited the campus with our daughter last year. She was a high-school junior and everybody (including her) thought she was headed to Miami (University) in Oxford. And why not? It’s my Alma mater and I still love the college.

But admittedly, Ohio State was incredibly impressive. And it is indeed a big place. But whether you like academics, athletics, the campus, or many other considerations, it’s hard to say no, once you have visited OSU. I may not root for the Buckeyes when they play Miami in hockey, but other than that, I’m officially a Bucknut.


OSU Football Winning Tradition

The Ohio State University

I love golf. However, if anybody reads the “About Me” in my websites and blogs, you may notice a reference to my “One Of  The 10 Worst Golfers On Campus” award I won in college. Well…I’m still awful, probably because I rarely play. I have been an avid tennis player for my entire life and it’s difficult to break old habits.

But I am committed (somewhat) to  becoming a good golfer. I suppose I need to practice more than the current one bucket of balls every other month.  It’s a shame there isn’t a virtual online training session that could knock 20 strokes off my score after an hour of viewing.


Vision Insurance. If you have it, keep it. If you don’t own this type of coverage, you may not be missing anything. Most policies cost about $100-$300 per year. The value of the benefits you receive are ironically…about $100-$300 per year. That’s right. A wash. Typically, you get a copay on a yearly preventive exam and perhaps some additional benefits for a frame of glasses every few years.

But many persons choose to simply find seasonal deals for a package that includes an office visit plus frames or contact lenses. Also, Sears, Penneys, Sam’s Warehouse and Costco often offer good prices, flexible hours and licensed Ophthalmologists. A typical exam is inexpensive, and you can choose to buy your glasses at the conclusion of the exam, or order online from several reputable options.


That’s enough rambling for now. Back to writing about healthcare, which, although is not quite as fun, is still very challenging since it is constantly changing.

Paul Ryan, Ohio Health Insurance Exchange And Miami University

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Paul Ryan, the Ohio Health Insurance Exchange and Miami University. What could they possibly have in common and why am I writing about it? I have to admit…the title is a bit odd, but I know a little bit about all three.

Of course, Paul Ryan is Mitt Romney’s running mate and nominee for Vice President of the US. And he also just happens to be a 1992 Miami University graduate with degrees in economics and political science. Long-time economics professor Richard Hart was one of his mentors while there.

As a 1980 graduate of Miami, I also was a business major although I don’t remember Professor Hart. But I did take many of the same classes as Ryan, and perhaps was taught by a few of the same professors. And I assume we took classes in many of the same buildings. But I have a feeling that he spent more time at the library than I did.

I ate many of these at Miami. Too many!

I am certain that Representative Ryan and I have crossed many of the same paths while at Oxford. Of course the “Bagel & Deli” shop is where Ryan stopped to eat on August 15th. I remember the place well, having ordered there about five times per week during my Miami stay. Delivery is a great feature about college eateries. Although I was not in a fraternity  and never drove the “Wienermobile”  as Paul did ( while he worked summers for Oscar Mayer), the memories we both share of Mother Miami are still quite fresh.

The Exchange?

By now, you may be wondering how the proposed Ohio Health Insurance Exchange fits in this discussion. Under existing legislation, the way you buy your health insurance will change in 2014. Currently, you can pick and choose among hundreds of available plans from more than a dozen reputable companies. You can pick and choose the benefits that YOU want and often exclude coverage you don’t need. You can apply for a policy at any time, and cancel your contract without worrying about non-compliance.

For example, if you’re in your 50s and simply don’t want to pay for maternity benefits, since it’s unlikely you’ll utilize it, you can pick plans that don’t charge you for that rider. Or, if you have been reasonably healthy and prefer to cover large medical claims instead of paying for office visit coverage you never use, you can choose a high-deductible catastrophic plan.  Do you want a $10,000 deductible? No problem. Do you prefer a cheap Ohio temporary health insurance plan that costs less than $50 per month? Consider it done!

In 2014, It All Changes

But in 2014, your choices will be drastically cut and you will be forced to pay for coverage you may not need or want. You’ll have to choose between a Platinum, Gold, Silver or Bronze plan. That’s it. Maternity and other benefits you may not want will be required on all policies. And yes, you’ll pay for that. Although tax incentives may help, premiums will go up and the number of providing physicians will probably decrease.

By now, everyone knows that Paul Ryan is one of the leading proponents of changing and improving our health insurance system, but in a much more cost-effective and consumer-friendly way than the current proposed changes. His ideology will reward healthy persons with personal health saving accounts that accumulate funds if you don’t use it. And unhealthy persons will be able to afford to purchase quality health care through the top health insurers.

Regardless of who wins the election, I do know this. Paul Ryan will be a major contributor to lowering our national budget, Miami University will still attract the brightest high school students, and I’ll continue to eat bagels. As for health insurance in Ohio,  you can count one one thing. You will continue to view the lowest rates on our website. You can buy direct, or with our help. And if you’re in the area, we’ll recommend a good bagel place as well!

Will Medical Insurance Increase For Having Too Many Claims?

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The more claims you submit on your medical insurance, the higher your rate will become. Is that true here in Ohio? Well, not really. Whether you have an incredibly healthy year or just one of those years when you and other family members caught the flu six times, it will not make a significant difference in your healthcare premium. The price you pay is determined by your age, where you live, the type of plan, the carrier, your smoking status, and the amount of your federal subsidy (if applicable).

I realize many Ohioans may not be aware of this. You’re probably used to your auto insurance tripling after three or four accidents in the last three years. Or perhaps your homeowner’s policy was canceled after two roof claims and a hailstorm that ruined your shed. But healthcare is different now, compared to prior when Marketplace options were not available.

Fewer Claims Probably Means You Have No Major Medical Conditions

Of course you want to have very few claims each year since the result is that you and other family members were healthy. And presumably, other than your premium, very little copays, deductibles or coinsurance were paid. It also means that if you had an active Ohio Health Savings Account (HSA), more of your contributions stayed in your account, instead of being disbursed for qualified expenses. The unused funds can continue to accumulate and be utilized in the future for any family member listed on the policy.

However, to the surprise of many Buckeye State residents, generally, your medical insurance rate does not necessarily increase based on the volume of claims you submit. For example, if during the calendar year, you have numerous surgeries, along with many prescriptions and specialist office visits that total more than $100,000, your insurer is not going to attempt to “recoup their losses” by doubling or tripling your rate. Of course, if a significant number of individuals and families submit catastrophic medical claims with the same carrier, prices will be impacted.

Why Do Rates Increase?

Health insurance rates do increase just about every year. But the real cause of your premium going up may not be you. Here’s how it works: When you originally bought your medical insurance plan, you were “clumped” together with similar persons that purchased that same type of policy at the same time. Thus, if you purchased your coverage in March of 2016, you are unlikely to be placed in the same group of persons that bought their policy in June of 2013.

Very extensive statistics are kept on the block of business for your specific plan. Over time, some policyholders will cancel, others will renew, and some will add or subtract dependents. And of course, there will be families that have very few claims and others with huge claims each year. The process of submitting a health insurance claim is typically the same, regardless of the dollar amount involved.

Typically, those insureds in very good or excellent health will tend to shop around for better rates within a few years and many will cancel their coverage and start a policy with a different company. For example, a person may purchase a policy with Humana. And after three years of rate increases, they buy a similar plan from Medical Mutual and reduce their premium by 20%. Does this sound familiar? That’s why it pays to shop every 3-5 years (although there are other considerations).

Let’s take this a step further. Let’s say you have a block of 10,000 males in their mid-40s that bought the same type of Ohio medical insurance policy in a given year. Five years later, 2,000 of the healthiest policyholders switch to a different company to get a better rate. Now, you have a block of business of 8,000 persons and the percentage of claims paid per premium has jumped. So guess what else must jump? That’s right…the rate.

And so eventually, you may have a block of business that consists of even more unhealthy persons submitting multiple claims and far fewer extremely healthy people submitting very few claims. If you’re uninsurable, you may be stuck. If you are reasonably healthy, you can find an alternative.

So…although your own claim history won’t alter rates, collectively, many policyholders can.    Should you now shop for new health care coverage every year? Every six months? The answer is no. But if you notice that your premiums are constantly increasing by larger amounts each year, then contact us and we’ll review your current policy and determine if there are better options for you.