Rotarian Pam Nelson spoke about her career and informed Rotarians about options and changes coming in the near future during a recent luncheon gathering at Mountain View Inn.
“Health insurance is scary for a lot of people,” she said, a fact she has learned from her extensive experience in the field. “I have been in the health insurance industry for almost 30 years.”
She said many people who have always been a part of a group or company plan are unsure how to buy insurance when they have to get an individual plan.
“A lot of it depends on how healthy you are or how unhealthy you might be,” Nelson said.
What kind of plan you have determines which doctors and hospitals you are covered under, Nelson said.
Different kinds of plans have different policies about seeing out-of-network doctors. For example, an HMO will only cover a non-network doctor or hospital in a life-threatening situation.
Changes made by the federal government have also affected the health insurance industry, according to Nelson.
Medicare was a major part of her discussion.
Nelson said Medicare can offer good coverage, especially when combined with a supplemental plan. Advantage plans have become a widely advertised choice within Medicare.
She said many advertise zero premiums which lead to a lot of questions. She reminded her audience that usually “you get what you pay for.”
Advertisements do not give all the details, Nelson pointed out.
Insurance fraud is also something consumers in this market need to be aware of.
Prescription plans under Medicare create a “donut hole effect,” Nelson said.
The plans merely require a co-pay up to $2,930 of prescription payments, then prescription coverage stops.
“That coverage doesn’t start back up again until you’ve got about $4,200 worth of insurance claims. So you have coverage and then you don’t have coverage, then you have it again,” Nelson said. “So, that is the donut hole.”
“Right now there are 50 million people on Medicare,” Nelson said. “10,000 people a day are becoming eligible.”
If changes are not made, Medicare will be unable to cover those who qualify by the year 2024.
Nelson said changes will be made.
Changes are also anticipated in health insurance as a whole. Nelson said she is a member of a committee to form a health care exchange in Tennessee.
If the health care reforms go into effect, Tennessee will have its own exchange rather than having the federal government handle it.
“The exchange basically is a place ... is where you will be able to go to buy health insurance, either on an individual basis or for a small business,” Nelson said.
Small businesses will be defined as those with less than 100 employees or those with less than 50 employees.
An exact definition has not been chosen, according to Nelson.
The Supreme Court will make a decision on whether the current health care reforms proposed are legal.
During her talk, Nelson also spoke about how many of the people who were fellow Rotarians had been an important part of her life when she was starting and choosing a career in sales.
“When I first joined Rotary it meant a lot to me to see these faces again that I don’t see very often,” Nelson said.