Tag Archives: Health insurance

Caught in the Middle: The Growing Health Insurance Squeeze Facing Texans (Why 2027 May Be a Difficult Year for Middle-Income Americans Who Buy Their Own Health Insurance)

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By D Kenton Henry, editor, agent, broker

For all my three and a half decades as an independent health insurance agent, I have worked with people who don’t fit neatly into the health insurance system.

They may be self-employed. They may own a small business. They may work for an employer that doesn’t provide health insurance. Some have retired before becoming eligible for Medicare at age 65.

They aren’t poor enough to qualify for Medicaid. They don’t have an employer paying most of their health insurance costs. And they certainly aren’t wealthy.

They are simply caught in the middle.

As we prepare for the 2027 Affordable Care Act (ACA) Individual and Family Health Insurance Open Enrollment Period, I am increasingly concerned about this group.

Health insurance premiums are rising. The enhanced federal premium subsidies that temporarily made coverage much more affordable expired at the end of 2025. And there are signs that healthier people—particularly younger people—are increasingly deciding they simply cannot justify the cost of coverage.

Unfortunately, that can make health insurance more expensive for everyone who remains.

First, What Happened to the ACA Subsidies?

The Affordable Care Act has provided premium tax credits to eligible individuals and families who purchase health insurance through the federal Marketplace since its major coverage provisions took effect in 2014.

During the COVID era, Congress substantially increased those subsidies.

The American Rescue Plan of 2021 increased the amount of financial assistance available and eliminated the ACA’s previous income ceiling of 400% of the Federal Poverty Level for receiving premium assistance. The Inflation Reduction Act subsequently extended those enhanced subsidies through 2025.

The result was dramatic.

Millions of Americans who previously received little or no assistance suddenly qualified for significant help paying their premiums. Marketplace enrollment soared.

But those enhanced subsidies expired at the end of 2025.

The original ACA premium tax credits did not disappear. Eligible consumers can still receive substantial assistance.

What disappeared was the additional assistance provided under the temporary enhanced subsidy program.

And for many middle-income Americans, that distinction is enormous.

The Return of the “Subsidy Cliff”

One of the most significant consequences is the return of what has commonly been called the ACA subsidy cliff.

Under the temporary enhanced subsidies, people earning more than 400% of the Federal Poverty Level could still receive assistance if the cost of the benchmark health insurance plan represented too large a percentage of their household income.

Beginning in 2026, that protection disappeared.

For 2026 coverage, 400% of the Federal Poverty Level is approximately $62,600 for a single person. Someone whose income exceeds the applicable limit can find himself or herself responsible for the entire health insurance premium.

That can be particularly painful for someone in his or her late 50s or early 60s because ACA premiums are age-rated.

Imagine being 62 years old, self-employed, earning too much to qualify for a subsidy—but still several years away from Medicare.

You may be doing reasonably well financially.

But you may suddenly be staring at a health insurance premium that looks more like another mortgage payment.

That is the population I mean when I say caught in the middle.

We Are Already Seeing People Walk Away

This isn’t merely a prediction about what might happen.

We are beginning to see it.

Nationally, average monthly Marketplace premium payments after tax credits increased approximately 58% from 2025 to 2026.

People responded in several ways.

Some moved to less expensive plans with higher deductibles.

Some dropped their coverage.

And some selected coverage during Open Enrollment but apparently decided they couldn’t afford to actually put it into effect or keep paying for it.

Texas provides a particularly interesting example.

Approximately 206,000 more Texans selected an ACA Marketplace plan for 2026 than had selected one for 2025—an increase of about 5%.

At first glance, that sounded like great news.

But selecting a plan and actually paying for it are two different things.

When federal researchers subsequently looked at people who had actually effectuated their coverage—generally by paying their premiums—Texas enrollment had fallen by approximately 146,000 people, or about 4%, compared with the previous year.

In other words, Texas had hundreds of thousands more people sign up, yet ultimately had fewer people maintaining coverage.

That should tell us something about affordability.

And Who Is Most Likely to Leave?

This is where the situation becomes troublesome for the health insurance market itself.

Health insurance works because we pool risk.

Some insured members become seriously ill and incur hundreds of thousands of dollars in claims.

Others may go an entire year without doing much more than getting an annual physical.

The premiums paid by everyone help finance the medical expenses of those who need substantial care.

But what happens when insurance becomes so expensive that people begin asking themselves:

“Do I really need this?”

A healthy 28-year-old may decide to take the gamble.

A 58-year-old cancer survivor probably won’t.

Neither will someone with diabetes, heart disease, multiple sclerosis or another serious chronic condition requiring ongoing treatment and expensive prescription medications.

Those people know they need insurance.

This creates what insurers call adverse selection: healthier people disproportionately leave the insurance pool while people who know they will incur substantial medical expenses do everything possible to maintain coverage.

We are already seeing evidence of it.

Marketplace enrollment among Americans ages 18 through 34 fell by approximately 542,000 people—or 8%—for 2026. That relatively young group accounted for approximately 46% of the entire decline in Marketplace plan selections.

Meanwhile, people with incomes just above the returning subsidy cliff were hit especially hard.

Consumers with known incomes above the subsidy cutoff represented only about 7% of Marketplace enrollment in 2025 but accounted for nearly half—48%—of the decline in plan selections for 2026.

That is almost a textbook illustration of the problem.

Why Does That Affect My Premium?

Insurance companies don’t establish premiums based solely upon what they spent last year.

They have to estimate what the people they expect to insure next year are going to cost.

If relatively healthy people leave while people with serious health conditions remain, the average expected medical cost per insured member increases.

The insurance company has to price for it.

According to KFF’s analysis of insurer rate filings, insurers estimate that deterioration in the health of the individual-market risk pool added approximately four percentage points to 2026 premiums and could add approximately another four percentage points in 2027.

That isn’t the only reason premiums are rising.

Far from it.

Hospitals cost more. Physicians cost more. Labor costs more. Prescription drugs—particularly specialty medications—can be extraordinarily expensive. Insurers estimate that underlying medical and prescription drug costs alone are increasing by approximately 10% for 2027.

But losing healthier members from the insurance pool only makes matters worse.

What Are Texas Insurance Companies Predicting for 2027?

We now have preliminary indications.

Texas insurers have submitted their proposed 2027 individual-market rates, and many are requesting substantial increases.

Among the proposed average increases currently filed are approximately:

Blue Cross and Blue Shield of Texas — 8.9%

Superior HealthPlan/Ambetter — 11.1%

Molina Healthcare of Texas — 13.0%

Wellpoint — 15.3%

Community Health Choice — 27.2%

UnitedHealthcare — approximately 27% to 34%, depending upon the underwriting entity

Other Texas insurers have filed increases both above and below those figures.

These are proposed average rate increases—not necessarily the final rates consumers will pay in 2027. Regulators review the filings; rates can change before approval, and an individual person’s premium will depend upon age, county, tobacco use, family composition, plan selection, and eligibility for a premium tax credit.

Nevertheless, the trend is difficult to ignore.

Nationally, insurers are currently requesting a median ACA Marketplace premium increase of approximately 15% for 2027, following a finalized median increase of approximately 20% for 2026.

Two consecutive years of increases of that magnitude inevitably put pressure on people purchasing their own insurance.

People Are Buying Less Insurance to Keep Some Insurance

There is another revealing statistic.

As premiums increased for 2026, consumers migrated dramatically toward Bronze plans.

Bronze plans generally offer lower monthly premiums in exchange for substantially greater out-of-pocket exposure when medical care is needed.

The percentage of Marketplace consumers selecting Bronze plans jumped from 30% in 2025 to 40% in 2026.

At the same time, the average Marketplace deductible increased from approximately $2,759 to $3,786 per person—a 37% increase in a single year.

That doesn’t necessarily mean the insurance company dramatically increased the deductible on the same policy.

Much of the increase occurred because consumers themselves moved into higher-deductible plans in an effort to reduce their monthly premiums.

In plain English:

People are buying less insurance in order to afford to remain insured.

Medicaid Is No Longer Catching as Many People Either

There is another part of this story.

During the COVID public health emergency, states generally were required to maintain continuous Medicaid enrollment as a condition of receiving enhanced federal funding.

That requirement eventually ended.

States resumed reviewing Medicaid eligibility, and more than 25 million people nationwide were subsequently disenrolled from Medicaid or CHIP during what became known as the Medicaid “unwinding.”

Some remained eligible and lost coverage for procedural or paperwork reasons. Others legitimately no longer met Medicaid’s income or other eligibility requirements.

For those who don’t have employer coverage, that frequently leaves the ACA individual market as their principal alternative.

And once again we arrive at the same group:

Too much income for Medicaid.

No employer health plan.

Too young for Medicare.

And increasingly concerned about whether they can afford individual health insurance.

So What Does This Mean for Texans Shopping for 2027 Coverage?

It does not mean you should assume you can’t afford health insurance.

And it certainly doesn’t mean you should automatically renew whatever policy you have now.

The original Affordable Care Act premium tax credits still exist. Many Texans will continue to qualify for substantial assistance in 2027.

Texas also has some characteristics in its Marketplace pricing that have helped many subsidy-eligible consumers obtain relatively inexpensive Bronze—and sometimes Gold—coverage.

But your eligibility for assistance depends upon your household income and circumstances.

And the insurance company that was the best choice for you in 2026 may not be the best choice in 2027.

Premiums change.

Provider networks change.

Prescription formularies change.

Deductibles and copayments change.

And your own income and health care needs may have changed.

That makes comparison shopping particularly important this year.

Don’t Shop for Health Insurance on Premium Alone

I have been an agent since 1986 and an independent health insurance agent since 1991.

One lesson I’ve learned repeatedly is that the cheapest policy isn’t necessarily the least expensive policy to own.

A low premium doesn’t help much if your physicians aren’t in the network.

A low premium may not be much of a bargain if an important prescription isn’t covered.

And saving $100 per month can become an expensive decision if it means accepting several thousand dollars of additional exposure when you actually need medical care.

For 2027, many individuals and families may have to make some uncomfortable compromises.

The objective is not necessarily to find the policy with the lowest premium or the richest benefits.

It is to find the best balance among:

Premium.

Deductible and maximum out-of-pocket exposure.

Physician and hospital network.

Prescription drug coverage.

And the financial protection your family can realistically afford.

For people caught in the middle, that balancing act may be more important in 2027 than it has been in many years.

But those people shouldn’t simply give up.

They should shop carefully, understand what financial assistance is available to them, understand what they are buying—and make the most informed decision their circumstances allow.

That’s what Open Enrollment is for.

The 2027 Affordable Care and Patient Protection Act (ACA) Open Enrollment Period begins November 1 and runs through December 15th for a January 1 effective date. If you have not bound or changed coverage by then you have through January 15th to apply for a February 1 effective date. After January 15th (aside from qualifying for a Special Enrollment Period) you will be locked into any health plan you may have—or locked out of health insurance altogether for the remainder of the calendar year if enrolled in no health insurance plan.

I would appreciate the opportunity to be your agent and an advocate on your behalf. Please call me. I charge no fee, and you are under no obligation. Whether you qualify for a subsidy or not—or just want to find out—you will have access to virtually every health insurance option available to an individual or family in your zip code and county at no additional cost.

D Kenton Henry
Office: 281-367-6565
Text my cell 24/7 @713-907-7984
Email: Allplanhealthinsurance.com@gmail.com

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Medicare Advantage and the Choice Between It and Medicare Supplement (Changes Are on the Horizon)

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By D Kenton Henry, editor of HealthandMedicareInsurance.com, agent, and Independent Insurance Broker

When most people compare Medicare Advantage plans, they focus on premiums, dental benefits, vision coverage, hearing aids, grocery cards, or over-the-counter allowances.

Those benefits certainly have value. However, after nearly four decades in the health insurance business, I have found that the biggest differences between Medicare Advantage and Medicare Supplement plans often become apparent only when a beneficiary actually needs medical care.

As Medicare Advantage enrollment continues to grow and healthcare costs continue to rise, provider networks and prior authorization requirements are becoming increasingly important issues for Medicare beneficiaries.

Provider Networks Continue to Change

One of the primary advantages of a Medicare Supplement policy is flexibility.

Generally speaking, a Medicare Supplement policyholder may receive treatment from any physician or hospital in the United States that accepts Medicare patients.

Medicare Advantage plans operate differently.

Most Medicare Advantage plans utilize provider networks. Those networks may change from year to year as insurance companies renegotiate contracts with physicians, specialists, hospitals, and healthcare systems.

A doctor who participates this year may not participate next year.

A hospital system that is in-network today could become out-of-network in the future.

For beneficiaries who travel frequently, maintain residences in multiple states, or simply want maximum freedom in choosing healthcare providers, network changes can sometimes create unexpected challenges.

Prior Authorization Remains a Concern

Another issue receiving increased attention is prior authorization.

Many Medicare Advantage plans require advance approval before certain services are performed. These may include:

  • MRI scans
  • CT scans
  • Physical therapy
  • Skilled nursing facility care
  • Certain surgical procedures
  • Some specialty medications

The concern is not always whether a service is ultimately approved.

Rather, the concern is that treatment may be delayed while additional documentation is gathered and reviewed.

Physicians across the country have frequently expressed frustration regarding the administrative burden associated with prior authorization requirements.

By contrast, beneficiaries covered under Original Medicare with a Medicare Supplement policy generally encounter fewer authorization hurdles because Medicare itself determines coverage.

An Aging Population Means More Healthcare Utilization

The first wave of Baby Boomers entered Medicare in 2011.

Every year, Medicare beneficiaries grow older, utilize more healthcare services, and gain access to increasingly sophisticated—and expensive—medical treatments.

Insurance companies face growing pressure to control costs while keeping premiums competitive.

Common tools used to manage those costs include:

  • Narrower provider networks
  • Increased care management programs
  • Expanded prior authorization requirements
  • More intensive utilization review

These trends are unlikely to disappear anytime soon.

Rural Beneficiaries May Face Additional Challenges

Provider access can be especially important for beneficiaries living outside major metropolitan areas.

While beneficiaries in cities such as Houston, Dallas, Austin, or San Antonio may have numerous participating providers available, individuals living in smaller communities may have fewer options.

When specialty care is needed, network limitations can sometimes require additional travel or create fewer choices regarding where treatment is received.

A Medicare Supplement policy largely eliminates those concerns because coverage follows Medicare rather than a specific provider network.

The Hidden Value of Medicare Supplement Coverage

Consumers naturally focus on premium.

Insurance professionals often focus on risk and long-term flexibility.

When affordable, Medicare Supplement plans provide several advantages:

Predictability

  • Generally lower out-of-pocket exposure
  • Fewer surprise medical bills
  • Greater budgeting certainty

Provider Freedom

  • No network restrictions
  • No referrals required
  • Coverage that travels with you throughout the United States

Administrative Simplicity

  • Fewer authorization requirements
  • Less paperwork
  • Fewer coverage-related obstacles when seeking care

Medicare Advantage Still Has an Important Role

None of this means Medicare Advantage is a poor choice.

For many beneficiaries:

  • Monthly budgets are limited.
  • Medicare Supplement premiums may be unaffordable.
  • Health conditions may make medical underwriting difficult or impossible.

In those situations, Medicare Advantage plans can provide valuable protection at little or no additional premium.

The key is understanding the tradeoff.

Medicare Supplement

  • Higher monthly premium
  • Broad provider access
  • Minimal prior authorization concerns
  • Predictable healthcare costs
    With certain Medicare Supplement Plans (F and G) out-of-pocket costs–with the exception of RX drugs at the pharmacy counter–can be a little as $0 to Medicare’s current Part B out-patient calendare year deductible of $282

Medicare Advantage

  • Lower monthly premium
  • Network restrictions may apply
  • Prior authorization requirements are more common
  • Cost-sharing occurs as healthcare services are utilized
    If using an MAPD PPO and going both in and outside the network in 2026 your out-of-pocket maximum expenses can be over $13,000 with certain plans

Final Thoughts

As healthcare continues to evolve, I believe annual reviews are becoming more important than ever.

The Medicare Advantage plan that works well today may not be identical next year. Networks change. Benefits change. Drug formularies change.

For beneficiaries who can comfortably afford the premium and qualify for coverage, Medicare Supplement insurance continues to offer the broadest provider access, the greatest flexibility, and the fewest obstacles to receiving care.

As always, each individual’s circumstances are different. If you have questions about your Medicare coverage options, I encourage you to contact me for a personalized review.

D Kenton Henry
Independent Medicare Insurance Broker Since 1986


Office: 281-367-6565
Text my cell 24/7 @ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com

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Changes May Be Coming to ACA Individual & Family Health Insurance Plans in 2027

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By D Kenton Henry, editor HealthandMedicareInsurance.com, agent, broker

The Affordable Care Act Marketplace continues to change, and 2027 may bring several important updates for individuals and families who buy their own health insurance.

Some of the most important changes on the horizon include:

1. More income verification
Marketplace applicants may face stricter income documentation requirements, especially when tax records do not match the income reported on the application.

2. More oversight of agents and brokers
Federal rules are tightening around marketing, consumer consent, and application review documentation. This is intended to reduce unauthorized enrollments and misleading advertising.

3. Fewer standardized plan requirements
Insurers may have more flexibility in how they design plans. This could mean more plan choices, but it may also make plan comparisons more complicated.

4. New flexibility for Bronze and Catastrophic plans
Some lower-premium plans may become more flexible, but lower premiums often come with higher deductibles and greater out-of-pocket exposure.

5. Possible non-network plan designs
Beginning in 2028, some Marketplace plans may be allowed without traditional provider networks if they meet access standards. These could work differently from the PPO, HMO, and EPO designs consumers are used to.

6. Premium tax credit changes remain a major issue
The enhanced ACA premium tax credits that made coverage more affordable expired at the end of 2025. Unless Congress acts in the future, many people may continue to see higher premiums than they paid during the enhanced subsidy years.

What should consumers do?

Do not assume your 2027 plan, subsidy, doctor network, deductible, or drug coverage will remain the same. Before renewing, review your options carefully. A lower premium may look attractive, but the deductible, copays, provider access, and prescription coverage may differ significantly.*

As always, I will monitor these changes and help clients compare their options when 2027 plans become available. In the meantime, please follow me on my blog: HealthandMedicareInsurance.com or call or text me for a personal conversation and an opportunity to ask all your questions for no fee or obligation.

D Kenton Henry

Office: 281-367-6565
Text my cell phone 24/7 @ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com
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*Sources:
Main sources: CMS finalized the 2027 Payment Notice on May 15, 2026, effective July 20, 2026, covering broker rules, income verification, standardized plan changes, Bronze/Catastrophic flexibility, and future non-network QHP certification. KFF notes the enhanced premium tax credits expired at the end of 2025 and many Marketplace enrollees now receive less help or none above the prior income limits.

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DENTAL INSURANCE – IS IT REALLY WORTH WHAT I PAY FOR IT OR JUST A TIME PAYMENT PLAN?

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By D. Kenton Henry – editor, agent, broker

Dental Insurance: Worth the Premium — or Just a Payment Plan?

“Is dental insurance really worth what I pay for it?”

That’s a question I hear often—and it’s usually followed by:

“Or am I just spreading the cost of my dental work over time?”

My answer?
It depends—but it doesn’t have to be a losing proposition.

Employer vs. Individual Coverage

If you receive dental insurance through an employer, part (or all) of your premium is subsidized. That makes the value proposition much more favorable.

However, if you are:

  • Self-employed
  • Retired
  • Or purchasing coverage on your own

…then you’re paying the full premium—and the math becomes more important.

Without the right strategy, dental insurance can become nothing more than a time-payment plan. Worse yet, you could end up paying more in premiums than you ever receive in benefits.

The Reality of Dental Costs

Let’s be honest—dental work is expensive.

A single dental implant can cost anywhere from $3,500 to $7,000. And unlike medical insurance, dental plans come with strict limitations.

Before choosing a plan, there are three key concepts you need to understand:

1. “Reasonable and Customary” Limits

No insurance company pays unlimited fees.

Instead, they base payments on what is considered “reasonable and customary” for your geographic area.

  • A crown in Beverly Hills will cost more than one in Brenham, Texas
  • If a dentist charges above the accepted range, you pay the difference

Understanding this concept is critical to avoiding unexpected costs.

2. Network vs. Non-Network Plans

Dental plans fall into two categories:

Network Plans (Recommended)

  • PPO (DPPO): Flexibility to go out-of-network (at higher cost)
  • HMO (DHMO): Must stay in-network for coverage

These plans offer lower negotiated fees because dentists agree to discounted rates.

Non-Network Plans

  • “Any dentist” plans
  • Typically higher premiums
  • Often result in higher out-of-pocket costs

Why? Because dentists are free to charge above what the insurance company considers reasonable—and you’re responsible for the difference.

3. The Most Important Rule: Avoid Excess Charges

Here’s where many people get burned:

  • With a non-network plan, you can be billed above what insurance pays
  • With a network plan, dentists must write off excess charges

That means:

If your share is 20% or 50%—that’s all you pay. No surprises.

Finding the Right Dentist (and Plan)

As an individual, you don’t have the bargaining power of a large employer.

So how do you gain access to lower fees and quality care?

You choose an insurance company that:

  • Has a large, reputable network
  • Pays claims promptly and reliably
  • Attracts high-quality dentists

Then you select a dentist based on:

  • Credentials
  • Technology used
  • Patient reviews
  • Location and convenience

Understanding Benefit Limits

Dental insurance is not unlimited coverage.

Typical plans:

  • Cover $1,000–$1,500 per year
  • Higher-end plans may go up to $5,000 annually
  • Often include waiting periods for major work

A smarter strategy is to choose a plan that:

  • Starts affordable
  • Increases benefits over time
  • Aligns with your expected dental needs

A Real-World Strategy (From Experience)

After decades in the business—and personal experience with extensive dental work—I approached my own coverage strategically.

I selected:

  • A financially strong insurance company
  • A plan that started at $1,500, then increased to $2,500, and ultimately $5,000 annually
  • A highly qualified dentist within the network

This allowed me to:

  • Stage treatment over time
  • Maximize benefits
  • Avoid excessive out-of-pocket costs

Bottom Line: How to Make Dental Insurance Work

To get real value from dental insurance:

✔ Choose a network plan

✔ Match benefits to your expected needs

✔ Select a skilled, in-network dentist

✔ Work with a knowledgeable advisor

How I Can Help

With over 30 years of experience in health, Medicare, and dental insurance, I help clients:

  • Compare plans from top-rated carriers
  • Avoid costly mistakes
  • Maximize benefits relative to premium

I represent companies such as:
Aetna, Ameritas, Anthem, Blue Cross Blue Shield, Cigna, Delta Dental, Humana, and UnitedHealthcare.

Let’s Talk

If you’re considering dental coverage—or wondering if your current plan is worth it—I’d be happy to help.

D.Kenton Henry

TheWoodlandsTXHealthInsurance.com
📞 281-367-6565
Text my cell 24/7 @ 713-907-7984

Final Thought

Dental insurance can either be:

  • A smart financial tool
    or
  • An expensive payment plan

The difference lies in how you choose—and how you use—it.

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News Flash: Indiana Medicare Supplement “Birthday Rule” Expanded! (Good news for Hoosier Medicare Supplement policyholders)

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By D. Kenton Henry – editor, agent, broker
12 March 2026

Good news for Indiana Medicare Supplement policyholders.

A recent update to Indiana’s new Medicare Supplement Birthday Rule has expanded the period during which eligible individuals may change their Medigap coverage without medical underwriting.

This change may reopen opportunities for some individuals who believed they had already missed their window.

HOT OFF THE PRESS

What Changed?

Beginning March 15, 2026, the Birthday Rule now allows policyholders to apply for a replacement Medicare Supplement policy during a period that begins:

31 days before their birthday and continues through 31 days after their birthday.

This creates a 63-day annual window centered around a person’s birthday.

What This Means

If you currently have a Medicare Supplement (Medigap) policy, you may now apply during this window to switch to the same plan letter offered by a different insurance company.

The insurance company must approve the application regardless of health conditions, provided the rule’s requirements are met.

Example

If your birthday is March 4, your Birthday Rule window would run from approximately:

February 1 through April 4

This means individuals with March birthdays who thought they missed the opportunity earlier this year may still qualify to apply.

Important Requirements

To use Indiana’s Birthday Rule:

• You must currently have a Medicare Supplement policy
• The new policy must be the same plan letter as your current coverage
• The application must be submitted within the 31 days before or after your birthday
• The new policy will take effect on the first day of the month following the application date

Your broker will also need documentation confirming your current plan letter.

Why This Matters

For many seniors, this rule creates an opportunity to:

• Review Medicare Supplement premiums
• Change insurance companies
• Potentially lower monthly costs

— without answering health questions or risking denial of coverage.

Need Help Reviewing Your Options?

If your birthday falls within this window and you would like to see whether switching carriers might benefit you, I would be happy to help review your options.

D. Kenton Henry
Office: 281-3676565
Text my cell 24/7 @713-907-7984
Email: Allplanhealthinsurance.com

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2026 ACA Subsidies: What’s Happening With Advance Premium Tax Credits?        

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(What Consumers Need to Know for the 2026 Marketplace)

D. Kenton Henry – editor, agent, broker

As we approach the 2026 plan year, one of the biggest questions in individual and family health insurance is what will happen to Advance Premium Tax Credits (APTCs)—the subsidies that lower monthly premiums for millions of Marketplace enrollees.

Why This Is Happening

During the COVID era, Congress passed temporary legislation — most recently extended under the Inflation Reduction Act (IRA) — which made Marketplace subsidies more generous and available to more households. These enhanced subsidies are scheduled to expire at the end of 2025, unless Congress acts to extend them.

If they expire, the Marketplace will revert to pre-COVID subsidy rules, which means:

1. Lower income thresholds for subsidy eligibility

Some households who qualified for subsidies under the temporary rules will no longer qualify at all.

2. Smaller subsidies for many who remain eligible

People who received very large subsidies during 2021–2025 would see higher net premiums for 2026, even if their income has not changed.

3. The return of the “subsidy cliff”

Under pre-COVID rules, households with income even slightly above 400% of the Federal Poverty Level received no subsidy. The COVID-era rules removed that cliff. If not renewed, the cliff returns.

This is why some people are seeing early projections showing their 2026 premiums rising sharply.

Where Things Stand in Congress

Both parties publicly acknowledge that the expiration would lead to large premium increases for many families. As of today:

  • There is broad interest in finding a solution, but
  • No final legislation has been passed,
  • No guarantee exists that the enhanced subsidies will continue, and
  • Any resolution will likely be tied to larger budget negotiations.

In short: Congress is still debating it, and the outcome directly affects what consumers will pay for Marketplace coverage in 2026.

What Consumers Should Expect

Until Congress acts, the Marketplace must begin preparing 2026 rates under the assumption that the enhanced subsidies expire. This means:

  • Preliminary quotes may show dramatically higher net premiums
  • Some currently subsidized families may temporarily appear ineligible for assistance
  • Final 2026 subsidy amounts cannot be known until legislation is passed — if it is passed

It is important to remember that this may change, depending on Congressional action in the coming months.

Practical Guidance for Individuals and Families

  • Don’t panic if early projections show large increases.
  • Stay informed — subsidy rules may be extended or modified.
  • Review your 2026 options with a licensed, experienced broker who can calculate subsidies under both scenarios.
  • Update income estimates accurately during Open Enrollment; small changes can affect substantial tax credit differences.

Bottom Line

The enhanced ACA subsidies that helped make Marketplace coverage more affordable since 2021 are set to expire after 2025, and Congress has not yet determined whether they will be renewed. Until a resolution is reached, 2026 Marketplace premiums may appear significantly higher for many Americans.

I will continue to monitor developments closely and provide updates as soon as new information becomes available.

Additionally—

It has come to my attention that my clients have been told the First Health PPO network plan is being mistakenly interpreted by them as being an Affordable Care Act (ACA) compliant PPO network. As such, they incorrectly believe any and all of their pre-existing health conditions will be covered and that all preventive exams and medicine will be covered at no out-of-pocket cost to them. This is wrong and here is the truth, as confirmed by me and ChatGPT:

✅ 1. There are no ACA-compliant PPO plans available in Texas individual/family (On- or Off-Exchange)

Texas has not had a true ACA-compliant individual market PPO option for several years.
All carriers (BCBSTX, Ambetter, United/Optum, Aetna CVS, Oscar, Cigna, Moda, etc.) offer only:

  • EPOs
  • HMOs

These networks limit out-of-network benefits and require referrals or tighter network management.

A PPO requires:

  • National or multi-state contracted provider access
  • True out-of-network benefits
  • No referral requirement

No carrier has offered this in the ACA individual Texas market since around 2017–2018.

✅ 2. Aetna is not selling ACA individual/family plans in Texas for 2026 (and has already exited)

Your clients may be confused because Aetna offers:

  • Medicare Advantage PPOs
  • Employer-based PPOs
  • First Health networks tied to group/other products

But Aetna does NOT offer ACA individual/family plans in Texas for 2026.

So if someone believes they have an “Aetna PPO” under an ACA plan, they are mistaken. It is either not an ACA plan, or they are misinterpreting the network type.

✅ 3. If their plan is marketed as “PPO-like,” it is almost certainly:

a) A short-term medical plan

These frequently use PPO networks—including Aetna’s First Health—but they are:

  • NOT ACA-compliant
  • Do NOT cover pre-existing conditions
  • Can cap benefits
  • Can deny claims based on underwriting

b) A health-sharing ministry

Often marketed as “PPO plans” because they use rented networks, but also:

  • Not insurance
  • Not regulated as insurance
  • No claim guarantees
  • No ACA protections

c) A fixed-benefit plan that uses First Health or MultiPlan PPO

Again:

  • Not insurance
  • No ACA protections
  • No out-of-pocket maximums
  • No guaranteed coverage

d) A direct primary care + medical indemnity bundle

These are sometimes misrepresented as “PPO plans,” but they are not.

✅ 4. How to confirm instantly whether the client is on ACA-compliant coverage

Ask for one of the following:

A) The name of the carrier.

If it’s not:

  • BCBSTX
  • Cigna
  • Ambetter
  • UnitedHealthcare (UHC Marketplace)
  • Aetna CVS (in some states, but NOT Texas 2026)
  • Moda
  • Oscar (until exit)

…then it’s almost certainly not ACA-compliant.

B) A copy of the Summary of Benefits & Coverage (SBC).

All ACA plans must include an SBC — short-term plans and sharing ministries do not.

C) Their monthly bill or ID card.

If it says things like:

  • First Health Network
  • MultiPlan PPO
  • PHCS PPO
  • Aetna PPO
  • United Healthcare Choice/Choice Plus PPO

…that is almost certainly a non-ACA plan.

✅ 5. Bottom line for you:

If you believe you they are on an ACA-compliant “Aetna PPO” for individual/family coverage:

You are not. No such product exists in the Texas ACA market. You are almost certainly on a short-term plan, health-sharing product, or fixed-benefit plan using a rented PPO network.

This is an excellent opportunity for ne to help you transition to true ACA coverage, where you will regain:

  • Pre-existing condition protection
  • Essential health benefits
  • No annual/lifetime caps

And – perhaps most importantly – Out-of-pocket maximum protection

Please feel free to call me with any questions you may have or for assistance in obtaining 2026 ACA compliant health insurance. I will make the quoting and application process go as quickly and smoothly as possible whether you quailify for a subsidy or not.

The Open Enrollment Period for a January 1 effective date ends December 15th. You have until January 15th to obtain an effective date of February 1.

D. Kenton Henry
Office: 281-367-6565
Text my cell 24/7@ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com

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What Texas Consumers Must Know as the 2026 Individual & Family Health Insurance Market Evolves

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By D. Kenton Henry, Editor / Agent / Broker — TheWoodlandsTXHealthInsurance.com, AllPlanHealthInsurance.com, HealthandMedicareInsurance.com 30 October 2025

Each November in Texas marks more than just the start of the new health insurance year—it’s your gateway to securing coverage for the year ahead. This time around, the 2026 individual and family health insurance market is undergoing noticeable changes. Here’s what you need to know—and how you can be ready.

1. Why 2026 matters

Open enrollment for 2026 policies begins November 1, 2025, and runs until January 15, 2026 for most Texas consumers. If you don’t act in this window, you could be locked out of making changes until next year unless a qualifying life event occurs. Given major shifts among carriers and plan options, early action is more important than ever.

2. Carrier changes you should track

One of the major headlines: Aetna will exit the Texas individual and family market beginning in 2026. That means if you currently have an Aetna plan, your policy will not renew for 2026. You’ll need to select a different carrier in the upcoming enrollment period.

Other carriers are repositioning their offerings, adjusting networks, benefits, and rates. Even if your carrier is staying, plan names and design may change. As your broker, I’ll review all available options from multiple carriers and ensure you’re not simply renewing by default.

3. What this means for you

  • No automatic renewal: If your carrier exits the market, your current plan will not carry over. You’ll receive a Notice of Change—or termination—and need to select a new plan.
  • Shop your options: Differences between plans are not only about monthly premiums. Review networks, cost-sharing, deductibles, out-of-pocket maximums, and whether benefits match your healthcare needs.
  • Subsidy changes: The federal subsidy rules continue to evolve. Even small changes in income, household, or eligibility can shift your subsidy level. I’ll help you analyse eligibility for Advance Premium Tax Credits (APTC) and other cost-saving tools.
  • Timing matters: Beginning November 1, I’ll be available to assist you through the selection process—not just on carriers and plans, but on ensuring accurate enrollment to avoid coverage gaps.

4. Why working with a broker matters

As an independent broker specializing in medical insurance since 1986, I work with virtually every major carrier licensed in Texas. My services to you are free of charge. My goal is to ensure you get the best plan that fits your health needs, budget, and preferences—especially in a year of significant market change.
Rather than navigating dozens of plan names on your own, let me do the heavy lifting and help you make an informed choice.

5. What to do now

  1. Gather your information – your current health plan, recent premium receipts, summary of benefits, and any health changes.
  2. Schedule your review – open enrollment kicks off November 1. If you’d like early preparation, I’m available now to pre-review your situation so you’re ready to act.
  3. Act during the window – November 1 through January 15 is your open period. Plans go into effect January 1, 2026, or, depending on carrier rules, as early as December 1, 2025.
  4. Don’t wait – with carrier exits and plan redesigns in motion, the sooner you start the review, the better your chance of finding the optimal match.

Working together, we’ll turn these market shifts into an advantage—so instead of scrambling when notices arrive, you’ll move confidently into 2026 with coverage aligned to your needs. Let me handle the complexity so you can focus on your life, your health, and your goals.

If it’s after hours, or you simply prefer, you can do preliminary research before calling me by obtaining quotes from my quoting engine. You do NOT have to log in to obtain them but be certain to call me afterwards with questions, and assistance in finding your providers within the networks, as well as applying. CLICK HERE: https://allplaninsurance.insxcloud.com/get-a-quote

D. Kenton Henry

Editor · Agent · Broker
TheWoodlandsTXHealthInsurance.com * AllPlanHealthInsurance.com * HealthandMedicareInsurance.com

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KEY CHANGES TO MEDICARE PART D DRUG AND ADVANTAGE PLANS IN 2026

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D. Kenton Henry
Editor, agent, broker
30 SEPTEMBER 2025

Medicare 2026: Welcome clients and prospective clients! Before reading this (if you have not already), you should go to your mail box and retrieve your 2026 Annual Notice of Change from Medicare. You were due to receive it no later than today per Center For Medicare Rules and Regulations. If will give you a good idea if you need to re-shop your Medicare Advantage or Part D Drug plan for the coming calendar year. If not, the following changes may.

10 changes to review before the Annual Election period, often referred to as the Open Enrollment (Oct 15–Dec 7)


If you’re on Medicare, 2026 brings important updates—especially to prescription drug coverage. The Part D out-of-pocket cap rises to $2,100, the standard deductible becomes $615, and Medicare’s first negotiated drug prices start on January 1, 2026. Medicare Advantage also gets new guardrails around prior authorization and appeals, and some supplemental “perks” are being narrowed. Check your Annual Notice of Change (ANOC) (it should arrive by Sept 30) and compare your plan options—small differences can mean big savings. If you’d like help, I’ll review your medications, doctors, and benefits to make sure you’re in the right fit for January 1.

Here is an itemized list of the 10 Key Changes:

Medicare changes your 2026 plan review should cover

1) Part D’s annual out-of-pocket cap rises to $2,100.
Once a member’s 2026 Part D out-of-pocket spending reaches $2,100, they’ll pay $0 for covered Part D drugs for the rest of the calendar year.

2) The standard Part D deductible increases to $615.
Plans can’t set a deductible higher than $615 in 2026 under the redesigned Part D rules.

3) Drug price negotiations start showing up at the counter.
Medicare’s first set of negotiated Maximum Fair Prices (MFPs) for 10 widely used Part D drugs take effect January 1, 2026. Members should review their ANOC and plan formularies to determine how these prices impact their medications.

4) Insulin and adult vaccines: protections continue.
Part D insulin remains capped and no-deductible; starting in 2026, the cap is the lesser of $35, 25% of the MFP, or 25% of the negotiated price. ACIP-recommended adult vaccines remain $0 under Part D.

5) “Pay-over-time” for prescriptions auto-renews.
The Medicare Prescription Payment Plan (monthly billing instead of paying large amounts at the pharmacy) auto-renews in 2026 unless the member opts out. It smooths payments but doesn’t lower total costs—good to remind clients who tried it in 2025.

6) Medicare Advantage prior-auth and appeals guardrails tighten.
For 2026, CMS says MA plans must honor previously approved inpatient admissions (can only reopen for obvious error or fraud), and CMS closes appeals loopholes so members and providers receive required notices and can appeal adverse coverage decisions. Expect fewer mid-stay reversals. Centers for Medicare & Medicaid Services

7) Limits on certain “extra perks” in MA (SSBCI) take effect.
CMS codified non-allowable Special Supplemental Benefits for the Chronically Ill—examples include non-healthy food, alcohol, tobacco, and life insurance. Some plans may rebalance extras as a result.

8) Star Ratings update: new/returning measures.
2026 Stars add or reintroduce measures like Kidney Health Evaluation for Patients with Diabetes plus Improving/Maintaining Physical and Mental Health (weight = 1). Tougher cut points in 2026 may shift plan bonuses and benefit richness—worth watching locally.

9) Part D benefit design shifts behind the scenes.
Liability shares change across phases (plans, manufacturers, CMS), and there’s a new subsidy for selected (negotiated) drugs. Members may see formulary/tier adjustments—another reason to compare plans.

10) ANOC timing: what to tell clients.
Remind everyone: Annual Notice of Change (ANOC) letters arrive by September 30 each year; if they didn’t see one, call the plan. Open Enrollment runs Oct 15 – Dec 7 for Jan 1 effective dates.

  • Check your Annual Notice of Change (ANOC) (it should arrive by Sept 30) and compare your plan options—small differences can mean big savings. If you’d like help, I’ll review your medications, doctors, and benefits to make sure you’re in the right fit for January 1.

Other Developments

  • Some Medicare Advantage supplemental benefits (i.e. nutrition support, OTC medicine) may be reduced in favor of core services.
  • In six states, prior authorizations for certain Original Medicare services will be tested.
  • Part B and Part D premiums and deductibles are both set to increase—Part B premium up ~11.6%, and Part D premium by about 6%.

Who Am I?

In addition to being the editor of this blog I have has been helping individuals and families navigate the health and Medicare insurance landscape since 1986. With nearly four decades of experience, he specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D prescription drug plans.

As an independent broker, I am appointed with virtually every competitive, A-rated Medicare insurance company in Texas, Indiana, Ohio, and Michigan. This broad access allows him to recommend the plan that truly best fits each client’s needs.

Above all, I work for my clients—not the insurance companies. You will never pay more by enrolling through me than you would if you purchased an insurance product  directly from the carrier. My mission is to provide clear guidance, personalized recommendations, and ongoing support to ensure my clients get the coverage and peace of mind they deserve.

If you have any questions about 2026 Medicare Part D prescription drug plans, Medicare Advantage, or Medicare Supplement (Medi-Gap) policies, please give me a call.

D. Kenton Henry

Office: 281-367-6565
Text my cell 24/7 @ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com

For all the latest news on health and Medicare related insurance, please follow me on my blog @ Https://HealthandMedicareInsurance.com

https://TheWoodlandsTXHealthInsurance.com

**********************************************************************************

FEATURE ARTICLE 1

By: Elizabeth Casolo                                                                                                                                        Friday, September 26th, 2025

Average premiums, benefits and plan choices for Medicare Advantage and the Medicare Part D prescription drug program should remain relatively stable next year, CMS said in a Sept. 26 news release. But MA enrollment is projected to decrease 900,000 in 2026.

Despite a slight dip in available MA plans nationally, over 99% of Medicare beneficiaries will still be able to access an MA plan.

The agency estimates the premiums for MA plans to drop from $16.40 to $14.00. On average, the total premium for standalone Part D is estimated to fall $3.81. 
CMS’ July forecast predicted elevated Medicare Part D base premium increases in the neighborhood of 6%.             

NAVIGATING THE FRUSTRATIONS OF FINDING INDIVIDUAL AND FAMILY HEALTH INSURANCE

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By D. Kenton Henry
Editor, Agent, Broker

Finding Your Doctor and Understanding Subsidies in HMO Plans

Shopping for individual or family health insurance can feel like navigating a maze—with dead ends, confusing signs, and few clear answers. Two of the most common pain points for shoppers are (1) trying to keep your current doctor while limited to an HMO network and (2) figuring out whether you qualify for a subsidy, known as an advance premium tax credit (APTC). Both challenges can make the process frustrating and overwhelming, especially during open enrollment when time is limited.

The HMO Headache: “Will My Doctor Be Covered?”

One of the biggest shocks people face when shopping for health insurance is realizing that their trusted doctor or medical provider might not be covered under a new plan—especially if it’s an HMO (Health Maintenance Organization). Unlike PPOs (Preferred Provider Organizations), which offer broader provider access and out-of-network options, HMO plans restrict coverage to a specific network of doctors and hospitals. If your doctor isn’t in the network, you may have to pay the full cost of your visit out of pocket—or switch doctors entirely.

Unfortunately, trying to find this information is often easier said than done.

  • Outdated or Inaccurate Provider Directories: Online directories can be incomplete or outdated. It’s not uncommon for a provider to be listed as “in-network” only for you to find out later they’ve left the plan.
  • Hard-to-Navigate Insurance Websites: Many insurance carrier sites don’t make it easy to search by doctor name, location, or specialty. Even worse, each plan may have its own “network tier,” adding another layer of complexity.
  • No Universal Search: There’s no centralized tool that lets you enter your doctor’s name and see every marketplace plan that includes them. You have to check each insurance company or plan individually.

For people with ongoing care needs—like managing chronic conditions or continuing with a trusted pediatrician or specialist—the possibility of switching providers isn’t just inconvenient, it can feel risky.

The Subsidy Puzzle: “Do I Qualify for Help Paying My Premium?”

The Affordable Care Act (ACA) made health insurance more accessible by offering subsidies for people who meet certain income guidelines. These subsidies, officially called advance premium tax credits, lower your monthly premium based on your household size and income.

The good news is that many people qualify.

The bad news is that determining whether you qualify can feel like filling out a tax return just to get a quote.

  • Income Guesswork: Subsidy eligibility is based on your estimated household income for the upcoming year. That’s right—you must predict your future income, even if you’re self-employed or work variable hours.
  • Family Dynamics Matter: Your household size includes dependents—even if they don’t need insurance—and income from every working member. This means getting it right often requires gathering data from multiple people.
  • Mid-Year Changes Complicate Things: If your income or family size changes mid-year, you may need to report it or risk having to repay part of your subsidy at tax time.
  • The ACA “Cliff” and “Glide Path”: Previously, you could lose your subsidy entirely if your income was even $1 over the limit. Recent changes have smoothed this out, but they are still complicated and frequently misunderstood.

And while tools like Healthcare.gov’s calculator are helpful, they often rely on broad estimates. They can’t account for all variables, such as gig work, investment income, or multiple part-time jobs.

Why It Feels So Frustrating

When you shop for health insurance, you’re not just picking a product—you’re making decisions that affect your finances, your family’s well-being, and your access to care. The stakes are high, yet the process often feels opaque and unnecessarily complicated.

You’re expected to:

  • Compare dozens of plans with unfamiliar terms,
  • Check if your providers are covered (without reliable tools),
  • Predict your income a year in advance,
  • And hope you don’t make a mistake that costs you money or coverage.

Tips for a Smoother Experience

While the system isn’t perfect, there are ways to reduce frustration:

  • Use a Licensed Agent or Broker: Agents specializing in ACA plans can often help you find plans that include your provider and determine if you qualify for subsidies—all at no extra cost.
  • Call Your Doctor’s Office: Don’t rely solely on insurance directories. Call your provider’s office directly to confirm if they accept a specific plan.
  • Keep Documentation: If your income fluctuates, keep clear records. This will help you provide accurate estimates and support your case in the event of an audit or dispute.
  • Update Changes Promptly: If your income or household size changes mid-year, report it on your health insurance marketplace to avoid surprise bills or tax penalties.

In Summary

Shopping for individual or family health insurance can be a stressful process—especially when you’re trying to keep your doctor and figure out if you qualify for financial help. Between restrictive HMO networks and confusing subsidy rules, it’s easy to feel stuck. But with a little extra diligence, some expert help, and the right questions, you can find a plan that fits your needs without sacrificing peace of mind.

If the process still feels overwhelming, you’re not alone. Many Americans share the same frustrations—and continue to hope for a more user-friendly system in the future.

Below is a chart outlining estimated income thresholds for qualifying for an Advance Premium Tax Credit (APTC) in 2025. These thresholds are based on a percentage of the Federal Poverty Level (FPL), which is adjusted annually. For simplicity, the chart includes 2024 FPL figures (used for 2025 coverage) and the income ranges (100%–400%+ of FPL) where most people qualify for subsidies under the ACA.

📝 Note: Due to the American Rescue Plan and Inflation Reduction Act, subsidies may extend beyond 400% of the FPL, with a sliding scale that caps the percentage of income spent on premiums. These extended subsidies are currently in place through 2025.

2024 Federal Poverty Level (FPL) and APTC Income Guidelines for 2025 Coverage

Household Size100% / FPL400% / FPLTypical APTC Eligibility Range

1 (Individual) $14,580 / $58,320 / $14,580 – ~$58,000+

2 (Couple) $19,720 / $78,880 / $19,720 – ~$79,000+

3 $24,860 / $99,440 / $24,860 – ~$99,000+

4 (Family) $30,000 / $120,000 / $30,000 – ~$120,000+

5 $35,140 / $140,560 / $35,140 – ~$141,000+

6 $40,280 / $161,120 / $40,280 – ~$161,000+

Key Notes:

  • Minimum Income: You must earn at least 100% of the FPL to qualify for a subsidy in most states. In Medicaid expansion states, if you earn less than 138% FPL, you may qualify for Medicaid instead.
  • Upper Limit Removed: Thanks to temporary reforms, people earning above 400% FPL may still qualify for a subsidy if the cost of the benchmark plan exceeds ~8.5% of their income.
  • Household Size: Includes you, your spouse, and any dependents claimed on your tax return.

💡 What This Means for You

  • If your estimated annual income falls between the ranges shown above, you likely qualify for help paying your monthly health insurance premium.
  • Households earning more than 400% of the FPL may still qualify if their premiums exceed about 8.5% of income, thanks to current federal subsidy expansions.
  • Eligibility is based on your tax household — including you, your spouse, and dependents you claim on your tax return.
  • If your income is below 138% FPL, you may qualify for Medicaid (in most states).

DO NOT CALL AN 800 NUMBER and talk to some anonymous employee of an insurance company. Not only are they restricted to limiting you exclusively to their company’s options—but your personal information will be instantly sold and shared. Your phone is going to begin ringing off the hook!

I’ve been specializing in Medicare-related insurance for over thirty years, right here in The Woodlands, Texas, USA! I represent every Medicare-related product, including Supplement, Advantage, and Part D Drug plans, from virtually every “A” rated company doing Medicare-related business in Texas. And I CHARGE NO FEE for my services! Deal with a local agent/broker who values your business enough not to share it with anyone!

D. Kenton Henry
Editor, Agent, Broker
Office: 281.367.6565
Text my cell 24/7 @713.907.7984
Email: Allplanhealthinsurance.com@gmail.com

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NOW IS THE TIME TO RE-SHOP YOUR MEDICARE SUPPLEMENT POLICY!

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By D. Kenton Henry
Editor, HealthandMedicareRelatedInsurance.com
Agent, Broker
28 January 2025

Hello again, and welcome to 2025! Early last October, just prior to the Medicare Annual Election Period (AE), I informed you of the many changes coming to Medicare Part D Prescription Drug Plans in the coming calendar year in which we now find ourselves. I explained the pros and cons that many of you are now experiencing in real time. On the positive side, I am certain many are celebrating that their annual drug costs (for Part D covered drugs) can never go beyond the new annual maximum out-of-pocket (OOP) of $2,000! And, hopefully, you are not experiencing the negatives—such as learning your Rx drug (which was previously covered) is no longer or its price has increased dramatically! Once again, we realize the government can giveth or taketh away.

But there is one thing in which you have a certain amount of control, and this is the ideal time of year to exercise that control. During the AEP, insurance companies, agents, and brokers work overtime seven days a week to see that their clients, and prospective clients, are guided to the Medicare Advantage and Part D Drug plans that best meet their needs. To do this correctly, an agent must understand the client’s needs and objectives and then do, what is often, extensive research to ensure a person’s drugs are covered and they have access to their preferred providers. In some cases, this can take minutes and, in others, hours over repeated phone calls. In most cases, you won’t get the latter from a company employee on the end of an 800 number, but you will get it from me.

Now that the AEP ended December 7th, agents have much more time to assist you in improving the cost of your Medicare Supplement coverage. As you may know, Medicare Supplement is not subject to annual enrollment periods in Texas or most states. What this means, is you can re-shop your Supplement coverage to find identical (or improved) coverage 365 days per year. The incentive for doing so is that you may save 30% or more in premiums. Because Medicare Supplement premiums go up each year as we age, it doesn’t take too many years before most of us begin to wonder if our premium is still reasonable or competitive. The reality is, if your policy is three years or older, you will indeed safe significantly by switching to a policy with the same letter designation, e.g., Plan G. I have many clients whose policy premiums had increased to well over $300 per month that I was able to lower (with new coverage) to less than $200 per month!

Additional reasons to re-shop now are that a few “A” rated companies are particularly interested in expanding their block of business. This does not imply a compromise in the quality of their customer service or rate stability. It simply means that through prudent management and staff expansion, they can be more competitive, significantly lowering your premium. Additionally, you may now have a spouse, or in some cases, simply another adult living with you—making your new policy available for a “Household Discount”. Typically, these discounts can lower your premium 7-12%, and—if the other person is covered by the same company—that discount will apply to their existing policy also!

So what is the catch? The catch is that now that you have been in Medicare Part B 6 months or more, you must go through underwriting and be approved for the new coverage based on your current health and relatively recent health history. The bottom line is, if your current conditions are well controlled with medication, you do not suffer from any chronic condition that poses a long-term liability to the insurance company, and you have no pending surgeries or hospitalizations—you are a good candidate for replacement coverage. The worst scenario is you are declined. In this case, all you are out of is the small amount of time you took to complete the application.

THE FOLLOWING IS A SYNOPSIS OF THE PROS AND CONS OF RE-SHOPPING YOUR COVERAGE:

Re-shopping a Medicare Supplement (Medigap) policy can provide several advantages for recipients, especially if their needs or circumstances have changed since they first enrolled. Here are the key benefits:

1. Cost Savings

  • Premium Reduction: Medigap premiums can vary significantly between providers for the same coverage. Shopping around may uncover lower premiums for the same plan (e.g., Plan G or Plan N).
  • Health Status Discounts: If your health has improved since your initial enrollment, you might qualify for a lower premium rate with another insurer.
  • Household Discounts: Some insurers offer discounts if multiple members of the household enroll in their Medigap plans.

2. Better Coverage Options

  • Change in Needs: If your healthcare needs have increased or decreased, you might find a plan that better aligns with your current situation, such as switching from a high-deductible plan to one with lower out-of-pocket costs.
  • Additional Benefits: New Medigap plans might include perks like fitness programs, telehealth, or wellness benefits that weren’t available when you initially enrolled.

3. Access to New Insurers

  • Competitive Market: New insurers entering the market may offer attractive rates or better customer service than your current provider.
  • Provider Reputation: Switching to a more reputable insurer can improve your overall satisfaction and ensure reliable claims processing.

4. Avoiding Rate Increases

  • Age-Based Increases: Some policies increase rates as you age. Shopping around may allow you to switch to a community-rated policy where premiums are based on a group average rather than individual age.
  • Annual Adjustments: If your current insurer has raised premiums significantly, exploring alternatives can help you lock in a more stable rate.

5. Improved Customer Service

  • If your current insurer has poor customer service or limited support, switching to a provider with higher satisfaction ratings can enhance your overall experience.

6. Medicare Advantage Comparison

  • While re-shopping Medigap policies, some recipients may realize that a Medicare Advantage (Part C) plan is more cost-effective or suitable for their needs. These plans often include additional benefits like dental, vision, and hearing coverage.

7. Regulatory Benefits

  • Guaranteed Issue Rights: In some situations (e.g., losing coverage or moving), recipients have guaranteed issue rights, allowing them to switch Medigap plans without medical underwriting.
  • Trial Rights: If you tried a Medicare Advantage plan for less than 12 months and decide to switch back to Original Medicare, you may have a guaranteed right to re-enroll in a Medigap plan.

8. Customizing for Future Needs

  • Planning ahead for potential healthcare changes can ensure that you are prepared for costs that might arise later, such as skilled nursing care or extensive outpatient services.

Considerations When Re-Shopping

  • Medical Underwriting: Outside of guaranteed issue periods, you may need to answer health questions, which could affect your eligibility or rates.
  • Plan Standardization: All Medigap plans with the same letter (e.g., Plan G) offer identical core benefits, regardless of the insurer, making it easier to compare prices.
  • Timing: The best time to switch is typically during your open enrollment period or when you have guaranteed issue rights.

By re-shopping their Medigap policy, Medicare recipients can ensure they are getting the best value and coverage for their evolving needs.

I am an independent agent with more than three decades in the medical insurance industry. As I have aged, so have my clients, and Medicare-related insurance (Supplement, Advantage, Part D) has become my specialty. I represent virtually every “A” rated insurance company in Texas as well as three others. I provide objective advice based on empirical numbers inclusive of costs and satisfaction surveys.

Significantly, I do not charge a fee for my service. You are charged no more for acquiring a product through me than if you went in the front door of the insurance company whose product you elected and acquired it directly from them!

Please allow me to assist you in lowering the cost of your Medicare-related insurance. I look forward to working with you!

D. Kenton Henry

Office: 281-367-6565
Text my cell 24/7 @713-907-7984
Email: Allplanhealthinsurance.com@gmail.com

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