Got Insurance?

Last fall when I announced I was quitting my job to pursue freelance journalism, I expected people to ask (implying inherent contradiction): "You're going to try to make a living as a… journalist?"

No doubt a sign of our troubled times, most people actually responded: "Dear God, woman! What about health insurance?"

After futile attempts to dissuade me from my crazy plan, many people suggested I purchase COBRA -- an extension of the health benefits I had through my soon-to-be former employer. When it turned out COBRA cost over $400 a month, they started e-mailing me job links.

So with (as yet) untarnished entrepreneurial spirit and can-do attitude, I set out to prove them all wrong. I would not only win a Pulitzer Prize for reporting, but I would accomplish the truly impossible: finding myself an affordable health care plan.

Unfortunately, the latter goal was overly optimistic, and after two months of slogging through incomprehensible benefit summaries and product comparisons, I decided to call a professional.

Increased Access

From an unassuming office in a 28th Street strip mall, insurance agent Sarah Mayne helps everyone from college students to small business owners like herself navigate the increasingly turbulent waters of the American health care system.

"There are as many plans as there are stars in the sky," says Mayne, confirming my suspicions, when we meet.

And they are not all treated equal, one of the many reasons Mayne recommends working with a professional agent rather than going it alone.

"We take the time to research the plans. We try to be as informed as we can," Mayne says. In addition to her work at Access Insurance -- a one-stop shop for every possible type of insurance -- Mayne also runs a belly dancing studio in East Hills.

"You want to run your business. My clients want to focus on living their lives. They don't want to be insurance specialists."

Explanation of Benefits

The insurance learning curve has always been steep. But national health care reform and a sputtering state economy that has tossed thousands of people into the individual insurance market -- in Michigan alone, the number of people with individual plans is projected to rise to 2.4 million by 2014 -- have made choosing the right plan more difficult than ever.  

Fortunately, Mayne can hook you up. First, she assesses clients' current health needs and financial considerations. Then she factors in lifestyle and even family history to help forecast medical concerns that could potentially crop up in the future.

"Nobody wakes up on a Tuesday and says, 'Gosh, it's a great day for cancer or a heart attack. I think I'll do that today'," she says, with characteristic light-hearted sarcasm.

Finally, Mayne generates a list of best-fit products and walks clients through each plan's pros, cons and costs -- the part of the experience I most valued. She not only makes sure clients have adequate, affordable coverage, but that they know what costs and liabilities to anticipate under their new plan.
Out of Pocket Costs

Mayne's "comprehensive" approach and her decision to become an insurance agent are rooted in first-hand experience. Her mother, an Amway employee, was diagnosed with breast cancer in 1998.

"Because her health declined so much, Amway allowed her to retire early," Mayne, now 30, remembers. "We had quite a long battle with cancer."

Her brother's health began to deteriorate around the same time. Nine years her junior, Jesse Mayne had been born with hydrochephalus -- literally "water on the brain." Within one week of his delivery, doctors had to perform brain surgery, placing a shunt to drain excess fluid. Luckily, at the time, the family's Priority Health plan covered this treatment.

"He fell under the group insurance program that we had, which means he had great coverage," says Mayne. "Amway does a wonderful job of with their coverage in the group world."

Problems arose years later, for mother and son, when the Maynes sought elective and experimental treatments around the country and in Germany -- all out-of-network.

"Priority Health here is phenomenal," explains Mayne. "Outside the network is where we experienced some extreme changes in health care costs."

To defray these expenses and, eventually, funeral costs, the family threw benefits at Forest Hills Eastern High School. Mayne's father even refinanced their house.

Jesse passed away in January of 2005, and Mayne lost her mother one year later. "To this day [the medical bills] are still not completely paid for and won't be for some time," she says.

Health insurance companies no longer cover hydrocephalus.

"I have looked on every insurance application out there and hydrocephalus is a declinable condition through every single company in the individual medical world," Mayne says.

Affordable Care?

Health reform ultimately increases the number of insured Americans, but it has also prompted many insurance companies to discontinue coverage of certain treatments.

Mental and behavioral health care was one of the first to go, because, after the Affordable Care Act passed last year, thousands of individuals under 26 were enrolled in their parents' plans. Fail to see the connection? Statistically, this demographic is the mostly likely to pursue mental and behavioral health treatment.

Depressed college kids are not the only group affected by new legislation. Other providers have effectively opted out by inflating the cost of adding dependents to parents' policies.

"Dependents are mandated to be covered, but [they] are not free to get in by any means," Mayne, who has two daughters of her own, says.

Mayne recently made an application for a couple with two hearing impaired children that needed cochlear implants. The insurance company was willing to accept the children... for $1,000 a month.

"There was no way the family could insure their children under their policy, so they were left with Medicaid," she says. "It's basically the insurance companies saying, 'We're not interested'."
Despite these new challenges, Mayne remains extremely selective when choosing insurance companies to work with. She observes how companies perform and treat customers over time -- something that would be nearly impossible for individuals to do on their own.

"There are a few insurance companies that I refuse to write business for, even though they are some of the larger ones the industry," says Mayne. "My focus is finding companies that are great with claim-paying obligations, easy to work with, have good relationships with underwriters and that you know are going to take care of the customers and their families if they fall on hard times."

The Triple Bottom Line

To be fair, consumers are not the only ones feeling the squeeze.

Established insurance companies like American Community and American Medical Securities have already been bought out. Aetna removed its individual products from the market in January, and other companies are leaving the world of medical insurance altogether. According to Mayne, "a lot of companies can't keep up with the changes" or anticipated future financial burdens.

Insurance companies are required to reserve a percentage of their total funds to pay claims. In the past, they earmarked 70 percent for claims and 30 percent for overhead. The post-reform split is 80-20, which means companies have 10 percent less money to pay their staff, maintain facilities, and pay commissions to agents like Mayne.
"All of us get paid differently," Mayne says. "But the bottom line on health insurance is we receive a percentage from the insurance companies. The entire commission structure is changing and everyone's commissions are going down."

But that doesn't stop her from trying to find the best deals for clients- -- "combining health and auto insurance could save you 25 to 40 percent" -- and even offering referral incentives to her clients. Ultimately, Mayne sees her work in the insurance industry as a contribution to the community -- one she hopes her clients will pay forward.

"I believe building a strong community is something we need to continue doing," she says emphatically. "It's about working with someone within your community who specializes in what they do... working here locally to build Grand Rapids economy and community."

Ruth is a freelance writer and fundraising consultant living in East Hills. She enjoys world foods, travel, crafts and those BBC ocean documentaries. Ruth also has very curly hair.

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