According to the Florida Department of Health in Monroe County, 19.3% of residents in Monroe County are uninsured. In Marathon, the number is 23.8%. Many residents say they simply can’t afford it. Now, one company is offering health care alternatives that might solve the problem.

“The future of health care in our country is so confusing and convoluted,” said Brandi Card, a self-employed Pilates instructor who’s gone from corporate-style health insurance to Obamacare to no health insurance to these new health care alternatives in the last 16 years. Of the new plans, Card said, “I’m so grateful this option came along. It puts me at ease.”

Card used to pay between $900 and $1,000 a month in premiums with traditional health care and still paid out-of-pocket for services. “Anytime I had to have something done, they’d tell me it wasn’t covered by my insurance. They overcharged me for many things, and I felt like they were always trying to trick me,” said Card.

And so Card opted just not to have health insurance for the past two years. Still, she’d worry: “It’s too scary not having coverage. What if something big happens?”

In August of this year, Card found her goldilocks solution – two health care alternatives that, used in conjunction, can act like insurance. “I pay $320 a month,” she said, “and that covers all my preventative care — mammograms, bloodwork, annual stuff. The prescriptions are ridiculously affordable.”

The first plan is for preventive and ongoing services. It’s available through Apex and is designed to cover day-to-day medical needs, including basics like annual check-ups, common colds and mammograms. For the 80 federally mandated preventive services, there is 100% Apex coverage; no co-pays. Apex also covers three primary care visits a year with a $20 co-pay and three specialist visits with a $50 co-pay. There’s a huge network of covered doctors in the PHCS network, which Apex belongs to. (Visit www. smallassociations.org and search for a full listing of doctors in the Keys.) Locally, the plans are sold by Stacey Dumas, a broker for SALA that sells the healthcare alternative.

Dr. Ronald Samess of Marathon said the plan works. He’s been accepting patients in the PHCS network (which includes Apex) for 15 years. “Whether a patient has traditional health insurance or one of the Apex plans via Keys to Health, they can absolutely see me or any physician, nurse practitioner, etc. in my office.” He said the quality of care and level of treatment is equal whether the patient has traditional insurance or one of these alternatives.

The second plan is Sedera, an add-on, cost-sharing membership for unexpected medical needs. This is used for events like car accidents, pneumonia and heart attacks. It also provides access to medical bill negotiations, anytime access to a board-certified physician through telemedicine, expert second opinions, and personal member advisors.

Sedera isn’t health insurance, so it doesn’t use a network. Members go to whichever hospital or doctor they need to receive care from. They present themselves as a “self-pay” patient and ask to be billed. These bills must then be uploaded to the Sedera portal for payment. Sedera sends members a check for the balances owed on services, which members use to pay their medical bills.

“I love this idea of the cost-sharing program for major medical,” said Card. “Technically, I’m paying out of pocket, but if I ever do have to have surgery, I can call them ahead of time, and Sedera will often negotiate and prepay the cost of the procedure for me.”

Businesses, too, are seeing the benefits of the alternative healthcare, not just for their employees’ well-being, but also as a competitive tool for recruitment. Chuck Meier, president of SALT (Sea Air Land Technologies) in Marathon, began offering Apex and Sedera to his employees last month. “The things we really like are affordability and flexibility. You can sign up to for one or both plans, and you can enroll or dis-enroll at any time. There’s also a minimal wait period.”

One month in and having enjoyed strong participation during sign-ups, Meier is “guardedly optimistic.” He said, “It’s a challenge to get employees in the Keys. Insurance is important and really expensive for small businesses, and I expect this will make us more competitive in hiring.”

For more information about the program, visit keys2health.org or call 877-622-9990.

 

9 things to know

 

 

 

  1. The APEX preventative care plan complies with the Affordable Care Act mandated preventative care services. Visits must be made in network. Apex High Deductible, High Premium is less expensive but does not cover prescriptions or specialists but does allow for a Health Savings Account. The Apex Advantage provides a prescription plan and co-pay structure for specialists.

2, Sedera is NOT insurance; it is a cost-sharing health care membership. Nationwide, members share the costs. When a member has a “medical need,” it comes from the shared fund. Medical needs are considered single events like a car accident or child birth or cancer.

  1. Sedera has NO network. Members go where they wish and self-pay. The initial unshareable amount (what traditional insurance companies would call a deductible) is what would be paid by the member and overages or total cost are shared. Sedera reviews the medical need and cuts a check to the member. The member then pays the provider.
  2. With Sedera, an individual is required to pay the IUA (Initial Unshareable Amount) for their first three needs per year, or five per family.
  3. Members are required to do their own paperwork for the Sedera plan. Plan representatives estimate it takes the average person about six hours a year to upload bills for reimbursement.
  4. The Apex plan offers “teledoc” services at no charge. Patients will be able to consult via computer or phone with medical professionals.
  5. The Sedera membership for multiple members, for example, a family of four, will be based on the age of the oldest family member.
  6. Sedera imposes a $75 monthly surcharge for smokers.
  7. Any medical history that is more than 36 months (where the patient is no longer receiving treatment and exhibits no symptoms) is NOT considered a pre-existing condition with Sedera. Even those with pre-existing conditions can participate, but will be subject to sharing restrictions in the first three years of membership.

 

Example 1

Single | 25 years old

Apex basic:                   $71.43

Sedera $2,500 IUA:    $142.00

Total monthly cost:   $213.43

In this scenario, Apex covers 100% of routine checkups. In the event of a serious injury or illness, the member is responsible for the first $2,500 of the bills and the balance shared by the members. Sedera includes the cost sharing of prescriptions related to an illness or injury.

 

Example 2

Family of five | 37 years old

Apex Advantage:        $307.45

Sedera $2,500 IUA:    $389.00

Total monthly cost:   $696.45

In this scenario, Apex covers 100% of routine checkups plus tier 1 generic prescriptions. (Tier 2 and 3 are offered at 10% and 20% coinsurance, respectively). In the event of a serious injury or illness, the member is responsible for the first $2,500 of the bills and the balance shared by the members. Sedera includes the cost sharing of prescriptions related to an illness or injury.


Two info sessions will be held this weekend to discuss the plans as affordable health care alternatives:

Mon., Nov. 18 at 4 p.m. at Hyatt Centric Key West. RSVP at [email protected].

Tues., Nov. 19, at noon at Overseas Pub & Grill in Marathon. RSVP at [email protected] or 305-743-5417. Space is limited.


 

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