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View Full Version : My next question: Individual Health Insurance because ours sucks.



underthecity
08-19-2008, 01:18 AM
First off, thanks to everyone who responded in my previous day care thread. Your comments were all taken to heart.

My wife told me today that our insurance deductible is $4000, which means, that for her to have her baby, it will cost us $4000 out of pocket.

We have insurance through her work. (At present, I can't get insurance through my work, so it's not an option.)

So, she has declared our insurance sucks and wants to drop them and get individual health insurance.

Has anyone pursued buying insurance? How do you do it? I've heard Author's Guild has good insurance, but they don't do Kentucky.

Do we have any good options?

allen

maestrowork
08-19-2008, 01:24 AM
My opinion is if you're starting a family -- and a baby's on the way -- it's not a good idea to get individual insurance. They're more expensive and have more restrictions, and have higher deductibles, actually. You may want to look into a more comprehensive family plan.

I have a plan with Anthem, and I think it's decent. I do have a high deductible ($2500) but since I'm healthy, I only use it for emergencies and big ticket items. So far, my 2008 out-of-pocket cost was like $350. My premiums are about $120 a month, which is very reasonable. Again, I put the "savings" I get toward the deductible, and chances are I won't need more than $2500 a year on medical expenses since I'm healthy. Even if my out-of-pocket spending is $1000 this year, I still win out (my monthly premiums would amount to less than $200 a month).

But check out the individual plans and I can assure you that if you want a plan with lower deductibles (under $2000, for example) you would pay more in premiums anyway. So if you opt out of your wife's company plans, you may end up paying more because, with a baby, you will incur a lot of medical expenses, definitely. So you need to do a cost and risk analysis and find out what makes sense to you. For me, an individual plan makes sense because the one offered to me was over $400 a month with a $1500 deductible. That's crap compared to what I have now.

Jersey Chick
08-19-2008, 01:29 AM
I went out to look at Horizon Blue Cross's site - they have a rate wizard. And trust me, it's expensive... I tried various family plans with $1,000 deductible and the monthly costs ran up into thousands...

https://www.horizon-bcbsnj.com/members.html

Here - you can put in what type of plan you want, what deductible, and what co-pay, depending on the plan. It'll give you the monthly costs. But make sure you're sitting down first.

Other carriers probably have the same kind of wizard - so you can get an idea of what it'll run you. But be warned, it WILL most likely be more expensive than whatever you pay now through your wife's job...

underthecity
08-19-2008, 02:31 AM
Ray, thanks for the info.

Jersey Chick, thanks for pointing me to Anthem Blue Cross.

We've been looking over the plans that Blue Cross provides, and we think we may be able to go with one of them, as they have different kinds with different levels of premiums and deductibles.

In the long run, over the year, it would be cheaper to go with Blue Cross than through her work (United Health Care).

Humana is another one we're considering.

Only one problem: they may turn us down since she's pregnant. It would be considered a pre-existing condition.

allen

Jersey Chick
08-19-2008, 02:33 AM
I'm glad I could help - I wonder how much more expensive my quote were based on my location?

Once upon time pregnancy was considered pre-existing, but I don't know now. I know when I was working (pregnant with 1st) my company was bought out, so our insurance switched. But since it wasn'y by my choice, the new carrier picked me up. I don't know how it works privately.

Either way - good luck - you guys have enough to worry about as it is... :Hug2:

Disa
08-19-2008, 05:07 AM
Definitely check into pre-existing clauses with any new company you consider. HMO's don't usually have pre-existing clauses, it may be different in your state. You also want to specifically ask if the insurance company covers well baby care- immunizations are frequent and expensive with new borns and some policies don't cover well baby care. Check out all the big ones Blue Cross, Cigna, Aetna, Kaiser. I probably wouldn't drop what you have, since your wife is pregnant, but maybe one of these others could be a way to supplement what you've already got. Whatever you do, don't let there be a lapse in coverage. Oh yeah, make sure you have proof in writing that you are covered before you drop your other policy-if that's what you decide to do. If you end up having trouble getting your claims paid, you can file a complaint with your state's insurance commissioner. Hopefully that won't happen. Oh, there's always the health department if you can't afford the immunizations.I know people don't often want to go there for various reasons, but they aren't as bad as the stigma that's assoicated with them.

Good luck, and congratulations.

Silver King
08-19-2008, 05:12 AM
Insurance? That seems like such a foreign concept these days.

Last time I checked, a couple of years ago, my cost was two grand per month for family coverage with ten thousand deductible per claim. That's the cheapest I was quoted. But that's all right. I've been thinking of leaving the country with my family and returning as illegals. This way, our health needs will be provided for at no cost to us but at everyone else's expense.

It's the American way.

Ol' Fashioned Girl
08-19-2008, 05:25 AM
Check that $4000... it may be that that's the MAX out of pocket. Many policies have something like a $500 deductible before the policy starts paying 80% of the 'normal and reasonable' charge for whatever is being done. And it realy isn't wise to go changing insurance carriers during a pregnancy. Really.

Clair Dickson
08-19-2008, 06:27 AM
I've dealt with the pre-exiting condition thing with insurance. With many place, the way it works is that if that condition was covered for the last six months (or something like that), then the new policy will cover it, too. So, when I changed insurance, they covered my conditions because I had previosly been covered.

I don't know how exactly that works with pregnancy, but you can talk to the customer service people. They can tell you for certain if it will be covered. My guess is probably because your wife was insured before.

I never had any trouble-- which is good because if I loose coverage, I'll never get it again! And I went from being on Hubby's plan to going into Cobra, but just for me (that was a messed up situation!) to being on Hubby's plan at New Job. Never lost coverage, had no issues.

willfulone
08-19-2008, 07:34 AM
Policy type does not dictate if a policy will have a pre-existing condition (HMO, Traditional, Comprehensive Indemnity, PPO, EPO, etc.). Pre-x is determined by other factors and insurance companies do not waive them for policy types, but for other reasons. An employer policy waives pre-x for new hires who enroll within the first enrollment period offered if they elect to - I have not seen one yet that does not (this may also be waived at employer disgression - they can waive for new dependants added to policy in some cases if they have it in their policy to allow it). New hires with pre-x application may be out there and I have only worked in the insurance field for 4 years, but I have never seen a new hire have a pre-x on an employer policy if they enrolled within the first enrollment period offered. They may apply pre-x if an employee does not take the health insurance the first time they can enroll, but take it at a later date. This does not apply in your case, as you are looking to private purchase, but I am putting that out there so you have the knowledge.

If you purchase a private policy there WILL be a pre-x clause listed on the policy, regardless of the type of policy you buy. Most people do not realize they are there for the pre-x clause is often buried in techno speak and not easy to decipher out of a plan. Whether or not it applies to you is dependant upon criteria of the plan. In some states, mandates exclude pregnancy as pre-X, some do not. You will have to do your due diligence to find out if it applies in your case if you decide to go private purchase rather than employer plan. However, it may be moot in your case even if it applies to the policy you ultimately buy. Policies have a clause in the pre-x area. If you can show continuous coverage without a lapse of so many days (some it is 6 days, 15, some 30, some up to 63 days) then the pre-x is waived. Thus, her pregnancy could be waived as a pre-x if you keep her employer coverage until you took over buying your family plan through Humana, Blue Cross, etc. You are best set if you do not have a lapse of any length to thwart pre-x application. For, figuring out and getting claims paid after they have denied for pre-x can take a long time (several months) and you can be in collections from the facility or doctor while the pre-x is reviewed by the insurance carrier. Once your credit is ruined, it is ruined and you cannot fix it easily even if the hospital gets their payment from the insurance company. So, it is best to have your term date and your new enrollment date be two consecutive dates on the calendar.

Have your broker tell you what the pre-x clause is, have them highlight it on the policy so you can review after you leave to consider your options (do not buy because something sounds good initially, take time to absorb the policy - too many people are underinsured in some areas of their policy if they look to buy with one goal in mind - lower deds, snf benes, for example). Have them also highlight the circumstances wherein the pre-x is waived and what the specific waiting period is for the pre-x if it cannot be waived in your case. If it states Pregnancy is NOT a pre-x, have them highlight that also, do not take their word for it if they just say it is not. Most policies have a pre-x waiting of 12 months from date of enrollment, but several have 180 days (6 months). Of course the waiting period is moot if you can provide your COCC (certificate of credible coverage). In all policies I have seen in 4 years, there is such a clause. But there may be the stray out there that does not waive it. I have never seen it though. Make sure that clause is in the policy too and highlighted by your broker. You would be surprised by the number of items in print that are never used by the insured or that are never appealed because the insured did not know their policy and what it really contains.

You will not be buying individual insurance. It will be a H & W plan until the babe is born, then covert to Family. You will want to make sure what the techno speak is on the ded & coins payments for many have clauses that apply to singles and not to family and visa versa. For instance, there may be an individual 2000 ded per person listed on the policy and family will be when 2x or 3x the individual amt listed. Do not assume that the 2000 applies per person in a family plan unless it specifically states that once A POLICY MEMBER has met their $2000 ded then coins kicks in. For, there are many policies that state if there is more than one person on the policy the family ded applies to any ONE or combination of people meeting the ded. Which means, if you have family only application of ded and individual ded is 2000, then your wife will have to meet (typically family ded is 2x or 3x individual ded) 4000 - 6000 BEFORE her coins kicks in (if you use none of yours) and you are no better off.

Also, please be sure, whether you stick with the employer or go with private purchase your babe is added to policy within first 30 days of life. If not, the babe is put on pre-x for days 31 on until pre-x clause is met. Yes, this happens frequently for members believe notification to employer makes it to insurance company. It does not always. So, make that call yourself for notification to insurance company. It will save you countless headaches. For, if the child is NOT put on the policy within 30 days, the insurance company can waive paying the baby portion of the hospital bill if they elect to and your fight to get it paid will take a long time.

Buy a policy that the bene period is calendar year and not enrollment year if you can. It does not cost extra and will save you headaches when it comes to utilizing routine benes of the policy. Especially regarding children and yearly physicals. Calendar bene periods versus enrollment years? You can have services that occur once a year in calendar year ANYTIME during that year. For instance, your wife could have a mammo (if applicable) on November 21, 2008 and another on June 6, 2009 without denial of bene. Enrollment bene period limits services to occurring after 365 days have lapsed since last routine bene used, where applicable. In this case your wife could have her first mammo Nov. 21, 2008, but have to wait until Nov 22, 2009 (or after) to have same routine bene on enrollment bene period or the claim can (and likely will) be denied. While not a biggie, it sux if you cannot get into your doctor until after said dates when dealing with kiddos. If you are there for an ear infection 1 week prior to yearly routine visit, a doc will often just do all if you request it and save time from another trip. However, if you get those routine benes (including immunization) prior to after the 365th day after last routine bene (in the enrollment year type) your claim will be denied for those services for the routine part. Even though you were there already for that other and wanted to save another trip and/or office charge the insurance company will have to pay. In fact, they can and often do, deny the whole claim rather than just the line items that apply to a specific bene that was not followed. You can be stuck with a huge bill for not following policy benefit guidelines to the letter.

I work for Blue Cross, Blue Shield of NJ (Horizon) if you have any questions that I can assist you with, post here or PM me and I will be happy to assist you.

Sorry so long, & Hope this helps!

Christine

Jersey Chick
08-19-2008, 07:39 AM
Whoa... you just made my head explode...

hope my insurance covers it ;)

Beach Bunny
08-19-2008, 07:58 AM
Check that $4000... it may be that that's the MAX out of pocket. Many policies have something like a $500 deductible before the policy starts paying 80% of the 'normal and reasonable' charge for whatever is being done. And it realy isn't wise to go changing insurance carriers during a pregnancy. Really.

I am going to second OFG's advice to check that $4000. Most group insurance plans (what you are getting through work) are way much better than individual insurance. Usually the cost per month is a lot less and the deductible is a lot lower than with private insurance. And they usually cover things like well-baby check-ups that private insurance does not cover.

willfulone
08-19-2008, 08:00 AM
Check that $4000... it may be that that's the MAX out of pocket. Many policies have something like a $500 deductible before the policy starts paying 80% of the 'normal and reasonable' charge for whatever is being done. And it realy isn't wise to go changing insurance carriers during a pregnancy. Really.

You may be right about this (bolded). Even if it IS the deductible, many plans allow for a higher deductible, then 100% covered after that. Although, many have 90/10, 80/20, 70/30 or even 50/50 after dedictible. It will also depend upon the type of bene used to determine what applies. Some services (routine mammo for instance) may be covered 100% no matter what. Or they may not.

In the case of inpatient (IP) services, many policies (even with high deductibles) will only have a copayment for the hospital stay if you go in network (INN). Many policies only apply ded & coins when going out of network (OON) or for certain services. It is hard to state what applies in his case when he states the ded is $4000 for it may or may not apply in this case, depending upon a number of variables.

Thus, Allen needs to read his policy and determine if the ded applies to ALL benes, the INN, the OON or what. He may have a 500 copay for IP and nothing else.

A subscriber/policy member should always call member services and get a quote for what applies to a certain benefit for a certain service. Then they will know exactly what applies where. Also, the Representative will be able to tell the subscriber if the policy has a 4th quarter carryover (which is great if you are having a baby early in the year following a year where accumulation of ded & coins took place in the fourth quarter of the year) that will apply to the following year accumulations. The rep will also be able to tell the member how much of the accumulation has been met and how much is remaining.

In this case, Allen or his wife should call member services and ask what the IP maternity benes are for the facility charges to ensure he does not get the physician benes quoted. They should also ask what the guidelines for authorizing IP mat is (just because the auth is waived in many states for Maternity, the policy does not have to follow the state mandates of the state he lives in if the policy is from an out of state carrier - they follow the policy guidelines then). Auth is facility responsibility and Allen would NOT be responsible for any unpaid bills if the facility did not get said auth if required. He would not have to pay until retro auth obtained and facility got insurance to pay policy portion first. He should ask - how many days are allowed for the policy bene (2-4 days is standard), what ded is, what copay is, what coins is. He should also ask if the baby follows the mama on the auth and what the circumstances are for child needing own auth if applicable (he cannot get the auth, but it never hurts to have the knowledge), he should also ask what the state guidelines are for adding child to policy and how many days he has for notification to carrier (regardless if they go with hers or new policy). Then he should ask how and who they need to inform at the insurance carrier so he can make notification to cover his ass if company does not make timely notification.

He should also always get a call reference number when talking to the insurance company. He should write date on it, rep's name and the number to reference call. Insurance companies record calls and if has an appeal issue, the record will be easily locatable with this information.

Christine

willfulone
08-19-2008, 08:03 AM
Whoa... you just made my head explode...

hope my insurance covers it ;)

It will as long as it is not self inflicted. Some policies do not cover self inflicted wounds or wounds obtained while committing a crime. If it just implodes, your carrier will cover it. Although, they WILL want a determination of medical necessity (sadly).

Christine

willfulone
08-19-2008, 08:11 AM
I never had any trouble-- which is good because if I loose coverage, I'll never get it again! And I went from being on Hubby's plan to going into Cobra, but just for me (that was a messed up situation!) to being on Hubby's plan at New Job. Never lost coverage, had no issues.

If you lose coverage and cannot obtain benefit from another carrier (in my state it is 2 denials required - may be different in yours) you are often then eligible for whatever benefits the state offers through its medical assistance program. This has nothing to do with income levels or low income offerings. It has to do with covering people so that medical professionals will not turn away uninsureds when services are needed or because of a person's lack of ability to pay for said services if they are not covered. It is hard to find a doctor that will not require up front payment if no insurance coverage. Many people decline medical assistance (meaning they will not go to a doctor when they really should) for this very reason and it is horrible that it has to happen.

You may want to check your state guidelines. It will offer you piece of mind if nothing else, in case the worse should ever happen. If you need help doing this, PM me your state and I will link you up to the info needed on such.

Christine

willfulone
08-19-2008, 09:01 AM
We've been looking over the plans that Blue Cross provides, and we think we may be able to go with one of them, as they have different kinds with different levels of premiums and deductibles.

In the long run, over the year, it would be cheaper to go with Blue Cross than through her work (United Health Care).

Humana is another one we're considering.

Only one problem: they may turn us down since she's pregnant. It would be considered a pre-existing condition.

allen

You do not want to just look at your initial premiums when you go to buy right now. You will be converting to a family policy from husband & wife once babe comes. You may see a significant jump in premiums once that occurs. Check that out when determining your costs as you look for a policy. What you think is a savings now, could be a huge burden later on and not cost effective in the long run when you take that higher premium payment for family policy versus H & W. Many employers do not have a huge premium leap (although some do) when going from husband and wife to family enrollment. But, a private purchase premium could (and most likely will) take a significant leap once the babe converts your policy from H & W to Family. However, this can be avoided (but you will pay more now for premiums) if you buy a Family policy immediately and ensure there is no jump in premiums to add that third person to the policy.

maestrowork
08-19-2008, 09:07 AM
My $2500 "deductible" is also the max out-of-pocket (annual), BTW. I agree you have to check both the deductible AND the max out-of-pocket, as well as copayment and the % coverage (some may pay only 50% for certain procedures and medical costs, not 80 or 100%).

Again, with a baby coming your way, it's very important to think it through and check out all your options. List all the pros and cons and do a cost analysis.


Also, please be sure, whether you stick with the employer or go with private purchase your babe is added to policy within first 30 days of life. If not, the babe is put on pre-x for days 31 on until pre-x clause is met.

underthecity
08-19-2008, 10:16 PM
Willfullone,

Thanks for the detailed posts. I'll be printing them out to share with my wife as we decide what to do.

Initially, she thought the deductible was $2000. And we thought that was a lot, but we could handle it. Then she called the insurance company and discovered that it was a $4000 family deductible. Then, as she told me later, she cried and cried at work--pregnant emotions and all that.

That's when she declared that our insuranced Sucked and we should get something else.

Thanks everyone for your advice. And we are listing the pros and cons of each insurance as well as cost analysis. Humana has a decently priced policy, and Blue Cross has comparable ones as well.

Willfullone, I will be in touch.

allen

Ol' Fashioned Girl
08-19-2008, 10:25 PM
He should also always get a call reference number when talking to the insurance company. He should write date on it, rep's name and the number to reference call. Insurance companies record calls and if has an appeal issue, the record will be easily locatable with this information.

Christine

This paragraph is worth repeating, copying, printing, and posting close to the phone. IOW: It's very important to get the info so you can quote it back to the next person you have to talk to if there's a problem - and there will be... no matter who your carrier is.

willfulone
08-20-2008, 01:04 AM
[quote=willfulone;2669191][quote=underthecity;2668558]Willfullone,

Thanks for the detailed posts. I'll be printing them out to share with my wife as we decide what to do.

Initially, she thought the deductible was $2000. And we thought that was a lot, but we could handle it. Then she called the insurance company and discovered that it was a $4000 family deductible. Then, as she told me later, she cried and cried at work--pregnant emotions and all that.

That's when she declared that our insuranced Sucked and we should get something else.

Thanks everyone for your advice. And we are listing the pros and cons of each insurance as well as cost analysis. Humana has a decently priced policy, and Blue Cross has comparable ones as well.

Willfullone, I will be in touch.
[quote]

I bolded what I wish to reply to here. Just because the family deductible is $4000 does NOT mean you will have to pay $4000 for the hospital stay for ded as a family plan. This is why policies are so hard for people to understand - the techno speak is hard to muddle through.

If her policy has the phrase and/or clause in the deductible area that states Once A PERSON/INDIVIDUAL has met their ded...you are fine and will only have to meet the ded for her - you are not required to meet the family ded with that one person then. She will ONLY have the $2000 ded to meet for the IP mat stay (if it even applies in lieu of an IP copayment) if that is the case and/or her coins if applies in such a case. A family policy does not eliminate the possibility of individuals meeting single quotas, it just can in some instances if the policy makes it so.

I will also state this: A representative at an insurance company can misread and misintrepret benefits when they quote them (everyone makes mistakes). Also, it is imperitive to ask the right questions if you are on the line with a rep who does not probe you further for additional information so that they can provide exactly what you need. They are required by HIPPA regulations to answer your questions and not provide extra information or they can get a ding for violation of HIPPA. Thus, they should be asking you questions to assist you further - especially members versus professional providers who deal daily with insurance policies and companies. The hard thing is, most people do not know how to ask for what they need in these cases. It has nothing to do with lack of intelligence either. It is just that the questions that make sense when you ask them may not be what you are after specifically given a certain circumstance.

You can call on the policy for benefits as an adult dependant on the policy. Maybe you could do so and save her the frustration and angst at hearing something that upsets her. Call up and ask these questions and do it specifically:

1. What type of policy is this? PPO, HMO, ect. and H & W or Family?
NOTE: you should be able to look on your card and see if it says FAM or H&W - that will help. Most husband and wife policies (not all) will take all accruals as individuals and never take the family quotas when giving benes as they may not apply.
2. Do I have In Network benefits and Out Of network benefits?
3. What is the ded for my policy? Does it change INN and OON? If so, give me those amounts please, I want INN ded and OON ded amounts for the individuals and family (if family applies to your policy).
4. Does ded apply to IP stays? Please read the full paragraph verbatum from my policy quoting this - thanks
5. What is my coins percent?
6. Does coins percent apply to IP stays? Please read the full paragraph verbatum from my policy quoting this - thanks
7. What is my MOOP (maximum out of pocket individual and family) - get INN and OON if has both
8. Does the MOOP include the ded amt or apply AFTER ded amts?
9. If ONE person meets the single ded is their ded met, or will they be required to continue until the family ded is met (if it applies) if no one else has met any ded accrual? Please read me the full paragraph from my policy verbatum quoting this - thanks.
10. Does this policy have 4th quarter carryover benefits? If applicable, please read me the full paragraph from my policy verbatum quoting this - thanks.
11. How much of our deductibles have been met to date for both of us as individuals? If INN and OON please give me all.
12. For IP stays, is there a copay? (Please read the full paragraph from my policy verbatum quoting this - thanks.) - does this copay (if applicable)apply to INN and OON or which if only one?
13. If there is a copay, is the ded and coins moop (maximum out of pocket) waived if the copay applies? (Please read the full paragraph from my policy verbatum quoting this - thanks.)

Get the answers to those questions and pm me or post the replies here and I will tell you what the replies mean if you are still unsure what the information states. Also, it would be best if you have your policy booklet handy to question anything that differs in the quote than what is printed in your booklet. Employers change benes all the time and do not hand out new books for employees - sucks, but happens often enough you want to be aware of it.

Let me know if I can help further.

Christine

maestrowork
08-20-2008, 05:23 AM
Makes me really want to have universal healthcare and just rid of the whole insurance nightmare. ;)

Shadow_Ferret
08-20-2008, 06:07 AM
Shh. Don't open that can of worms in here.