Reason #79 to read your health insurance policy

[dgoldenz]

Just a warning for those making the switch to individual health insurance and looking at different policies online (like the eHealth website). I found this contract language in a hospital/surgical plan today (read: not a full major medical policy) and if I were a policyholder, this would concern me. If you are buying individual health insurance, make sure to read your contract cover to cover.

Also note the statement above - this is a hospital/surgical plan. Reading the benefits summary makes it seem like prescriptions are covered, outpatient is covered, etc, when in reality prescriptions are only covered when you are in the hospital or if related to a surgery, and outpatient services are not covered period unless related to a surgery. Need a CT scan because you bumped your head? Well, that's not a surgery. Need chemo treatment or cancer drugs? Well, that's not surgery and it's not inpatient.

So reading the following language, is it covered, or isn't it?

Hospital Services
Inpatient:
The following may be Covered Services when rendered in an Inpatient Hospital setting:
1. room and board in a semi-private room when confined as an Inpatient, unless the patient must be isolated from others for documented clinical reasons;
2. intensive care units, including cardiac, progressive and neonatal care;
3. use of operating and recovery rooms;
4. use of emergency rooms;
5. respiratory, pulmonary, or inhalation therapy (e.g., oxygen);
6. drugs and medicines administered by the Hospital (except for take-home drugs);
7. intravenous solutions;
8. administration and cost of whole blood or blood products (except as outlined in the Drugs exclusion of the "What Is Excluded?" section);
9. dressings, including ordinary casts;
10. anesthetics and their administration;
11. transfusion supplies and equipment;
12. diagnostic Services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., EKG);
13. chemotherapy and radiation treatment for proven malignant disease;
14. Physical, Speech, Occupational, Cardiac Therapies; and
15. transplants as described in the Transplant Services category in this section.
Exclusion:
Expenses for any Services rendered in an Inpatient Hospital setting are excluded when such Services could have been provided without admitting you to the Hospital.
In addition, expenses for the following and similar items are also excluded:
1. gowns and slippers;
2. shampoo, toothpaste, body lotions and hygiene packets;
3. take-home drugs;
4. telephone and television;
5. guest meals or gourmet menus; and
6. admission kits.

 

[73ss454]

Great post, it's almost as bad as buying an annuity.

 

[kumquat]

SPIA or otherwise?

 

[73ss454]

If an insurance company is involved, I'm out. Do you think that the many pages of disclosures have anything in them that's for the consumers benefit?

With that said, if I had to buy one it would be a SPIA. I have a LI policy with a CV that would change my tax bracket and a SPIA is a way to beat the tax, for a while anyway. Most likely I'll just pay the tax when it's time to cash it in. I figure the insurance company will figure a way to take more of my money than Uncle Sam.

Sorry Golden, I didn't mean to pull a hijack here.

 

[ls99]

Read my individual policy when issued four years ago. Does not cover ambulance transport among other things.

We do make a sizable donation each year to the local EMS/Fire association. We KNOW they get it, since we make the checks payable to them, and not some boiler room shills.

For being a donor, they provide several per year ambulance runs both emergency and transport requiring care to the hospital 18 miles away. And we like to support the locals, both fire and EMS. All volunteer, and they are very good, very dedicated bunch. Their response times are insanely fast.

Typical charge for ambulance emergency run to the hospital is around $1200.

So yes, do read your policy.

 

[brucethebroker]

Be sure to check the fine print on the ambulance clause. I recently was airlifted to the nearest heart center, 35 miles. Cost of my helicopter ride? $17k. I was not asked nor told the price, it was just "ordered" from my local hospital EMR.

 

[chinaco]

Doesn't Medicare categorized plans to help people understand the minimum coverage? Or Supplemental Plans?

It would seem to me that categorize health plans such that it is easy to understand the minimum coverage of a plan wold be helpful. No doubt some insurance company would figure out how to game it... but with a little vigilance, it would keep people from making a mistake.... or worse be tricked by some agent.

 

[travelover]

Doesn't Medicare categorized plans to help people understand the minimum coverage? Or Supplemental Plans?

It would seem to me that categorize health plans such that it is easy to understand the minimum coverage of a plan wold be helpful. No doubt some insurance company would figure out how to game it... but with a little vigilance, it would keep people from making a mistake.... or worse be tricked by some agent.

I believe that the new health care law has certain minimum coverages so that insurance that covers for instance "$100 a day if you are hospitalized", or "$10,000 maximum lifetime payout" are no longer allowed. During the debate this was roundly criticized as excessive government interference in the insurance companies' offerings.

 

[travelover]

Be sure to check the fine print on the ambulance clause. I recently was airlifted to the nearest heart center, 35 miles. Cost of my helicopter ride? $17k. I was not asked nor told the price, it was just "ordered" from my local hospital EMR.

You mean you did not comparison shop? That is how the free market keeps prices low.

 

[M Paquette]

Be sure to check the fine print on the ambulance clause. I recently was airlifted to the nearest heart center, 35 miles. Cost of my helicopter ride? $17k. I was not asked nor told the price, it was just "ordered" from my local hospital EMR.

CALSTAR asks for a $45/family annual donation to cover their service. For folks living on the northern California coast, where medical services are few and far between, this is a bargain. With recent cutbacks, if you manage to make it to the emergency medical facility in Gualala or Fort Bragg, you are very likely going to be flown out to Santa Rosa where the nearest real hospital is located.

CALSTAR offers reciprocity with services across Oregon, Washington, Idaho, and Wyoming. And yes, without the membership donation a flight can be many thousands of dollars. The membership acts as secondary insurance for air medical services.

My parents in Fort Bragg made use of their services.

 

[Gotadimple]

Doesn't Medicare categorized plans to help people understand the minimum coverage? Or Supplemental Plans?

It would seem to me that categorize health plans such that it is easy to understand the minimum coverage of a plan wold be helpful. No doubt some insurance company would figure out how to game it... but with a little vigilance, it would keep people from making a mistake.... or worse be tricked by some agent.

Yes MedSup plans have categories of coverage.

 

[dgoldenz]

I believe that the new health care law has certain minimum coverages so that insurance that covers for instance "$100 a day if you are hospitalized", or "$10,000 maximum lifetime payout" are no longer allowed. During the debate this was roundly criticized as excessive government interference in the insurance companies' offerings.

The "minimum" coverage required by the new law for plans in the exchange in 2014 exceeds what most plans on the individual market have today, and thus will be much more expensive, plus another 3 years of medical inflation before then. So who is going to pay for them? Most families struggle to pay $300-500/month, let alone $1000-1500/month.

Also, mini-med plans, which you are referring to, are still legal and being sold to unsuspecting consumers every day. I wish they would be banned already or require large, bold print disclosures with a "THIS IS NOT HEALTH INSURANCE" message on the first page. That's another story though.

 

[travelover]

The "minimum" coverage required by the new law for plans in the exchange in 2014 exceeds what most plans on the individual market have today, and thus will be much more expensive, plus another 3 years of medical inflation before then. So who is going to pay for them? Most families struggle to pay $300-500/month, let alone $1000-1500/month.

Also, mini-med plans, which you are referring to, are still legal and being sold to unsuspecting consumers every day. I wish they would be banned already or require large, bold print disclosures with a "THIS IS NOT HEALTH INSURANCE" message on the first page. That's another story though.

Maybe the law will need to be amended, if that level of coverage is unaffordable.

 

[dgoldenz]

Maybe the law will need to be amended, if that level of coverage is unaffordable.

Their first reaction will be to increase subsidies, not reduce benefits, don't worry.

 

[travelover]

.......... don't worry.

OK.

 

[frank]

when the federal government gets involved you can be sure it will cost more. the sad part is what to do when you have some savings and can't afford the health insurance? this is coming in the not to distant future.

 

[Martha]

when the federal government gets involved you can be sure it will cost more.

Are you sure? Look at other countries. This does not need to be the case.

the sad part is what to do when you have some savings and can't afford the health insurance? this is coming in the not to distant future.

This is here now. The numbers of uninsured increase every year. The numbers of small employers dropping insurance increase every year.

 

[Martha]

Also, mini-med plans, which you are referring to, are still legal and being sold to unsuspecting consumers every day. I wish they would be banned already or require large, bold print disclosures with a "THIS IS NOT HEALTH INSURANCE" message on the first page. That's another story though.

Agree!