changing plans

[teejayevans]

Lets say I ER, in good health, I have a choice of HSA plans, some with and
without outpatient benefits. If a choose a low cost plan, lets say 10 years
I decide that I like to change plans (staying with same company) to get more
coverage, etc.
Is this like starting over?
TJ

 

[mykidslovedogs]

TJ -

If you are talking about an individual plan, you will have to be re-underwritten if you want better benefits - even if you stay with the same insurance company. However, anytime you raise your deductible or make your benefits less, then you can just do a simple plan design change without having to be underwritten. It's usually better to start with the best and reduce benefits later if you don't want to worry about being re-underwritten.

It has to be that way, otherwise, people would just buy the cheapest plan and then upgrade when they get sick. For example, I once had a customer who chose a 3000 deductible major medical plan. Later on, she became diagnosed with Diabetes, so she wanted to lower her deductible at that time in order to reduce her out of pocket responsibility. Unfortunately, she could not qualify for a lower deductible plan because of her new health condition.

On the other hand, if you are on a company retiree plan, you can pretty much change to any kind of plan that is offered at open enrollment time. Company retiree plans are guaranteed issue, so you can make any kind of changes you want at "open enrollment".

 

[FinallyRetired]

TJ - For example, I once had a customer who chose a 3000 deductible major medical plan. Later on, she became diagnosed with Diabetes, so she wanted to lower her deductible at that time in order to reduce her out of pocket responsibility. Unfortunately, she could not qualify for a lower deductible plan because of her new health condition.

She might have been denied even if she had not been formally diagnosed with diabetes. Here's a personal example of the crappy health insurance business. I have the military Tricare Prime, with nothing out of pocket. I'm thinking of switching to Tricare Standard so I have more choices of doctors and can be treated when I'm traveling out of my tricare region, with Mediplus to cover the 25% Standard copay and $3000 catastrophic cap. Seems like a straight forward deal.

Mediplus has a six month waiting period for pre-existing conditions, so I have to decide how much I'm willing to risk that one of my pre-existing conditions may flare up in the next six months before switching over.

I can make an informed decision over the conditions that I know I have (which aren't many), but it's hard as heck to make an informed decision over conditions I don't know I have.

Situation: A couple of months ago I had a 4.2 PSA and was referred to a urologist. Urologist said I should retest, because PSA can have spikes for lots of reasons (eg, sex the night before). I retest and it's down to 2.9. Urologist says that's encouraging, wait three months, retest again, if it's high then have a biopsy to see if I have prostate cancer. I called the insurance company to ask if I switch insurance, then find my next PSA to be high, then have a biopsy, then the biopsy happens to show Prostate Cancer, then it turns out to be serious enough to be treated with surgery, would they consider that a pre-existing condition? The answer: Yes. My response: So in the unlikely case all of this happens, you would rather have me wait another few months to be covered by insurance, when the disease might be more serious and more costly to treat? The answer: That's our policy.

Fortunately, this is not a real problem for me, since I will just remain on my current policy for six months. But what if I didn't have that option? Or what if I didn't know better than to ask questions ahead of time? I don't care how much you defend it, this is a crappy, crappy system.

By the way, same thing happened with my dental insurance. It had a 12 month waiting period. I cracked a tooth after six months, was told I needed a crown, but had to wait another six months of eating on the other side until the insurance kicked in. I was tempted to just pay out of pocket but didn't want to give the insurance company the benefit of not having to pay.

 

[Beststash]

TJ - On the other hand, if you are on a company retiree plan, you can pretty much change to any kind of plan that is offered at open enrollment time. Company retiree plans are guaranteed issue, so you can make any kind of changes you want at "open enrollment".

My problem is that my retiree "group" plan doesn't have any options except the "lexus" version (90/10 - no deductible). They dropped dependent benefits after I retired but I can carry her under family plan at with no benefit (she was SAHM with no other options). For the DW (glaucoma) cost wise we don't have much choice - I wish we could get HSA or high deductible plan but I doubt that she would be accepted without pre-existing condition waiver. Also, it is my understanding that although our insurance is through Aetna the company is self-insured and uses them to administer the plan - thus making the HIPPA rules not apply. Any ideas?

 

[mykidslovedogs]

She might have been denied even if she had not been formally diagnosed with diabetes.

Soon, I wasn't really trying to defend anything with my response to TJ - I was just trying to explain to him what would happen if he decided he wanted a better plan later on down the road. Purchasing a plan with more benefits than the one you originally start out with, in the individual market, always results in being re-underwritten.

I'm not really sure why you think my client would be denied coverage for her diabetes. When she purchased her health plan, she bought it many years before she was originally diagnosed. She didn't even have pre-diabetes at the time of the application. Now, if she were to try to increase her benefits after having been diagnosed, then she would be declined, but they couldn't deny coverage for her condition on her existing plan, because she bought it way before she was ever diagnosed or had any kind of symptoms of the disease.

As far as dental plan waiting periods go, that's just the way dental plans are. They don't make you wait for preventive care...just basic and major services. It has to be that way, or else, who would ever buy dental insurance unless they were in immediate need of an expensive procedure such as a crown or root canal? I mean, let's put it this way. If you had an aquaintance who came up to you and said, I'll give you $20 bucks a month if you'll pay for my $2000 bridge and crown tomorrow, do you think you would lend them the money?...especially if you knew they'd probably drop off the face of the earth the day after the procedure? No. The purpose of insurance is to purchase it in advance, as protection, in the unlikely event of needing expensive services. If you don't want a dental waiting period, then a discount plan is probably the next best option. The networks are somewhat limited, but the discounts can be substantial and there are usually no waiting periods.

One more thing..are you sure the plan that you were thinking of switching to would not give you credit towards the pre-existing condition waiting period for the prior coverage you carried? In Colorado, at least, if you've had continuous coverage, insurance carriers always give you credit towards the pre-ex waiting period based on the length of time you were covered prior to applying for the new plan.

And one more tidbit for the board in response to Soon's PSA question. Yes. Individual and Family insurance carriers do not like uncertaintly when it comes to underwriting....because, if they approve you with no exclusion of coverage for the pre-existing condition, then they have to pay the claims down the road (unless they can prove that you fraudulently failed to disclose information on your application). In your case, you probably would have been declined for coverage anyway, until the doctor could be 100% certain that the abnormal PSA test was not caused by cancer. Once the doctor could put his confidence in writing that there is no immediate concern of prostate cancer, then the insurance carrier would accept you for coverage. The acceptance of coverage based on your medical records all becomes part of the contract, so, contractually, they would not have the right to deny coverage for prostate cancer down the road if they accepted you for coverage based on your doctor's prognosis.

 

[mykidslovedogs]

My problem is that my retiree "group" plan doesn't have any options except the "lexus" version (90/10 - no deductible). They dropped dependent benefits after I retired but I can carry her under family plan at with no benefit (she was SAHM with no other options). For the DW (glaucoma) cost wise we don't have much choice - I wish we could get HSA or high deductible plan but I doubt that she would be accepted without pre-existing condition waiver. Also, it is my understanding that although our insurance is through Aetna the company is self-insured and uses them to administer the plan - thus making the HIPPA rules not apply. Any ideas?

Best - Unfortunately, the glaucoma is going to create problems with underwriting on an individual plan. However, do you live in a state with a guaranteed plan that does not require HIPAA eligibility? (In Colorado, you don't have to be HIPAA eligible for the state guaranteed plan...you just have to have been declined or exluded from coverage elsewhere). The Colorado state guaranteed plan has an HSA option, and some other, high deductible options, too. Your options are really going to depend on what state you live in.

 

[FinallyRetired]

I'm not really sure why you think my client would be denied coverage for her diabetes. When she purchased her health plan, she bought it many years before she was originally diagnosed. She didn't even have pre-diabetes at the time of the application. Now, if she were to try to increase her benefits after having been diagnosed, then she would be declined, but they couldn't deny coverage for her condition on her existing plan, because she bought it way before she was ever diagnosed.

It depends what "diagnosed" means. Suppose she had a glucose test that was marginally high, then came down (this is the equivalent of a spike in a PSA reading). The doc wants to look at another glucose test a few months down the road. She goes for another few years, then is diagnosed with diabetes. The insurance company might want to look back at that spike and deny coverage. Again, I don't know, maybe diabetes is treated differently, but PSA testing is a controversial issue for men because of insurance implications among other things.

As far as dental plan waiting periods go, that's just the way dental plans are. They don't make you wait for preventive care...just basic and major services. It has to be that way, or else, who would ever buy dental insurance unless they were in immediate need of an expensive procedure such as a crown or root canal? I mean, let's put it this way. If you had an aquaintance who came up to you and said, I'll give you $20 bucks a month if you'll pay for my $2000 bridge and crown tomorrow, do you think you would lend them the money?...especially if you knew they'd probably drop off the face of the earth the day after the procedure? No. The purpose of insurance is to purchase it in advance, as protection, in the unlikely event of needing expensive services.

I did, I bought it in advance. I had no dental issues when I bought it, in fact I had just had a dental exam and been given a clean bill of dental health. It was just bad luck that six months later I cracked a tooth. So the insurance company has two choices: pay for the crown, or tell me to wait another six months, by which time I might also need a root canal, then pay for both the crown and the root canal. They chose the latter and, fortunately for them, I didn't need the root canal. Makes little sense to me.

And one more tidbit for the board in response to Soon's PSA question. Yes. Individual and Family insurance carriers do not like uncertaintly when it comes to underwriting....because, if they approve you with no exclusion of coverage for the pre-existing condition, then they have to pay the claims down the road (unless they can prove that you fraudulently failed to disclose information on your application). In your case, you probably would have been declined for coverage anyway, until the doctor could be 100% certain that the abnormal PSA test was not caused by cancer.

There is no way for a doctor to be 100% certain that an abnormal PSA is not caused by cancer without taking the prostate out and looking at it. Even a negative biopsy is not proof of no cancer, since it only samples a few locations. Anyway, I think you misunderstood my situation. It is not uninsurability, it is a waiting period, similar to the dental situation. I would indeed be covered, but have to wait six months for the coverage to kick in for pre-existing conditions. So the insurance company is essentially hoping a person will die in six months, it's the only way they can make money from this, since if the person lives, chances are they will need more care because the condition has progressed for six months. It is a sick system that we live under... well, I don't, thank God.

 

[mykidslovedogs]

It depends what "diagnosed" means. Suppose she had a glucose test that was marginally high, then came down (this is the equivalent of a spike in a PSA reading). The doc wants to look at another glucose test a few months down the road. She goes for another few years, then is diagnosed with diabetes. The insurance company might want to look back at that spike and deny coverage. Again, I don't know, maybe diabetes is treated differently, but PSA testing is a controversial issue for men because of insurance implications among other things.

OK - In her case, she had individual and family coverage. With individual and family coverage, there really isn't any such thing as a "pre-existing condition waiting period" once you've been accepted for coverage. Insurance carriers put the disclaimer on the application in case of application mis-statements, where something minor might have been mistakenly left off the application, and not discovered in the medical records. However, leaving something like an abnormal glucose test or abnormal prostate test off of an application is not a mistake...that would be fraud, in which case the insurance company could rescind coverage. If something like that were disclosed on an original application for individual and family coverage, it would result in a decline anyway.

I did, I bought it in advance. I had no dental issues when I bought it, in fact I had just had a dental exam and been given a clean bill of dental health. It was just bad luck that six months later I cracked a tooth. So the insurance company has two choices: pay for the crown, or tell me to wait another six months, by which time I might also need a root canal, then pay for both the crown and the root canal. They chose the latter and, fortunately for them, I didn't need the root canal. Makes little sense to me.

But, did you read your contract when you purchased the dental plan? All individual and small group dental plans typically have a 6 month waiting period for basic services (like fillings) and a 12-month waiting period for major services (like crowns and root canals).

You should have known about the waiting period when you purchased your plan, and it shouldn't have surprised you. Sometimes waiting periods are waived for covered groups with more than 10 lives on the plan, but that also depends on when you apply. If you are a late enrollee, someone who didn't apply when first offered the coverage, then you are subject to the waiting periods as a penalty for not having signed up for it when you first became eligible under the group plan.

There is no way for a doctor to be 100% certain that an abnormal PSA is not caused by cancer without taking the prostate out and looking at it. Even a negative biopsy is not proof of no cancer, since it only samples a few locations. Anyway, I think you misunderstood my situation. It is not uninsurability, it is a waiting period, similar to the dental situation. I would indeed be covered, but have to wait six months for the coverage to kick in for pre-existing conditions. So the insurance company is essentially hoping a person will die in six months, it's the only way they can make money from this, since if the person lives, chances are they will need more care because the condition has progressed for six months. It is a sick system that we live under... well, I don't, thank God.

I think I did misunderstand you, although I don't understand why you would have a waiting period if you had continuous, creditable coverage prior to applying with that plan. Most insurance carriers give you credit for prior coverage when it comes to waiting periods and switching insurance...especially on group plans.

 

[FinallyRetired]

However, leaving something like an abnormal glucose test or abnormal prostate test off of an application is not a mistake...that would be fraud, in which case the insurance company could rescind coverage. If something like that were disclosed on an original application for individual and family coverage, it would result in a decline anyway.

You've made a very important point about the problem of uninsurability in this country. I hope all guys reading this will take note. Do not, I repeat, do not, have a PSA test until you have all your health and insurance needs in order. The PSA test is notorious for false positives, yet is used by the insurance industry to deny insurance. Please note, I didn't say to not have a PSA test, that is between you and your doctor. But if you decide to have a test, heed these words about insurability. Oh, and no sex for a couple of days beforehand

But, did you read your contract when you purchased the dental plan? All individual and small group dental plans typically have a 6 month waiting period for basic services (like fillings) and a 12-month waiting period for major services (like crowns and root canals).

Oh yeah, I read it, and realized as soon as I cracked a tooth that I had rolled snake eyes. My point was not that the insurance company reneged, it was that it appears to me to be a stupid rule.

I think I did misunderstand you, although I don't understand why you would have a waiting period if you had continuous, creditable coverage prior to applying with that plan.

Neither do I. It's just the way it is.

 

[Beststash]

Best - Unfortunately, the glaucoma is going to create problems with underwriting on an individual plan. However, do you live in a state with a guaranteed plan that does not require HIPAA eligibility? (In Colorado, you don't have to be HIPAA eligible for the state guaranteed plan...you just have to have been declined or exluded from coverage elsewhere). The Colorado state guaranteed plan has an HSA option, and some other, high deductible options, too. Your options are really going to depend on what state you live in.

The State (Texas) High Risk Pool would be better economically but would she be eligible if I can still get coverage for her under my group plan - although not funded?? I think it would be much better for me to be able to use my group plan as an individual and for her to go to the High Risk Pool in the form of an HSA - do you know?

Peace

 

[mykidslovedogs]

Best - take a look at this site: It has info about the TX high risk pool. From what I see regarding eligibility, it looks like she may be eligible just with evidence of uninsurability or uprating (which you'd have to get by going through underwriting with an individual carrier like Blue Cross, first.)

TNHIS State-by-State Guide - Texas

 

[teejayevans]

Soon, I wasn't really trying to defend anything with my response to TJ - I was just trying to explain to him what would happen if he decided he wanted a better plan later on down the road. Purchasing a plan with more benefits than the one you originally start out with, in the individual market, always results in being re-underwritten.

As far as dental plan waiting periods go, that's just the way dental plans are. They don't make you wait for preventive care...just basic and major services.

I figured that was the way it worked, I have to decide if outpatient
services are worth $400 (office visits, drugs, etc). The problem is I'm
in the dark, because I don't know what things cost.

As far as dental, since I have my last bill, the math works like this:
$148 for cleaning, exam, x-rays, I wouldn't have x-ray on the next
semi-monthly visit, but assume I spent $300/yr anyways,
The quotes I got are $264/yr, pays anywhere 10-50%... that decision
is easy, I'll go without the dental (and its only $750 max).

I thought about getting a discount card, but even that works out to
be $80/yr...for no insurance, just a discount card!!


I didn't want this to degrade into another useless political discussion,

TJ

 

[Beststash]

Best - take a look at this site: It has info about the TX high risk pool. From what I see regarding eligibility, it looks like she may be eligible just with evidence of uninsurability or uprating (which you'd have to get by going through underwriting with an individual carrier like Blue Cross, first.)

TNHIS State-by-State Guide - Texas

Thanks MKLD. I guess we should go ahead and submit an application to BC now and see what happens. My open enrollment is in Oct. I appreciate the help.

Peace

 

[mykidslovedogs]

Hi Best - Try this site:

TNHIS State-by-State Guide - Texas

It gives you more info about the Texas high risk pool. In the eligibility section, it says that you can be eligible with evidence of uninsurablility or uprating. This is just like Colorado. The question, I guess, would be if they are taking new applicants. You might want to make a phone call to find out more. If she can get a decline or uprating from an individual carrier, then that would be the evidence you would need for eligibility into the risk pool based on what I am seeing here.

 

[mykidslovedogs]

I figured that was the way it worked, I have to decide if outpatient
services are worth $400 (office visits, drugs, etc). The problem is I'm
in the dark, because I don't know what things cost.

As far as dental, since I have my last bill, the math works like this:
$148 for cleaning, exam, x-rays, I wouldn't have x-ray on the next
semi-monthly visit, but assume I spent $300/yr anyways,
The quotes I got are $264/yr, pays anywhere 10-50%... that decision
is easy, I'll go without the dental (and its only $750 max).

I thought about getting a discount card, but even that works out to
be $80/yr...for no insurance, just a discount card!!


I didn't want this to degrade into another useless political discussion,

TJ

I promise it won't degrade . But on that dental issue, just FYI, sometimes those discounts can be very substantial...$5 preventive visits, and very nice discounts on fillings and major services too. The big disadvantage is that you have to use their limited networks. Take a look at this link. It shows a schedule of benefits which gives you an idea of what kind of discounts you can get on a discount plan. This is a Colorado only plan, but it will give you an idea. I am sure there are local discount plans where you are too.

http://www.efsbenefits.com/Vendor -...lications/Alpha Individual Enrollment Kit.pdf

On the other hand, sounds like your dental offering isn't too bad, but the $750 annual maximum isn't really a whole lot of coverage, either.

On your medical, are you saying they are going to charge you $400 more per month for the office visits, outpatient, Rx, etc? Wow - that is a LOT! On the other hand, I've had clients with expensive injectible drugs for things like blood clots and cancer where the drugs run more than $1500/mo, so the $400 would be a bargain in a case like that. Routine office visits run around $100. What you really want to make sure of is that, whatever plan you choose covers LAB & X-Ray. Diagnostic Lab & X-Ray is extremely expensive without insurance. With insurance, on the other hand, even if it goes to a deductible, you will get HUGE discounts if you are covered for it. For example, a $600 blood test could be discounted down to something like $75-$100 with insurance, even if the cost has to go to the deductible, you still get the HUGE discount, first. Without coverage for diagnostic lab & x-ray, you pay the whole bill.

 

[teejayevans]

On your medical, are you saying they are going to charge you $400 more per month for the office visits, outpatient, Rx, etc? Wow - that is a LOT!

no, its $34/month, 400 per year, if it were 400/month then it would be an
easy decision
TJ

 

[mykidslovedogs]

no, its $34/month, 400 per year, if it were 400/month then it would be an
easy decision
TJ

Oh - I was gonna say! That would be an easy decision! But IMO, if it is the difference between having Rx coverage or not having Rx coverage, I would spend the extra $34/mo. That's really not bad for outpatient and Rx coverage. I've actually said this before on other posts, but I really don't like the idea of selling plans that don't have Rx coverage. At the very minimum, I would want to at least have coverage after a deductible. The reason being is because Rx is one of the most expensive parts of health care, aside from hospitalization....and the whole reason for buying the insurance is to protect your assets from a catastrophic loss. Rx can quickly add up, especially for diseases like Rheumatoid Arthritis, Cancer, Blood Clots, Multiple Sclerosis, Diabetes, etc.

 

[kcowan]

Consumer Reports on HMO/PPO satisfaction

The September issue has ratings of the HMO/PPOs:Only 67 percent of our readers said they were completely or very satisfied with their plan; that's up slightly from our total in our 2004 survey of HMOs and PPOs (64 percent). That rate is only average compared with what we've found when we've done consumer satisfaction surveys of other services.

For example, 84 percent of people who had an auto insurance claim told us in a 2004 Consumer Reports survey that they were either completely or very satisfied with their plan's service.

Why isn't satisfaction with HMOs and PPOs higher? Problems getting an appointment to see a doctor were reported by 10 percent of our readers, 21 percent had to deal with billing errors, 25 percent said they had a problem with their primary care provider, and 36 percent who called a plan representative for assistance said they had trouble getting the help they needed.
and also this:

When compared to individuals deemed "well insured," CR uncovered a huge disparity:
Well-Insured% Underinsured% Circumstance
65 37 Prepared to handle unexpected major medical costs in next 12 months
22 56 Postponed needed medical care in past 12 months due to costs
09 33 Dug deep into savings to pay medical bills
11 21 Made important job-related decisions based mainly on health-care needs
07 63 Health plan does not adequately cover prescription-drug costs
12 34 Decisions about retirement affected by medical expenses (adults 50+)
Employers Struggle To Keep Up While Insurers Prosper
Because of the way health insurance works, insurers haven't been paying much of a penalty for failing to contain costs. Insurers typically keep around 15 and 25 percent of the premiums they collect. As noted in the Consumer Reports investigation, the nation's six biggest private health insurers collectively earned nearly $11 billion in profits in 2006.

Employers are struggling to keep up: in the past five years, insurance premiums have risen three times as fast as inflation. While employers by and large have not asked employees to pay a bigger share of the overall premium, employees are still paying rising premiums.

In 2000, the average employee contribution for a family health plan was $135 per month and in 2006 it was $248. People who work for small companies bear the biggest brunt because those companies have fewer employees over which to spread medical risk. And lower paid workers also get hit hard because premiums and co-pays typically cost the same for everyone, regardless of income.

Underinsured are respondents who had 2 or more of these complaints:
- plans with high deductibles
- inadequate coverage for doctor visits, prescription drugs, medical tests, surgery & nonsurgical procedures or catastrophic medical conditions

From escalating medical debt to postponed retirement, our exclusive national survey of working-age adults shows the depth of jitters even for those lucky enough to have insurance through their jobs or families:
* 29 percent of people who had health insurance were "underinsured," with coverage so meager they often postponed medical care because of costs.
* 49 percent overall, and 43 percent of people with insurance, said they were "somewhat" to "completely" unprepared to cope with a costly medical emergency over the coming year.
* 20 percent of people in our separate subscriber survey said they were so disappointed with their HMO or PPO that they wanted to switch plans (see "Rating the Health Plans").
* 16 percent had no health plan at all, including many working respondents whose jobs didn't offer insurance, or who couldn't afford the premiums or deductibles of the available plan.

Some specific plan ratings

 

[kcowan]

The CR article does show that the quality of care is highly dependent on the specific insurance company. The only thing that HMOs are consistently good at is Billing! PPOs are crappy at Billing but excel at Choice of doctors.

Overall satisfaction ranges from 72% to 85% for HMOs and 69% to 83% for PPOs. Desire to switch companies ranges from 37% to 11% for HMOs and 38% to 12% for PPOs. Check out your library to see where you carrier ranks.

 

[Meadbh]

"the nation's six biggest private health insurers collectively earned nearly $11 billion in profits in 2006."

US$11 billion is five times the budget of the Calgary Health Region, which provides universal health care to over 1 million people. So, if redirected, the profits of the US insurance industry could be used to provide comparable health care to approximately 5 million Americans.

I wonder what the total revenues of the US health insurance industry are?