Health Insurance 411

Patient Charity Update

2009-02-03T10:23:00.002-05:00

Are you uninsured and looking for help?

Patient Charity may hold the key.

Patient Charity is updated on a regular basis and contains links to a number of sites containing information on a wide range of topics.

Here is a sample.

Coverage For All, a resource of taxpayer funded and charitable programs for the poor and uninsured.

Insure Kids Now, up to date information on SCHIP for every state.

Patient Advocate Foundation, a national non-profit organization that seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability relative to their diagnosis of life threatening or debilitating diseases.

In addition, there are also resources for those who want and can afford insurance but have been locked out of the individual major medical market due to existing health concerns. Several resources include:

BeniCard, a national network of more than 450,000 providers (doctors, hospitals & pharmacy's) who have agreed to participate in discount pricing for the uninsured.

Core Health, a guaranteed issue insurance plan available to eligible members age 18 - 65.

In addition to resources for the uninsured, you will find valuable information for insured patients. We have links to forms and sites for all the major carriers.

Health Insurance and BCBSGA

2009-02-02T09:47:00.003-05:00

How does health insurance with Blue Cross Blue Shield of Georgia work?

In today's market (2/2/2009) BCBSGA offer's a mixture of old and new plan designs.

About half the plans available have whiskers. The HSA compatible HDHP is mostly overpriced for the Georgia market. The old Blue Value series of copay plans are still available, but not online.

The newer series, SmartSense and Premier, were introduced in the summer of 2008 and are available for review online.

Blue's underwriting can be both challenging and unpredictable. At one time they bragged about approving 96% of applications.

It now appears the approval rate is significantly lower.

Those who submit direct to Blue typically experience a much higher rejection rate than those who submit through a knowledgeable agent.

Blue is still trying to find themselves in the Georgia market. They have been losing market share to "newcomers" with names like Aetna, United, Humana and Coventry.

The older plans, while pricey, are more comprehensive than the newer plans.

The lower priced SmartSense covers up to 3 office visits per year before applying to the deductible.

All other covered charges are payable at 70% after the deductible has been satisfied. This includes lab, X-ray, preventive care (over age 5), emergency care, hospital, etc.

SmartSense only covers generic Rx. Brand name meds are not covered but may be discounted. There are no maternity benefits other than complications.

Premier plans are approximately one third higher in premium but include more first dollar items. The Premier plan covers unlimited doctor visits at $35 each. The deductible is waived for preventive care for all ages and payable at 80% of covered charges.

Generic Rx are covered by a copay. Brand name drugs are covered by a convoluted formula after a deductible. If a member elects a brand name drug, and a generic is available, the member will pay the difference between the generic and brand name drug plus any copay and coinsurance.

Got it?

All other services, including emergency care, are subject to the deductible and then payable at 80%.

Maternity is an option but it is pricey and there are better plans available through other carriers.

Customer service is not their strong suit.

Their online access is decent, but there are much better offerings through other carriers.

You can also call their customer service line at 1-800-441-2273. Customer service hours are M - F from 7 AM to 7 PM.

New business underwriting normally takes 10 business days but can sometime move a bit quicker.

Blue's billing practices are among the worst. Some times they may forget to bill for 60 days or longer. Asking for a refund is like asking for a federal grant. Once they take your money it can take months to get a refund.

In spite of the issues, BCBSGA is a player in today's market, although not as dominant as they once were.

You can run BCBSGA quotes by clicking this link.

You can compare BCBSGA against other plans by clicking through to Georgia Insurance Shop.

A Look at Creation

2009-01-27T12:18:00.001-05:00

If you are offended by humor, don't click this link.

(Powerpoint viewer required).

Turning No into Yes

2009-01-27T11:32:00.003-05:00

I had a referral a few weeks ago. A really nice guy. Sixty years old and in reasonably good health.

He takes something for high blood pressure, acid reflux and cholesterol.

And he is deaf in one ear as a result of a benign cyst from a few years ago.

He has coverage now, if you can call it that. The plan covers almost nothing and will leave him financially ruined if he ever has a major claim.

Every carrier refused to make an offer due to the cyst.

Every carrier but one.

They agreed to consider his application before making a final determination. We didn't have a problem with that and thought it was only fair.

We sent the application in, and waited.

A week later we got a letter declining coverage.

That would probably stop most people dead in their tracks, but I am not most people.

I have over 30 years in this industry, and know what works and what doesn't. I also know that "no" sometimes means "yes" . . . IF you know how to properly appeal your case.

So I made a call to "my people" inside the carriers home office and presented my case. I showed them earlier correspondence from underwriting indicating the cyst was not a problem, and then we reviewed their declination which was a complete reversal.

My contact agreed I had done a thorough job of laying out the situation in the pre-screen process, prior to the application. There were no surprises. The condition was exactly as first revealed.

So the appeal started.

It took a bit longer than anticipated and I did get feedback while waiting. It seems the initial review wasn't as thorough as it should have been, but the "final" underwriting was also a bit sloppy.

Today they called and said an offer would be coming in the mail. The policy will be issued standard, with exclusionary riders for acid reflux and the hearing loss.

Sounds like a fantastic offer to me.

My client is pleased.

This is what makes my business so rewarding.

Health Insurance and Aetna

2009-01-26T13:23:00.003-05:00

How does health insurance with Aetna work?

In today's market (1/26/2009) Aetna offer's the best overall value of any carrier in Georgia.

Of course, that can all change.

Aetna's underwriting can be the most onerous in some ways and flexible in others. I have a reasonably good offer rate for applications submitted through my office. This is mostly due to the extensive pre-screening I do. Even still, about 10% of applications submitted through my office are declined.

Those who submit direct to Aetna typically experience a significantly higher rejection rate.

Aetna has some of the best HSA plans on the market.

The also have some plans that leave much to be desired, such as the Preventive and Hospital Care plan and the Open Value 10,000.

Customer service is good but not great. It takes way too long to issue a policy . . . usually 2 months.

The good news is, you can go online withing 24 hours of approval to review benefits, locate providers and print ID cards.

You can also call their customer service line at 1-800-MY-HEALTH.

New business underwriting normally takes 10 business days but can sometime move a bit quicker.

The only real complaints clients have about Aetna involve billing and the way medications are handled.

Aetna's billing practices are among the worst. Sometimes it takes them 3 months to collect the initial premium. Other times they may forget to bill for 60 days or longer.

A new Aetna "member" is advised to have their doctor contact Aetna to get approval on existing medications. If you don't you may end up paying more for refills than is necessary.

In spite of the issues, Aetna is a major player in today's market.

You can run Aetna quotes by clicking this link.

You can compare Aetna against other plans by clicking through to Georgia Insurance Shop.

COBRA Options

2009-01-24T08:43:00.002-05:00

You lose your job and your employer sponsored health coverage. What do you do when you are unemployed?

In many cases, COBRA is an option. But there are situations when COBRA is not available.

If your employer has fewer than 20 employees, COBRA (at the federal level) does not apply. Many states have enacted their own "COBRA compliance" statutes that provide some continuation of coverage so you may have options even if you work for a smaller employer.

COBRA is an EXTENSION of the employer group plan. If the plan is terminated, you do not have COBRA options.

But here are some things you can do . . .

COBRA can be applied for in whole or parsed by family members who have conditions that cannot be covered with individual health insurance. Just because you are insured under your employer plan as a family unit does not mean that all family members must elect COBRA.

For many, a STM (short term medical) plan is fine. In Georgia, a STM plan is considered creditable coverage and can be used for up to 12 months to bridge you over to a new employer group plan. You can review STM plans by clicking THIS LINK.

Even though STM can cover you for up to 12 months, it is not advisable to keep it for more than 60 - 90 days.

You may want to have more options than are available in STM plans. Fully underwritten, traditional plans are available in many variations. You can run rates on roughly 140 different plans by clicking THIS LINK.

These are just a few options. For more information, visit my Resource page at Georgia Insurance Shop.

Health Insurance and You

2009-01-20T10:18:00.002-05:00

OK, so you bought a health insurance plan. Now what?

If you are like most people, you will read it AFTER you have a claim. That is too late.

Health insurance policies are great for insomniacs. If you can read one of those without falling asleep you really DO need help.

Navigating your policy is just the first step. Unless you know how to MAXIMIZE your benefits, you will end up spending more than is necessary.

Most folks I meet spend way too much on coverage they don't need and then overpay again by making expensive decisions on health care. I can teach almost anyone how to cut their total health care expenditures by 30% - 40% without sacrificing coverage.

That usually translates to anywhere from $300 to $5,000 per year.

Let's face it. The money you pay to a carrier is gone. The only way to get it back is to have a major claim and who want's to do that?

Not all policies are the same, not even with the same carrier. Each carrier has "good" policies and some really lousy ones.

Beyond that, navigating the maze of websites, phone numbers and networks really IS rocket surgery.

Hopefully we can help you make sense by providing tips on maximizing your health care dollars on a carrier by carrier basis.

Stay tuned . . .

Save Money on Drugs

2009-01-19T07:52:00.002-05:00

How do you save money on prescription medications?

There are quite a few ways. Many maintenance meds are available by mailorder in 90 day supplies. You can purchase meds at warehouse clubs such as Costco or Sam's (membership not required).

If you have health insurance all the top carriers have negotiated wholesale pricing for their policyholders.

You can purchase from other countries such as Canada or Israel. We have links to patient assistance programs as well as two top international pharmacy's at Patient Charity.

You can sign up for Rx discount cards but those are almost always a waste of money. You certainly don't need them if you have health insurance and you don't need them if you shop wisely. Most of the time a wise shopper can buy the same medication for less than the pricing available through the card.

And then there are generics . . .

But don't stop there. Several places such as Wal-Mart, Kmart and Kroger have $4 generic plans but that only covers some 300 medications.

There are THOUSANDS of older brand name drugs that are THERAPEUTIC EQUIVALENT'S to the newer, higher priced medication so often pushed by drug companies and doctors.

Therapeutic equivalents include generics AND brand name drugs that have been proven to be just as effective in most cases as higher priced drugs. You can find a list of therapeutic equivalents by visiting this FDA site.

You may also want to ask your doctor, pharmacist or carrier to suggest lower cost alternatives.

Every dollar you do not spend is a dollar saved in your pocket.

Maternity and Kaiser Permanente

2009-01-18T10:27:00.005-05:00

At one time there were only two real choices if you wanted maternity coverage . . . Blue Cross and KP.

The choices haven't expanded that much, but KP is still a good option if you live in there catchment area. KP is an HMO whereas the other options are all PPO offerings.

That isn't all bad except for those who say they want to use "their" OB. With KP you use their docs or you have no coverage.

All primary care (and some specialties) are all delivered at their clinics around the Atlanta area. They offer what I refer to as "one stop shopping" which is a real plus in today's busy society. You can literally get in and out of the clinic inside of an hour. You can have your exam, lab work and even pick up prescriptions all on site.

Compare this to waiting an hour or more before ever seeing your doc under a PPO setting.

The maternity benefit is unique in that there is no waiting period. Other carriers require 90 to 365 days.

The benefit is quite clear cut. You make a $1,000 copay to your doc and $2,000 to the hospital. That's it for a normal delivery.

Every carrier has their strengths and weaknesses and each has a distinctly different approach to maternity. You can review KP plans and rates by opening this link in your Internet Explorer browser.

Maternity and Blue Cross

2009-01-12T19:25:00.003-05:00

At one time Blue had the most popular maternity plans on the market.

Not so any more.

Now they are one of the worst.

Blue overhauled their plans last summer, but not for the good. Well, a few things were positive.

Prior to last August you could only get maternity coverage on family plans. Now single females can purchase the maternity rider.

You still have a 12 month wait before benefits can be accessed. But it takes a rocket surgeon to figure out how the plan works.

Here goes . . .

All outpatient and doctor charges (including the delivery) track the underlying plan benefits (copays, deductible, etc.).

Hospital charges are subject to a separate $3,000 maternity deductible.

Result is, you end up paying the lion's share of the cost of delivery.

Sweet deal for Blue, huh?

Blue Cross plans can be reviewed and quoted by clicking here.

Maternity and Time Insurance

2009-01-09T08:12:00.002-05:00

Time (AKA Assurant) offers more flexibility in maternity options than most.

It is also one of the more expensive plans on the market.

Most plans from Time have benefit caps and restrictions that make it less desirable compared to more comprehensive plans available from other carriers. While the maternity benefit is available on most plans, the only base plan I suggest is the HSA qualified One Deductible plan.

The Time maternity benefit is similar to all other plans (except Golden Rule/United HealthOne) in that you have a separate maternity deductible. You pay first, when the deductible is satisfied, the plan pays.

Time does have a waiting period, but only 90 days. This compares favorably to most of their competitors that require a 12 month waiting period before benefits can be accessed.

Maternity deductible choices are $1,000 - $2,500 - $5,000 and $10,000.

As is always the case, the lower the deductible the higher the cost of the benefit.

In spite of my misgivings about Time products and pricing, I do like their approach to maternity. The $10,000 deductible is usually only a few dollars per month and gives the insured full access to network pricing when using par providers.

This can produce significant savings over "retail" pricing. It allows you access to pre-negotiated pricing and avoiding the hassle of haggling over how much you will pay.

You may run quotes for various plans by visiting My Time Insurance, or contact us for details and underwriting advice.

Maternity and United HealthOne

2009-01-08T09:00:00.004-05:00

One of the most confusing issues is actually very simple when you break it down. Most folks know how maternity works under an employer group plan but the individual market is much different.

We previously looked at maternity plans in general in an earlier post. This one reviews the current structure for Golden Rule AKA United HealthOne.

Unlike other plans, the UH1 plan is a "first dollar" plan. Everyone else requires you to first satisfy a separate maternity deductible before they pay. UH1 pays first. Any residual is covered by the insured.

Full benefits under the UH1 maternity takes the form of a $4,000 "bucket" of money. You are free to use those funds any way you want (pre-natal, delivery, hospital), but once those funds are exhausted you pay the balance.

To receive the full $4,000 benefit, conception must occur after the maternity benefit has been in place for 12 months. If conception occurs before 12 months the benefit is cut in half.

Contact us for more details about how the benefit works, and current pricing.

You may also wish to run quotes and compare plans by clicking here.

Maternity in the Individual Major Medical Market

2009-01-08T08:07:00.000-05:00

When searching for maternity in the individual market your choices are few and pricey. Still, there are benefits for the planned event.

First some ground rules.

If you are currently pregnant, you cannot get coverage from a major medical carrier. Not just maternity, they won't issue a policy to you or your spouse. If you are pregnant and without coverage, check out your options at Coverage For All

Avoid discount cards including the so-called "maternity cards". Most are overpriced and a few have run afoul of the Attorney General's offices in several states. In other words, don't waste your money.

If you are not pregnant, then there is a good chance you can qualify for the coverage if you have not had prior, complicated deliveries. If you have tried to get pregnant and had problems in the past, you will not find plans that cover fertility testing or IVF.

Currently there are only 4 carriers in the Atlanta area that offer maternity options. Pricing and benefits vary widely.

Most will have waiting periods before benefits kick in but one carrier does not impose any waiting period. Of course you cannot be pregnant with any carrier, including the one with no waiting period, at the time coverage goes into effect.

Other carriers impose waiting periods of 90 days to 12 months. This applies to conception so advance planning is needed.

A normal delivery from a par provider will run about $4500 for everything. Add another $1500 - $2000 for a scheduled c-section.

Complications are covered as any illness under most plans (including those without maternity).

If you do not have maternity coverage and do not qualify for taxpayer funded programs, you can expect to be billed $7,000+ for a normal delivery and pre-payment is required. A scheduled c-section can add another $4,000.

You can (and should) attempt to negotiate with your OB and hospital and get as close as possible to the par figures quoted above. Cash works very well when negotiating. If you are willing to pay 80% or so of the expected cost of a normal delivery up front you should be able to get by on $5,000 or so for the doc & hospital.

Contact us for pricing and details on maternity options.

Alphabet Soup

2009-01-03T13:59:00.002-05:00

What is the difference in an HSA, HRA, FSA and all the other mix of letters assigned to different types of plans?

All are similar, but different.

Most of these plans are available only through an employer, but consumers can still take advantage of some of these options even without an employer plan.

Consumer's in Charge of Their Health Care

2009-01-03T13:51:00.002-05:00

Sadly, very few consumers are in charge of their health care. They take what their employer offers, even if it is wrong for their needs. Or many times they buy a plan that is similar to what they had under an employer plan.

These plans are terribly outdated and considerably overpriced. In addition, the plan design causes you to pay more for health care than is needed.

Fortunately, CDHP (Consumer Driven Health Plans) are becoming more prominent.

I teach consumers how to make wise choices in their coverage and health care. By making good use of your total health dollars families often save $500 per month or more vs. plans they would pick on their own.

Most people don't realize they are paying too much until we show them their plan side by side against a true, consumer driven plan.

How Do PPO's and HMO's Differ?

2009-01-03T13:48:00.003-05:00

Most individual major med plans are PPO contracts, but there are a few HMO plans.

Group plans through an employer come in different flavors, including PPO, HMO and POS.

So what is the difference?

Each has advantages and disadvantages. One is not inherently bad while another is good.

Like everything else, it depends on what you need.

I have several clients in HMO plans who would never change, and likewise for PPO plans.

Prescription Drugs and Health Insurance

2009-01-03T13:42:00.003-05:00

Unless you, or someone you know, has taken medication for a serious health issue, you probably are not aware of how expensive some medications can be. Believe it or not, there are some meds that are $8,000 per dose and quite a few that are $2,000 to $3,000.

Hopefully you will never need medication that is so expensive, but when you do you need good drug coverage.

Saving a few dollars now on a plan with lesser (or no) drug coverage can come back and hurt you in the end.

Ask for a review of your prescription drug coverage and discover ways to save money all around without jeopardizing your health or financial future.

What is a Provider Network?

2009-01-02T12:29:00.003-05:00

If you want to keep your costs down, use a par (participating) provider. In other words, stay in network.

This isn't always easy.

Your doc may be in network but may refer you to another provider who is out of network. When that happens, you pay more.

Emergency situations, and having surgery, especially as an inpatient can drive up the cost of your out of pocket.

If you have questions about par providers, PARE claim's adjudication, hidden providers and more, contact us.

Deductibles and Coinsurance

2009-01-02T12:22:00.002-05:00

Sometimes it seems health insurance is more complicated than it needs to be. This video should help explain the differences in deductibles and coinsurance.

If you have questions about this or other plan provisions, contact us.

Why is Health Care Expensive?

2009-01-02T11:23:00.002-05:00

We will be posting a series on health care, courtesy of Humana. I hope you find them informative.

We have several clients with Humana. If you would like a quote from Humana, or our other fine carriers, you may email us or click here.

How Much Does it Cost?

2008-12-27T14:07:00.002-05:00

One of the aversions some people have to a high deductible plan (such as an HSA qualified one) is, how much does it cost to have this done or that done.

Fair question, but what get's me is they should have a similar question on a typical copay plan. For some reason it almost never comes up when discussing a copay plan with a $2,000 deductible (and $4,000 out of pocket).

But suggest a HDHP (high deductible health plan) of say, $3,500 and all of a sudden they are concerned about how much they will have to pay before the carrier pays.

Most primary care office visits will run $50 - $60 . . . add $20 or so if you see a specialist. Testing can run anywhere from $10 to $300 depending on the extent of the lab work.

But if you have going to have an elective procedure, determining the cost is relatively easy.

Ask your doc for the CPT 4 codes.

Call your carrier and ask for a price for those codes.

Simple.

Rules for Alphabet Benefits

2008-12-15T08:50:00.002-05:00

HSA, HRA, FSA.

Alphabet benefits.

What's covered? What isn't?

How about lotion for sunburn? Or acne treatment?

Or breast augmentation? Surely an electric toothbrush is a covered item.

There are several sites where you can look these things up but this is one of the better ones.

Claim Review

2008-12-11T08:44:00.004-05:00

Post claim underwriting is prohibited in most states, but that does not mean filing a claim isn't without surprises.

My clients are told to contact me anytime they have a question about a claim, no matter how small.

Some remember that offer, some do not.

About a week ago I had an email from a client with a question about her policy. She had transitioned from a traditional copay plan with a $2000 deductible to a high deductible, HSA plan with a $10,000 family deductible.

Six weeks earlier her husband became ill while out of town on business. He was admitted through the ER into ICU where he spent 10 days, including several on a respirator. The onset of the illness was sudden and unlike anything he had experienced before.

The hospital Social Worker was assisting in contacting the carrier and had told my client she had a $20,000 deductible.

Going on the hook for $10,000 was bad enough, now she was told it would be $20,000.

Carriers are not allowed to communicate claim information to brokers such as myself so the only way for me to know about this is for a client to notify me, then ask.

I asked my client to send me copies of all correspondence and EOB's from the carrier as well as a signed HIPAA release. The release would allow the carrier to talk to me about current and future claims and do so with impunity.

Several phone calls and emails to the carrier and client have put me right in the middle. I have no problem with this, in fact, I told my client to attend to her husband and not to worry about the claim issues. I would handle it (as much as possible) and keep her in the loop.

As it turns out, the claim was first deemed out of network since her husband was in another state when the emergency arose. That issue has been addressed with the carrier and the out of network penalties will not apply.

Now comes the hard part.

Due to the diagnosis, a claim review was ordered. This is customary, regardless of the size of the claim, when a diagnosis is such that it could have been omitted in the initial underwriting stage.

Almost any illness related claim is subject to challenge and review when submitted during the first two policy years. Some carriers are more diligent in pursuit of pre-existing condition claims than others. Most of the time a cursory review is all that is needed before the claim is released for final adjudication.

But sometimes it is more detailed, and this is the case here.

The hospital stay alone is $88,000. Other bills for the ER, doctor, lab, etc will certainly push the claim over $100,000.

The review will generate a flood of inquiries to the doctors involved (six of them so far) as well as the hospital. Because providers are not always quick to respond to carrier inquiries, it will probably be another month before the review can actually begin. The actual review of data by the medical director will take another 3 weeks or so. I would not be surprised to see this claim extend into February before it is finally adjudicated and paid.

I have advised my client on what to expect and have asked her to keep me informed of any new issues as well as updating me on the health of her husband.

Out of this tragedy, there is some good news.

The out of network penalties will be waived which will minimize the out of pocket on this claim. I say minimize, because some of the providers are P.A.R.E. attendants who are usually not in any network.

We also refer to them as "hidden providers".

These are providers who are free to charge whatever they wish and balance bill the patient. This is one of the dirty secrets about health care that no one likes to discuss. Carriers do their best to hold down costs by having as many providers as possible in their network but they can't force any or all providers to join.

The other bit of good news is the carry over provision in the contract. Claims incurred in the last 3 months of the calendar year are allowed to carry over to the following year to satisfy the deductible. In this case, the $10,000 family deductible satisfies not only the 2008 deductible but 2009 as well.

A claim review is never fun or easy, but my clients know they do not have to walk that road alone.

Free Meds

2008-12-09T08:41:00.002-05:00

Blue Cross has never been a fan favorite, at least not in my book. But sometimes they show flashes of genius.

Like offering free meds.

Blue Cross and Blue Shield of North Carolina will offer free generic prescription drugs to about 1 million members during the first half of next year.

This is a test program, not available on all plans.

Plan participants still have to meet their Rx deductible where it applies.

Blue Cross has offered similar programs before. Its waiver of copayments for generic drugs saved members $80 million in 2006. The company says the waiver boosted the use of less-expensive, generic drugs.

I would consider this a win-win situation.

The member saves and so does the carrier.

If you aren't covered by one of these plans, programs like PPARx and Needy Meds.

You can also look for assistance at Patient Charity.

Blue Cross Ordered to Pay Up

2008-12-05T08:53:00.002-05:00

Insurance Commissioner John W. Oxendine has ordered Blue Cross and Blue Shield of Georgia, Inc. to make additional claims payments of $12 million for certain ambulance services rendered to its policyholders that were improperly reimbursed.

The consent order is the result of a market conduct exam initiated by Oxendine’s office which revealed that Blue Cross incorrectly reimbursed out-of-network ambulance providers for services rendered. In a number of instances, Blue Cross made inconsistent payments for comparable ambulance services. In other cases, Blue Cross failed to increase its reimbursement rates over a number of years, in spite of the increasing costs of providing ambulance services.

“The proper payment of claims for emergency services is vital to the maintenance of our trauma system and equally important to protect consumers from excessive balance billing. I want insurers to know that I expect providers to be paid according to the requirements of Georgia law,” Oxendine said.