Tuesday, February 28, 2006
Monday, February 27, 2006
Last week I spoke to a lady who found a plan that was just like the one I suggested, but was 30% less in premium. Of course she did not know, nor did she care to hear that the plan also had 50% less coverage.
Before that I had a woman who complained that her $1000 per month health insurance premium was too high for the benefit she received. When I suggested a more reasonable $450 premium plus another $400 monthly into a HSA she balked saying she could not afford the $5000 deductible nor the out of pocket for her annual doctor visit. She insisted there MUST be a plan out there that is better than what she has but doesn’t charge as much in premiums.
Today, at 8:06AM I had an email from a lady who is pregnant (2 months) and wanted health insurance to cover her prenatal & delivery. This is the same woman I talked to last Thursday and explained that the only plan she could find to accomplish this feat was a small group plan through a major carrier. (She and her husband do own a small business that would qualify them under Georgia small group laws).
In today’s email she stated she had found another carrier who does not impose the same requirements for eligibility as the carrier I proposed, and the rates were lower for more coverage. She had reviewed the application for this carrier and determined this carrier does not require payroll records to substantiate qualifying for group coverage.
Due to her pre-ex condition, the rates on the proposal (mine as well as the other carrier) are not reflective of final rates which can change as much as 65% (for the other carrier) or 45% for my proposal. This may tend to level the playing field once final underwriting is concluded.
Neither carrier makes mention of supporting documents in the master application. Yet both carriers do require such documents.
I do not claim to have complete understanding of all aspects of health insurance and readily admit that I still learn things every week despite a long tenure in the industry. But one thing I do know is this. If you think you can beat the carriers at their own game you are wrong. They have been doing this a lot longer than any of us, and have probably seen it all. They also have high paid attorneys, actuaries and underwriters who know how to protect the carrier.
I know for certain there are no ways to beat the carriers at their own game. But I also know that when you understand the rules, and I feel I know them as well as any, you can work the system to your favor. If you think you have found a way to beat the carrier, most likely the only thing you have accomplished is finding a way for the carrier to deny coverage at some future date, once all the facts come to light.
Once you are in claim, that is not the time to find out your policy isn’t what you thought it was.
The Carnival of Personal Finance, hosted this week by Money Blog Network, offers links to a variety of helpful posts. My favorite this week is this one from Joe Kristan, which illustrates tax-protestor follies.
IdeaLogic hosts this week's Carnival of the Capitalists, with links to useful and interesting info. For example, Searchlight Crusades has a helpful primer on mortgages, deconstructing the partial-truth that "all mortgage money comes from the same place."
Friday, February 24, 2006
Thursday, February 23, 2006
Wal-Mart insures less than half of its 1.3 million employees in the United States and has come under growing criticism for skimping on benefits and shifting the cost of health care to state governments.
More affordable coverage is on the way.
At the same time, Wal-Mart said it would make a new health-care plan introduced in several regions this year, with premiums as low as $11 a month, available to half of its employees by next year.
But it won’t be without its’ detractors . . .
That plan allows for several prescriptions and doctors visits before a $1,000 deductible kicks in. But it is unlikely to cover a complicated illness or expensive hospital stay during the first year, when there is a $25,000 insurance cap. In addition, out-of-pocket payments range from $300 for prescriptions to $1,000 for hospital stays.
Seems generous to me, but the $25k cap is dangerously low. It will be interesting to watch this (I am certain) continuing saga.
One of my newest clients came to me by way of taking a step in the wrong direction. Like many, they were looking for a way to save money on health insurance. They applied with a low price carrier and were almost immediately denied coverage within a few days of making application. Seems the health issue they considered more of a nuisance than anything was preventing them from being approved.
Once you have been denied by a carrier it becomes more difficult to obtain a fair review by later carriers. Every application has a gatekeeper question that goes something like this.
“Have you had coverage denied, postponed, modified or rated?”
That pretty much says it all. Answer yes and you are subject to intense scrutiny. Answer no and you have committed fraud and run the risk of having claims or coverage denied at a later date.
After much discussion and a review of the medical condition, I started polling my top 3 carriers. I work closely with these carriers and have a good feel for the way they underwrite.
I also have field underwriting manuals for all of these carriers as well as a dozen more.
The results from my inquiry were a “no”, a “maybe” and a “probably”.
The “maybe” was a strong carrier not known for aggressive underwriting but is almost always in the hunt on price. The "probably" is a lesser known carrier but strong in many ways and has recently become more reasonable in underwriting.
The “maybe” indicated a rate of $180 per month with a rider for the medical condition. The “probably” told me they would most likely cover the condition but with an extra premium bringing the total monthly to $300.
The condition is a “slight arrhythmia” that is asymptomatic and has remained unchanged in 15 years. The condition is controlled by two inexpensive medicines that cost less than $40 per month.
My new client did the obvious and wanted to apply for the lower priced plan. I counseled them by saying this might not be a wise choice. They stood fast so I countered with a form where they would attest that I showed them a plan with full coverage which they rejected.
Then they were the ones who balked.
In their mind, the $120 monthly premium savings more than offset the $40 monthly med cost. No argument there. What I did next was to explain why each carrier took their respective positions.
The one with the exclusion rider was not dodging the $40 monthly meds or even the annual EKG. They were more concerned about potential stroke or M.I. down the road.
The carrier with the higher premium was willing to absorb not only the meds and the annual EKG but the potential heart attack or stroke that could occur at any time.
Or never . . .
In the end the client agreed to make application to the carrier with the higher premium. I had not only stated my case in a logical and comprehensive manner, but they also agreed I had been more helpful than anyone else who had reviewed their case . . . including the initial agent who simply ran away once he had a rejection from his carrier.
This is not about me or my skills. Rather it is all about making an informed decision and not just taking the lower priced plan for the sake of saving money now. The $120 monthly savings could have gone for other things besides health insurance premiums. But all of that would have been worthless if the annoying medical condition were to take a turn for the worse.
HaloScan (which hosts our comments) appears to be having technical difficulties this morning. While that's being resolved, feel free to drop me an email (addy in profile) and I'll make sure it gets added once the glitch is resolved.
Wednesday, February 22, 2006
Tuesday, February 21, 2006
Monday, February 20, 2006
Saturday, February 18, 2006
OK, so why did they deny coverage?
When 44-year-old Joan McCarville was told she'd need a third transplant, the Health Insurance Risk Sharing Plan said a 2000 stipulation prevented it from covering a person for more than one transplant of an organ.
Interesting . . .
Guess that is what one can expect with a government run program.
Thursday, February 16, 2006
The group, Wisconsin Health Care for All, has proposed a universal health insurance plan called "Provide or Pay." It would force employers to make insurance available to all workers or contribute roughly 5 percent to 10 percent of payroll into a community health plan.
Will someone please tell me why it is the responsibility of government, or business, to provide health insurance for everyone???
Wednesday, February 15, 2006
Many who have not used their health insurance other than for minor illness or accident fail to see the other side of the equation. It always amazes me when I ask a prospective client what kind of benefits they would like, the response almost invariably goes like this. They want a low copay for doctor visits and meds. They want to be able to have an annual physical at little or no cost to them. Beyond that (they profess) they really don’t need health insurance since they never get sick.
My contention is, they really don’t need health insurance for routine things like doctor visits for mundane afflictions or even for most meds. Instead, what they need is catastrophic coverage, such as is found in the HDHP/HSA combination.
Regardless of whether you believe your insurance cover should cover the routine or be saved for the truly catastrophic, here is an example of WHY you need a plan with a GOOD major med benefit and no cap on things like medications.
Avastin is an example of a tier 3 or non-formulary medication. You won’t find it on any carriers list of meds that can be purchased for a $20 copay. Instead it will be in the non-formulary column that could carry a $60 copay or even higher.
In an attempt to be price competitive, some carriers have eliminated coverage for meds completely. Others have simply put an artificial limit of $2000 per year for meds.
If you were taking Avastin, and you had this plan, you would blow through your annual max in about 2 weeks.
Personally, I think it is very short-sighted of agents who sell cover that has limited benefits. I also think they should be sued when their client develops a condition that requires care that is not covered by the policy they promoted just because it was cheap.
But I also think the consumer should share some blame for failing to understand the pitfalls of purchasing a plan simply on the basis of a low price, and a feeling they will never need coverage for expensive meds.
You may never need such a powerful drug, but if you do the time to make the right decision concerning your coverage is now, not later.
Tuesday, February 14, 2006
Monday, February 13, 2006
Saturday, February 11, 2006
OK, I’ll bite.
According to the article," if you paid close attention--very close attention--to President Bush's State of the Union address, you may hear a distant knell for the way most Americans get their health insurance."
So what is wrong with that?
“In his address, the president said government has a responsibility to "help people afford the insurance coverage they need." The way to do that, his aides later explained, is to "level the playing field" so folks who buy their own insurance get as good a deal as folks who join their company's plan.”
And that would be accomplished how?
“Bush proposes a supercharged version of the health savings accounts (that would allow a) family sock away $10,500 per year tax-free. Moreover, they could claim a tax credit equal to 15.3 percent of the amount they deposited. But it gets sweeter. If the worker buys his own high-deductible insurance policy, rather than one offered at work, the premiums he pays would be fully tax-deductible and eligible for the 15.3 percent tax credit.”
I am not really sure how one is able to deduct premiums AND get a tax credit for those premiums, but I am definitely interested.
The balance of the article is mostly a tirade against the wealthy & healthy so I won’t even go there.
The HSA is an excellent tool and one that should be used by a large percentage of the population. So far less than 3% of those covered by health insurance agree with me but I am not going to let that stop me.
As for the Bush recommendation, tax credits really only appeal to those who actually pay taxes. Coincidentally, this is about half the population . . . those with an AGI that exceeds $29,019.
So what is wrong with the Bush proposal? Not much that I can see. Bring it on.
Thursday, February 09, 2006
Q. What does HMO stand for?
A. This is actually a variation of the phrase, "HEY MOE." Its roots go back to a concept pioneered by Moe of the Three Stooges, who discovered that a patient could be made to forget the pain in his foot if he was poked hard enough in the eye.
Q. I just joined an HMO. How difficult will it be to choose the doctor I want?
A. Just slightly more difficult than choosing your parents. Your insurer will provide you with a book listing all the doctors in the plan. The doctors basically fall into two categories: those who are no longer accepting new patients, and those who will see you but are no longer participating in the plan. But don't worry, the remaining doctor who is still in the plan and accepting new patients has an office just a half-day's drive away and a diploma from a third world country.
Q. Do all diagnostic procedures require pre-certification?
A. No. Only those you need.
Q. Can I get coverage for my preexisting conditions?
A. Certainly, as long as they don't require any treatment.
Q. What happens if I want to try alternative forms of medicine?
A. You'll need to find alternative forms of payment.
Q. My pharmacy plan only covers generic drugs, but I need the name brand. I tried the generic medication, but it gave me a stomach ache. What should I do?
A. Poke yourself in the eye.
Q. What if I'm away from home and I get sick?
A. You really shouldn't do that.
Q. I think I need to see a specialist, but my doctor insists he can handle my problem. Can a general practitioner really perform a heart transplant right in his/her office?
A. Hard to say, but considering that all you're risking is the $20 co-payment, there's no harm in giving it a shot.
Q. Will health care be different in the next century?
A. No, but if you call right now, you might get an appointment by then.
Tuesday, February 07, 2006
Monday, February 06, 2006
Friday, February 03, 2006
Thursday, February 02, 2006
OK, so maybe you don’t care. That’s OK. This is short. Deal with it.
Prospective client has an old fashioned plan with a major carrier. The plan is very rich in benefits with $20 doc copays; $25 Rx copays and a (GASP) $500 deductible.
It also carries a hefty price tag.
Over $900 per month.
The plan they have now will not be renewed by their carrier in the summer. They will have the option then of moving to a higher deductible, lower benefits and a higher price; or they can leave this carrier and go somewhere else.
Yes, I did say a higher price.
Based on other renewals with this carrier, for this product, my guesstimate is about 30% more in premium.
Did I mention the higher premium is for less benefit?
For the SAME $900 per month they can have an HDHP PLUS a FULLY FUNDED HSA.
That means NO out of pocket for anything.
No out of pocket for doc visits.
No out of pocket for meds.
No out of pocket for a major claim. Unless the claim exceeds $5,000,000 . . .
So what did they say to my proposal?
If I can’t show them how they can save money over their current plan, they would rather stay where they are until August when the plan renews.
These people are not stupid. I drew them a picture . . . literally. They just think they are better off paying $20 to go to the doc, than paying nothing (after the HSA reimbursement).
OK, maybe they are stupid.
Someone just go ahead and shoot me.
Wednesday, February 01, 2006
Sometimes real life imitates art, or in this case, cartoon art.
Back in 1996 the drug companies reached an agreement with Washington in exchange for an extension on some valuable drug patents. In exchange for this protection, the drug companies agreed to make certain drugs free or almost free to low income patients and those with AIDS.
This was a win-win situation.
Companies such as Med Solutions and others sprung up to aid qualified beneficiaries in filling out the paper work. These companies charge a nominal fee for handling the paper work and the recipients get their meds for around $3 per month per script.
And the drug companies get to keep their patents a little longer, prohibiting other companies from making generic equivalents, which keeps prices (and profits) high.
Such a deal!
Until now . . .
It seems that the drug companies see the new Medicare drug plan as a way to change the rules. Several companies have announced plans to discontinue this free ride for the elderly and disabled.
Just like Lucy and Charlie Brown, the football (in this case the free drugs) are pulled away at the last minute. Only this time, the one hitting with a thud are the elderly and disabled.
Sigh . . .
This might not be as far-fetched as you think. Some carriers are now allowing insured’s to dial up their meds and do a price check, while in the doctors office.
Think your doc isn’t spending enough time with you? Cigna has a better idea! Not only can you price check, but find out how much time a doc should be spending depending on the diagnosis and price charged.
Personally, I don’t think so . . .
[David Williams over at the Health Business Blog has more on this, as well]