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Insurance Options For Those Not On Ssdi

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I thought that I might try to use what I learned working for the last 6 years in the insurance industry to provide some information here about different sources of health insurance for those who are not on Social Security Disability or at the age where Medicare is an option.

Please feel free to add what you know to this thread as well.



There are 3 primary sources for health insurance -- group, individual, and government-sponsored.

A) GROUP: You are eligible for GROUP insurance when you belong to a group, like an employer.

* Normally, the employer pays/subsidizes a portion of the premium for the employee, so the cost for the employee is typically low. Some employers also subsidize premiums for spouse and/or dependents, but some don't. This can be why "employee only" coverage is $40/month, but "employee + family" is $400.

* The services that are covered have been designed by the employer group. This is why your UnitedHealthcare plan is different from your neighbor's or your sister's UnitedHealthcare plan. If something you need isn't covered, you can talk to the people in your Benefits department and ask them to write it into the plan for next year. The worst they can say is no, right?

* Group insurance is more affordable than other types because the risk is spread across a larger group of people. (With 900 people paying premiums, when one of them is diagnosed with cancer, it doesn't cost the insurance company as much money to treat them because there are 899 other healthy people paying their premiums and not seeing the doctor).

* Group insurance is also advantageous because often times you can bypass any pre-existing condition exclusionary periods when you are enrolling for the first time as a new employee. [i will address pre-existing conditions later in this post.]

* If you are not employed, there are other ways you can get group insurance. My husband belongs to the alumni association for the college that he went to. They have a group plan available. The premiums are higher than an employer group because there's no subsidizing, but they're still lower than individual. If you belong to any national trade organizations, they may also have group plans available.

* In my opinion, group coverage is ALWAYS preferred over individual. Your costs are lower because the risk is shared.

B) INDIVIDUAL: If you do not belong to a group, you can be eligible to purchase an INDIVIDUAL policy.

* Obviously, in an individual policy, the only person covering the risk is you, and there is no employer to subsidize the cost. So your premiums will typically be much higher.

* Individual policies can turn you down if you do not meet their eligibility criteria. I'm not sure if Narcolepsy is an immediate turn-down, but something like cancer would be for sure. That's too much of a risk for the insurance company.

* Individual policies may also have pre-existing condition exclusionary periods. [More about those later, I promise.]

* To find out which companies are authorized to sell individual medical policies in your state, contact your state's Department of Insurance.

C) GOVERNMENT-SPONSORED: Finally, if you do not belong to a group and cannot get or cannot afford an individual policy, there is the option of government-sponsored coverage. There are a couple of different types of government-sponsored coverage.

1) Medicaid - for those on limited incomes or below the poverty level

2) High-Risk Pool - for those who have more resources but cannot get group or individual coverage due to medical reasons

I'm going to start with Medicaid.

MEDICAID is mandated by the federal government, but the states get to run it however they choose. It is healthcare that the government provides for people who are on limited incomes or below the poverty level.

* Each state has different eligibility requirements. Generally you will have to be able to show your income and assets in order to qualify. You will normally have to re-certify eligibility every so often.

* Sometimes, the household might have too high of an income for the parents to be covered, but the children can be covered under CHIP (Medicaid for children).

* Often times there are no premiums; in some cases the state will allow households that are at the upper end of the income limit to pay a small premium in order to get Medicaid coverage.

* Contact your state's Department of Health and Human services for an application.

Now, on to the HIGH-RISK POOL.

I don't know a lot about these, but I do know of them. States have a high-risk pool, which is insurance that they make available to people who are unable to obtain insurance through other sources. Typically it is people who have a serious medical condition, can't get on group plan, have been rejected by individual insurance policies, and do not qualify for Medicaid.

* Contact your state's Department of Insurance to inquire about a high-risk pool.



OK, so now we know about different sources of insurance. I am going to spend a few minutes talking about some special circumstances -- Pre-Existing Conditions, Students, and COBRA.

D) PRE-EXISTING CONDITIONS: Pre-Existing conditions are medical conditions for which you have had treatment or consultation in the recent past, usually stretching back about 12 months (could be longer or shorter, depending upon which state you live in and whether your plan is group or individual). Insurance companies don't want to cover pre-existing conditions right away -- it's too much of a financial burden.

* If you have a new condition develop, get sick, or need preventive care, that is typically covered from the first effective day of your new plan.

* Most individual and some group plans have a pre-existing condition exclusionary period. This means that for the first 6-12-18 months of your coverage (again, depends on state and type of plan), they won't pay for care related to a medical condition that you had when you signed up. You can still see the doctor, but you'll have to pay for it yourself.

* You can reduce or eliminate the pre-existing condition exclusionary period by proving that you have had other healthcare coverage in the last 18 months. Your old plan will send you a "certificate of creditable coverage" that shows when you were covered. Save these and send copies of them to your new insurer. They can subtract months that you were covered from the pre-existing condition exclusionary period provided there was not a break in coverage of more than 60 or so days.

* Example: your new individual plan has a 12-month pre-existing exclusionary period. At your last job, you had continuous coverage for 9 months. You are able to reduce your pre-existing exclusionary period to 3 months.

* Example 2: your new plan has a 12 month pre-existing exclusionary period. At your last job, you had continuous coverage for 18 months. You are able to completely eliminate your pre-existing exclusionary period and get coverage for your pre-existing condition from day 1.

E) STUDENTS: Students have a couple of options for coverage: their parents' plan, or a school plan.

1) Parent's coverage: Most group plans allow for the enrollees to cover their dependent children up to age 18 or 21 (age can vary depending upon how the plan is written).

* If you are a full-time student, many plans will continue to cover you up to age 23-25 as long as your parents keep sending in your school enrollment forms.

* Plans may make special provisions for disabled children over 18 -- this would probably vary based on the policy, so have your parents look into it.

2) School plan: Most colleges and universities have student health insurance plans available. Most residential colleges and universities required that students have some sort of medical insurance -- if not their parents plan or an individual plan, then a student plan. REMEMBER: Group plans are usually always better than individual!!

* In most cases, you don't have to provide evidence of insurability.

* Treatment of pre-existing conditions will vary -- read the fine print and have copies of your last coverage available to send.

* Look to see whether you get coverage with specialists, or if it's just preventive care and emergency coverage. If you have Narcolepsy, some vey limited student plans may not be right for you and you may need to go the individual plan or Medicaid route for more comprehensive coverage.

F) COBRA: Continuation of coverage from a prior group plan.

First, let me say that COBRA IS NOT INSURANCE! Yes, that's right. COBRA is a law that allows you to continue your group coverage after your membership in that group terminates (for example, if you are laid off from your job).

* COBRA is the law that allows you to continue to participate in your former employer's group plan for up to 18 months.

* It is the SAME coverage that you had through your employer -- there is no insurance company named "COBRA"!

* You MUST elect COBRA coverage quickly after your other coverage terminates.. usually within 60 days or you're out of luck.

* Big difference: cost. When you worked for them, your employer subsidized your premium. Your healthcare may have cost $200 but you only had to pay a $40 premium. Well guess what? Now that you don't work for them anymore, you can stay on their plan but you will have to pay the entire $200. This can drive the premiums well over $1000 for a family.

* Miss one premium payment, and the coverage terminates without notice. So make those payments on time. Before, your premiums were taken out of your paycheck (most of the time). Now you will have to mail in a check or get on an automatic payment plan.



Although it may look seamless to you, most health insurance companies do not handle their members' prescription claims. There are companies called PBMs (Pharmacy Benefits Managers) that do this for them. For example, for UnitedHealthcare it is mostly Medco and for my current Blue Cross/Blue Shield Plan, it is a company called Prime Therapeutics.

* The PBM is responsible for putting together the PDL -- preferred drug list, also called a Formulary -- for your plan.

* Usually there will be one to several drugs on the formulary for each "class" of drug. So, there will be a number of antidepressants. But not every drug in that class may be on the formulary. So Wellbutrin might be on there, but Effexor might not be. PBMs usually consider all drugs within a class to be "equal" even though we all know they are not.

* Some precription plans have a "tiered" system where cheaper or generic drugs are available at a lower cost, while brand or expensive/newer drugs cost more.

* If a medication you have been prescribed is not on your formulary, you could go back to your doctor with the formulary and ask if there is something on the list that WOULD work for you. If not, you can submit a request for prior authorization to try to get it covered, or you may have to just pay for it out of pocket. For drugs that are not on your formulary that are extremely expensive, you might want to look into some of the pharmaceutical companies' patient assistance programs.

* Some drugs that are very expensive require prior authorization before your claim will be paid. In this situation, your physician would submit your medical records to the PBM for review by a clinician. If denied, phone your insurance company and ask about the appeals process [more on appeals later in this post]. Keep this in mind, and try to get samples of any new prescriptions your doctor gives you just in case!

* Following that line, you may not need prior auth for certain drugs, but you might need it for certain drug dosages that are above the norm.

* If something goes wrong at the pharmacy and you are being asked to pay more than you expected, have them try to run it through on your insurance again. Sometimes there's a glitch or they forget to run it the first time. If there's no change, see if they can call your PBM to see what the issue is.

* Pay attention to your formulary -- if you are on a group or individual plan, the formularies can change every time the plan year changes. Just because you're getting the same coverage for the same premium, don't assume your PDL didn't change or a drug didn't move from one tier to another.



Here are some ways that you can get the most out of your insurance dollars.

* Use in-network doctors when you can. In-network (also called "participating" or "contracted" doctors) are doctors who have made an agreement with you insurance company. When they perform service X, they will get Y dollars. Insurance companies prefer to deal with in-network physicians because they know how much they'll be paying out.

* If you must go out-of-network ("non-participating" or "non-contracted"), look into your benefits before you do so. Some plans will allow you to see out-of-network doctors with a lower benefit or higher copay. Others do not cover out-of-network at all. Know what you are getting into BEFORE that first appointment so there are no surprises.

* If you live in a rural area or have a rare condition and there are no specialists that treat your condition that are in-network, you can sometimes get an authorization to see an out-of-network doctor at in-network benefits. You would want to call your prior authorization department to learn more about this.

* Bring your formulary/prescription drug list to your appointments. If the doctor is going to prescribe you something, try to go with something from the list. This is not always possible, but it's a good start. If you suddently develop heartburn, try the first heartburn med on the lowest tier of your plan first to see if it works.

* If you are on "maintenance" medication (stuff that you take every day) and are stable on the dosage, look into mail-order prescriptions. Instead of getting a 30-day supply at the pharmacy, you get a 90-day supply and often times only have to pay for 2- 2.5 months worth of meds. Your physician will have to write a prescription for a 90-day supply and you can mail it in. This won't work for controlled substances, but I use it for my Provigil and my Effexor and it saves me money.

* If your doctor sends you for a diagnostic test, see if they can send you a postcard with the results or if you can get them by phone. This saves you a second visit and a second co-pay. Obviously you wouldn't want to do this for very involved testing, but if they sent you for a bone density screening and everything was normal, a postcard or phone call would do just fine.

* If you pay for anything out of pocket (a doctor visit or prescription), call and get a copy of a claim form so you can submit the receipt to your insurance for reimbursement.



You can appeal virtually every decision by your insurance company if you are unhappy with it. (If they deny your request to see a specialist, if a certain drug is not covered, etc.)

* Simply call the number on the back of your insurance card, and ask the customer service representative how to file an appeal for a denial of ____ . There may be different instructions for different types of appeals, so be specific. Also ask what the timeframe is for you to hear back a response. If you don't hear back within that time, document it and call again or send a letter of inquiry.

* Always, ALWAYS get the name and extension or name and office of the person you speak with, along with the time and date of your call. Get a notebook and take notes on every phone call.

* My personal preference is to file in writing, so there is a paper trail. Some states and companies will allow you to initiate an appeal verbally over the telephone, but check to see what kind of information they require in writing and how much time you have to follow up and send it.

* If you exhaust your appeals process and are still unhappy with the results, sometimes you can take your complaint to your state's Department of Insurance. This is where having all of your documentation pays off! Not all plans are governed by ERISA so not all plans will have this as an option (self-funded plans won't have this for sure).


Alright, this is everything I can think of right now. If you have questions, corrections, or comments I'd love to hear them.



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My goodness! That had to take a lot of time to write. Thank you for going to the trouble to do that. I'm sure it will be helpful to many of us.


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* Individual policies can turn you down if you do not meet their eligibility criteria. I'm not sure if Narcolepsy is an immediate turn-down, but something like cancer would be for sure. That's too much of a risk for the insurance company.

It is now! It's relatively new but they're catching on to sleep disorders. There's a box to check for it now on applications They'll also reject applications for things like asthma. Really!

Back in 2003 I went from group to individual coverage. There was nothing on the questionnaire about sleep disorders, so I didn't have to mark anything. They never requested my medical records, I guess. I got it no problem. (maybe this was just the 30-day thing, though...not sure.)

In 2005 I let my policy lapse due to lack of funds, and when I tried to re-apply, they not only rejected me for Narcolepsy, but also for asthma, gestational diabetes, and a whole host of relatively tiny medical problems. I think "breathing" was on there somewhere. <_< In fact, they not only rejected me for this, but my infant son as well, who was perfectly healthy. It took some negotiating by my agent to get coverage for my son, at least.

I went without coverage until 2006 when I got a job that offered it. But I was fired 4 months later. The boss said "don't worry, I paid up through next month, so you're covered." Well turns out I was dropped from the policy a week later and didn't have coverage. I didn't find out until I got a bill from the doctor 2 months later (I got pneumonia while I was unemployed.) Then after that I got a letter from the stupid insurance company telling me I was dropped 2 months before. They do this because Clinton passed a law while in office that requires insurers to take you within a month of losing coverage, regardless of pre-existing conditions. So they wait 30 days to tell you when you're dropped so they don't have to take you back.

This system is soooooo broken. It should be completey abolished and replaced with something that gives everyone the right to health care regardless of employment, social status, income, etc.

Being a living human being should be an inclusion not a pre-existing condition.

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