Interpretation of health insurance benefits
 

Thankfully I've now been enrolled in a Kaiser Permanente HIPAA plan. I only got a very vague letter which didn't indicate any of the benefits or even the price, just that I'd been enrolled with the maximum plan. Upon phoning I found out it's $730/month with only one other plan available as an option - I'm on a $25 co-pay plan but could switch to a 30/1500 deductible plan which is about $520/month. Beyond that she couldn't/wouldn't tell me any more - but I have only 30 days in which to switch, and if past experience is anything to go by, I might not get the plan pack for a few weeks.

So I managed to find something online which compares the two plans. I ought to know this but let's go back to basics to make sure I fully understand! One thing I'm confused/concerned about is a $200 copay per day for inpatient care. Firstly, does that include everything per day (rather than 200 for board, 200 for tests, 200 for meds etc), and secondly is that capped by the annual out of pocket maximum? So, for example, a 20 day hospital stay with open heart surgery will cost a maximum of $2500?

If I went for the deductible one, it says $500 per day (after deductible). With the above example and no other claims, I'd pay up to $1500 for the first three days and then insurance would pay everything beyond? Or is that back-to-front?

This is what I'm reading: http://www.davefluker.com/60067400_1...IF_FNL_LCK.pdf - I'm aware it's not a KP-sourced document but it's the best I can find.

At least I get free mammograms. :blink:

Re: Interpretation of health insurance benefits
 

After some research and question asking, I got the overall advice that it's best to use a broker for health insurance. The subject is so involved and the small print so important, that arguably it's wise to seek expert help. Some of these policies cost as much as a mortgage :blink:

just my two cents

Re: Interpretation of health insurance benefits
 

Doesn't it explain it on the Kaiser website? Here
We has the plan that cost me $20 a visit and $15 for each lab, then it was no cost per day for hospital admissions but times have changed.

Re: Interpretation of health insurance benefits
 

After being given the run-around by agents previously, I'm yet to be convinced! This HIPAA thing is only available from them direct anyway, and I'm already enrolled after 2 months of stressful rejections and debates over whether the NHS qualifies as prior credible coverage because they don't issue a certificate of such in a format that Americans understand (and why should the NHS provide it).

Unless I'm missing something... no! In addition, my personal log on is not available until they mail me a password as the online thingy didn't know enough about me to issue one there.

Was that HIPAA? Lots of plans though, all different. I was hoping somebody would say they were easy questions!

Re: Interpretation of health insurance benefits
 

Bummer that they haven't given you a password yet.
We had a booklet sent to us (this was a while back) it showed the costs for many things, for our plan and had phone numbers and stuff in it. I really used to like how I knew exactly what things were going to cost me.
We have Blue cross from Dh's work now. just as confusing :lol:

Re: Interpretation of health insurance benefits
 

There is at the moment no real standard in health insurance, every policy is different and even insurance companies at times can't tell you everything that is covered, at times things can be a case by case basis.

There is no easy way when it comes to health insurance, I have a jaded view on health insurance after I got stiffed with a 30,000 bill because the insurance company decided not to pay a hospital for treatment when I was ill several years ago and in hospital for a few weeks.

This website will help hopefully understand what HIPPA is.

http://www.hhs.gov/ocr/privacy/

Re: Interpretation of health insurance benefits
 

What kind of agents? guitarmaan meant an independent insurance brokerage that specializes in HI and can sift through the myriad companies/options and present you with choices in line with your needs -- and explain how they all work. I've used a broker for years and would never think of doing anything connected with HI without him.

Re: Interpretation of health insurance benefits
 

Health insurance agents. Maybe I just got unlucky but of the two I did actually use, both were misleading or simply didn't understand new immigrants' status, and the half dozen other local agents that I emailed, phoned, or visited, not one of them ever got back to me - even after calling/emailing again.

As I already said, no agent would have been able to help with the KP HIPAA plan anyway, as it's only sold direct by KP.

I am hoping KP are going to be more prompt than my previous experiences - in the kids' cases they sent the ID cards two weeks before coverage started and I think we had the policy documentation shortly afterwards. They wanted more information from me which I sent about 2 weeks ago, so it's fair enough that I haven't had a reply until now - maybe the rest will follow soon. Blue Shield, the kids' previous cover, didn't send their documentation until nearly a month after coverage started.

In any case it seems I only have two options anyway - the $25 copay or the 30/1500. My worry is that $200/$500 hospital stay issue. If both are capped at the max out of pocket then fine, but if they're not then my risk tolerance doesn't stretch to the $500 per day plan.

Re: Interpretation of health insurance benefits
 

Generally:

Agents act for one Company
Brokers act for several.

I have also noticed that Agents are very unwilling to get into details and just send you loads of bumf. I am familiar with the terminology but it would take several hours to get a grip of any given situation. And then I would not want to guarantee it.

Welcome to America.

Re: Interpretation of health insurance benefits
 

It really isn't worth it at that price. Four days in hospital, two in IC, one operation and every test known to mankind.....came out at not much more than your annual premium after discounts for cash and being uninsured.

And, of course, they'll throw you as soon as they can after you've had such an illness so it's not like you're paying for the future.

Seriously, save your money!

Re: Interpretation of health insurance benefits
 

Ah, thanks for explaining that: I hadn't realised there was a difference. In that case I have used both agents and brokers without much luck.

Re: Interpretation of health insurance benefits
 

OK, I have taken a look at the summary benefits page for these plans.

My interpretation is as follows:

Copayment 25: No deductible; co-pays you need to pay of between 25 and 100 bucks for visits/Xrays etc; in-hospital stays including board and bed/tests/meds/surgery are 200 bucks a day; other various copays for emergency treatment etc etc.

Co-pays go towards annual out of pocket expenses.

Annual out of pocket expenses maximum: 2,500 for individual/5,000 for family. This would be your total out of pocket expense.

l30/1500 Plan: Deductible (monies you need to pay) of 1,500 bucks before Plan kicks in to pay anything.

After you have paid your deductible there are various co-pays ranging from 25 for doctor visits to 250 for outpatient surgery. In-hospital stays of 500 bucks a day.

Annual out of pocket expenses 3,500 for individual/7,000 for family. this would be your total expense for this plan per year.

Have you actually been offered either of these plans by Keiser? (they are not available via agents).

Is this going to be for an individual or a number of family members?

The reason I ask is that these are HIPPA plans - Guaranteed issue plans which are USUALLY only offered under special circumstances and are therefore more expensive. They are usually offered once COBRA has been used up following being dropped from Group plans or where you have had continuous coverage under some other insurance plan, and have then taken COBRA.

See below:

For those who are exhausting COBRA/Cal-COBRA programs or are losing group health coverage with no employer continuation offering, HIPAA regulations allow you to purchase guaranteed-issue health coverage under the following rules:

-COBRA or Cal-COBRA benefits must be exhausted or not offered;

-You must apply for HIPAA coverage within 63 days after termination of COBRA, Cal-COBRA or employment if no COBRA offered;

-You must have been covered for 18 months continuously prior to HIPAA effective date with the most recent coverage being employer-sponsored group health insurance with no gaps greater than 63 days between any prior coverage;

-Must not be enrolled in nor eligible for Medicare Part A or B, Medicaid or MediCal or covered by another group health insurance plan.

If you qualify and are not medically able to obtain a private underwritten health insurance plan (which would normally be less costly), you can choose a guaranteed issue health plan. Below are plan options and rates for California residents. Please note that you do not need to be declined for individual coverage to elect a HIPAA plan.


I'm just asking because you have had such a bad experience with health insurance and I don't want to see you going down another route which will end in frustration and tears !!!

Re: Interpretation of health insurance benefits
 

Thanks for reading that. The wording is confusing when it says $500 after deductible - I would have thought the wording should say $500 until deductible met, as I would pay $500 for each of the first few days until the maximum is met. Still, they have an army of lawyers writing that stuff so I must be wrong!

Yes, what happened was I applied to KP (amongst others) as an individual. I must have ticked the HIPAA box because a few days after a letter declining cover, I was sent another letter saying that to be eligible for HIPAA coverage I had to meet seven criteria. I forget exactly what those were but can dig them out if anyone is interested. Most of the questions were very straightforward and thus had no problem answering them; a couple I had to read into a bit more to understand exactly what it was asking but again, I could be confident of the answers - and those meant I was eligible. The letter they sent a couple of days ago basically said I was covered from July 1st on their most comprehensive plan "as I hadn't chosen a plan" (wasn't given the opportunity!)

For me it's individual. I'll have to dig out the wife and kids' to see whether theirs is family or individual. I suspect I will be treated as an individual and thus independent from any family maximums.

I wasn't eligible for COBRA - I think 6 month residency was required, or 6 month lack of coverage, something like that.

Thanks, I appreciate it! :starsmile:

Re: Interpretation of health insurance benefits
 

To be fair, you're in a minority saying that! It really is all about risk tolerance and legalized gambling where the only rewards are not losing any more money. I'm glad it worked out for you but I'm not sure I could do that.

Re: Interpretation of health insurance benefits
 

I never gamble! Well, actually, I suppose I gamble on everything.....but only when I fully understand the odds. Unless you have substantial, unprotected assets, you're throwing $9000/yr on something that's probably worth almost nothing.

Re: Interpretation of health insurance benefits
 

I understand where you are coming from - but I had been here two years, fit as a fiddle and then had a brush with the big C and the insurance company was billed nearly 30K. OK, so they only paid about 60% of that but boy was I glad I had insurance.

I'm just low on the risk thresh-hold I guess.:)

Re: Interpretation of health insurance benefits
 

Unfortunately, if Geoff has a similar medical cost every 3 years, he'll still be better off without insurance given what they're charging him. Frightening thought!

I'm paying less than half his quotes for interim obamacare ($2k deductible, 80/20, $6k max oop),and I'm not convinced I'm quids in. Well I probably am, but as medical bills this year were going to cause a huge tax right-off, I've had my ingrowing toenail fixed and my moles removed. Wouldn't have bothered otherwise.

Another operation has cost me about the same it cost me with no insurance. The only advantage of the insurance was I don't have to negotiate with the retards in the billing department as the insurance company do it for me

Re: Interpretation of health insurance benefits
 

Everything is a gamble! If you choose not to pay for insurance then your actual costs for the year can run from nothing to unlimited. With the insurance it restricts the range from $9k to $12k.

If it was just about my pre-existing conditions (recent eye surgery) then I'd be confident and say I wouldn't need insurance to cover that as I know the risks - I could jump on a plane and see my old eye doctor in the UK as I knew how much that op cost (private healthcare, not NHS).

But it's the unforeseeable - hit by a truck, cancer, or whatever.

When you say they can drop you, that would have to be after the event, right? So they'd pay the bill and then say bye-bye? I could live with that. But if they fainted at the size of the bill and refused to pay then I can see your point.

What about in Bob's case where he's getting bills from a year ago - if he was covered at the time then the insurance should pick up the bill, even if he was no longer with them when the bill came through, right?

[Arguments over bills excluded for simplicity]

Re: Interpretation of health insurance benefits
 

The point is that the cost is not unlimited since bankruptcy is not a particularly difficult option in the US.

At the moment, they'll drop you as soon as they can after the event if you're not on an employer's group plan. Either that or charge you so much you'll voluntarily leave the plan. Not sure what's happening in 2014 -- not sure anyone is!

They'll pay for any service that were delivered during the policy's validity. As a corollary, any payment you make is only tax deductible in the year when you make payment, not when the service was delivered.

Re: Interpretation of health insurance benefits
 

Thanks. Presumably bankruptcy would kill your credit score and show up in your credit history though?

Re: Interpretation of health insurance benefits
 

Oh yeah! Although, surprisingly, some lenders are quite happy to lend to bankrupts -- they can't file again for x years. Also, your credit score is heavily weighted to the last 2 years, so you can recover quite quickly if you plan it out.

Re: Interpretation of health insurance benefits
 

Yup, you'd be covered, but it might be more hassle as they like to play games and deny things to make you go through hoops to show you were in fact covered by them at the time of service.

It's a time sink.

Re: Interpretation of health insurance benefits
 

It helps to keep every piece of paper the insurance company sends you (from renewal of membership card to notification of prescription drug list to every invoice).

..... and I always keep a record of my visits, who I saw and what tests were carried out.

Paranoid I know .........

Re: Interpretation of health insurance benefits
 

A bankruptcy is better then years of fighting the hospital and then collections when they decide to give up and let a collection agency deal with it.

My credit recovered faster after the bankruptcy because I now had no debt, and I wasn't having a negative reported every month from the collection agency.

And insurance companies pay good money to lawyers who will find ways to not pay a claim.

I was getting letters from car loan companies 6 months after my bankruptcy and was approved for a loan 9 months after.

Re: Interpretation of health insurance benefits
 

Wow... so bankruptcy isn't so much of a stigma here as it was in the UK then.

Re: Interpretation of health insurance benefits
 

Bankruptcy usually means you got ill and didn't have insurance. The stigmatized group is quite large these days.