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Interpretation of health insurance benefits

Interpretation of health insurance benefits

Old Jul 6th 2012, 10:21 pm
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Default 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.
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Old Jul 6th 2012, 11:37 pm
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Default 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

just my two cents
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Old Jul 6th 2012, 11:54 pm
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Default 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.
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Old Jul 7th 2012, 2:54 am
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Default Re: Interpretation of health insurance benefits

Originally Posted by guitarmaan View Post
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

just my two cents
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).

Originally Posted by Mummy in the foothills View Post
Doesn't it explain it on the Kaiser website? Here
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.

Originally Posted by Mummy in the foothills View Post
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.
Was that HIPAA? Lots of plans though, all different. I was hoping somebody would say they were easy questions!
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Old Jul 7th 2012, 4:50 am
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Default Re: Interpretation of health insurance benefits

Originally Posted by GeoffM View Post
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!
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
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Old Jul 7th 2012, 5:17 am
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Default Re: Interpretation of health insurance benefits

Originally Posted by GeoffM View Post
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!

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/
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Old Jul 7th 2012, 2:45 pm
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Default Re: Interpretation of health insurance benefits

Originally Posted by GeoffM View Post
After being given the run-around by agents previously, I'm yet to be convinced!
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.
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Old Jul 7th 2012, 5:08 pm
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Default Re: Interpretation of health insurance benefits

Originally Posted by Nutmegger View Post
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.
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.
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Old Jul 7th 2012, 8:47 pm
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Default 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.
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Old Jul 7th 2012, 9:03 pm
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Default Re: Interpretation of health insurance benefits

Originally Posted by GeoffM View Post
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.
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!
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Old Jul 7th 2012, 9:06 pm
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Default Re: Interpretation of health insurance benefits

Originally Posted by Boiler View Post
Generally:

Agents act for one Company
Brokers act for several.
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.
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Old Jul 7th 2012, 9:08 pm
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Default 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 !!!
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Old Jul 8th 2012, 1:50 am
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Default Re: Interpretation of health insurance benefits

Originally Posted by SanDiegogirl View Post
Annual out of pocket expenses 3,500 for individual/7,000 for family. this would be your total expense for this plan per year.
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!

Originally Posted by SanDiegogirl View Post
Have you actually been offered either of these plans by Keiser? (they are not available via agents).
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!)

Originally Posted by SanDiegogirl View Post
Is this going to be for an individual or a number of family members?
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.

Originally Posted by SanDiegogirl View Post
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.
I wasn't eligible for COBRA - I think 6 month residency was required, or 6 month lack of coverage, something like that.

Originally Posted by SanDiegogirl View Post
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 !!!
Thanks, I appreciate it!
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Old Jul 8th 2012, 1:54 am
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Default Re: Interpretation of health insurance benefits

Originally Posted by fatbrit View Post
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!
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.
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Old Jul 8th 2012, 2:11 am
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Default Re: Interpretation of health insurance benefits

Originally Posted by GeoffM View Post
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.
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.
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