RoadWarriorFromLP

You're not really following the issue here.

Let's say you run a widget business. In Market X, you're strong and have the potential to get stronger; in Market Y, you are small potatoes compared to some major entrenched players who aren't going anywhere.

You have a limited amount of money to invest in increasing your profits. Would you spend your cash in X, where it could help you, or in Y, where it probably will just cause you to waste your money?

California is not a prize to those minor players that have larger operations somewhere else. Their best options are elsewhere, and they'll focus on those.

Steerpike

Just curious (since this concept is supposed to go away under ACA anyway ...) ... with the lack of any comprehensive EMR system in the US (Electronic Medical Record), how could the insurer ever know what medical issues I may have had in the past 20 years? There seems to be a complete lack of information sharing at this point in time. Now, I know that, if I suddenly fell ill and started costing hundreds of thousands of dollars to the insurer, they will set the dogs loose digging through my history looking for reasons/excuses to deny my claims ...

RoadWarriorFromLP

You have to disclose pre-existing conditions.

If you get sick after buying the policy, then you run the risk of having your policy underwritten again. If it's a condition that you knew that you had (or presumably should have known that you had), then they'll take the position that you lied, which is grounds for recission or denial of claims.

Michael

In the case of Brat1, she filled out the application honestly and several years later, she was cancelled claiming that her new condition was caused by a pre-existing condition that she told them when filling out the application.

In my case, blue cross had me send them my medical records before they would analyze whether they would accept me and at what price.

So either they get medical records, you fill in the application correctly, or if they find something in your past even if it is reported on your application or was in your medical records that they incorrectly analyzed the risk, they can usually cancel you and/or deny claims in states with little regulations. In states with few regulations, a health insurance individual plans are not like most other contracts. When large medical bills occur, insurance companies after the fact look for any reason possible for denial of claims for individual plans.

And surprisingly, Brat1 was in a state that regulates insurance companies pretty well but unless you are going to hire a lawyer, they still try to get away with it.

Steerpike

Not sure how relevant this is to the discussion here, but my last employer was AZ based, but had offices and employees in MANY states, including CA. So United Healthcare (their group provider) was insuring people domiciled in CA, in an indirect manner. In fact, the primary reason for calling United last week was to verify that, as a Cobra participant of the United Healthcare group plan, was it ok for me to relocate to CA. They confirmed that it was.

That is very clear to me. My challenge is, what constitutes a 'condition' ...? I had a hernia repair, and I disclosed that. But what about a visit to the doctor for a complaint of back trouble - one that resulted in a visit to a physical therapist (probably need to disclose that...). And what about a visit to the doctor for a concern about a skin condition ... one that did NOT result in any further action ... ? Again - this should all be moot at this point assuming ACA takes hold - thank goodness.
How does one get one's medical records? That's the part I'm not clear on ... I've seen dozens of different doctors in the past 30 years, and been covered by at least 10 different (group) policies.

Michael

That's the problem since there isn't any definition and is up to the health insurance company. In my case, I probably saw a doctor typically only every few years for about 35 years of health insurance coverage and when my Cobra ran out, I applied to Blue Cross and ticked fatigue thinking that it was not a big deal but 2 months after the application, they denied me because of the fatigue and offered me a high deductible, high co-pay, and unlimited out of pocket expenses risk pool policy for $600 per month 11 years ago (probably $1,200-$1,400 today for someone 57 years old).
In my case, I always used one doctor as primary care and never went to a specialist so for me, it was easy since I authorized the insurance company to see my records with that doctor. If you saw specialists and there is a notation in your primary doctors medical records, then the insurance company will likely request you to authorize those medical records or just deny you or put you in a risk pool.

In my case, they just saw the 3-4 visits for fatigue during the previous year and that was enough to create the denial and the risk pool offer (I think California requires insurance companies to offer risk pool if you don't have a break in coverage and only offers California state risk pool coverage if there is a 6 month break in coverage). For the VA, my doctor just copied my records and gave them to me at no charge. The VA just wanted my records for my medical history but I doubt they used them since the VA is computerized and it would take too much effort try to read my doctors hand writing and put that information in the computer.

scrubbedexpat099

Insurance is not a suitable product for basic health care, nothing new.

I suppose if you wanted to compare to an existing insurance product then whole life would be the way to go.

Sign up for the rest of your life, rather than the term approach used.

Michael

It's called universal health care either government provided, single payer, or mandatory private insurance.

scrubbedexpat099

Of course.

SpoogleDrummer

I was under the impression that the maximum out of pocket was inclusive of the deductible, but here the oop is lower than the deductible, is that a typo or do I have even less understanding of insurance than I thought?

I didn't think you had to anymore as they can't refuse you or charge you more because of it? At no point during the application on Healthcare.gov was anything asked about pre-existing conditions, I assumed it was because they can't charge more for it so don't care what I have.

https://www.healthcare.gov/what-if-i...lth-condition/

Michael

I don't think it is a typo since apparently pre-ACA, "maximum out of pocket" expense could include the "deductible" or "not the deductible" depending on the fine print in the policy.

In my understanding, all ACA policies include the deductible when calculating the "maximum out of pocket" expense.

Steerpike

I had the same question; it is apparently (and as Michael says) not obvious - when I was talking to the lady on the phone about my (old, pre-ACA) plan, she wasn't sure and had to check. Sounds like post-ACA, it's a standard. What a concept ....
The context for the comment that caused your question was a pre-ACA plan.

Michael

At the beginning of December, I received a packet for my prescription drug benefit from First Health (previously I thought it was United Health Care) which contained two booklets with each about 120 pages long (one describing the plan and the other the foundry) but I never opened it since I wasn't going to read about 240 pages.

However today I opened the packet and on the 3rd page, it indicated last years cost was $24.40 per month and this years cost is $41.60 (a 70% increase in cost) even though I didn't use the plan last year and I had until December 7th to change plans or cancel. I should have paid closer attention since WellCare has the lower co-pays for a $22.40 per month plan.

The plan also increased the co-pay for preferred generic drugs. The following is a list of the co-pays for a 30 day supply.

Drug Type -------------------------------- 2013 co-pay ----- 2014 co-pay

Tier 1 (Preferred Generic Drugs) ---------- $7.00 -------------- $10.00
Tier 2 (Non Preferred Generic Drug) ------ N/A ---------------- $33.00
Tier 2 (Preferred Brand Drugs) ------------ $45.00 -------------$45.00
Tier 3 (Non Preferred Brand Drugs) ------- $95.00 ------------ $95.00
Tier 4 (Specialty Tier Drugs) --------------- 33% of cost ------ 33% of cost
Not all drugs are covered by the plan.

Through the VA, my cost is $9.00 per 30 day supply for any type of drug so I've never bothered using the Part D prescription drug plan.

I went through their foundry list finding the drugs that I use and discovered the cost through the plan for ever single drug was more expensive for a 90 day supply than it would cost me through the Health Warehouse web site.

http://www.healthwarehouse.com/simva...g-tablets.html

According to my understanding, the government pays 75% of the cost of the drugs. So it appears that the United Health Care not only gets my premium but also makes money if I order drugs through them plus they get a 75% subsidy from the government. What a great conservative program passed by the Bush administration.

If anybody thinks ACA is a bad program, Part D then appears to be an extremely terrible program and I doubt most people don't know how badly both the consumers and taxpayers are getting ripped off. If you don't think the cheaper plans are good enough, some plans have a monthly premium of $120 but still have co-pays of $5-$45 and 33%-49% with the primary difference being that it has additional Gap coverage which is currently covered at 50% by the government for all plans.

Even if I didn't have VA coverage, I don't see any benefit of Part D.

RoadWarriorFromLP

That's one of the key provisions of ACA -- the ACA plans do not consider pre-existing conditions. But the individual plans that aren't offered under ACA will continue to take pre-existing conditions into account.