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YAHIQ (yet another health insurance question)

YAHIQ (yet another health insurance question)

Old May 18th 2011, 12:56 pm
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Default YAHIQ (yet another health insurance question)

Firstly, I won't have the option of group health insurance as I won't even have an employer when I arrive (probably), neither will the wife. Though I will have a small business set up, it'll be a one-man band and not qualify for CA group policies, nor would I qualify for high risk pools etc. I realise all plans are different so these are general questions.

So, I'm stuck with individual/family policies. Though I think I'm understanding most of it now, there is something I want to be absolutely sure about. Let's say there is a deductible of $5000 and a co-pay of 30%, and keep the example simple so no prescriptions or ancillaries, just a hospital bill. If I had a first incident costing $5000 then I would not pay anything beyond the premiums so far, correct? If I then had a catastrophic disaster and ended up with a $1,000,000 bill, I would have to pay 30% of that, ie $300,000, correct? If so then I don't want a percentage co-pay like that! Yes, I know it'll bump up the premiums. Is that deductable payable up front, ie if I "use up" that deductible on day 1 then I pay that full amount very soon afterwards, not averaged out over the following 11+ months? Sorry for the dumb questions but as I say, I want to be crystal clear what I'm getting into.

Secondly, pre-existing. I've had cataract surgery and will probably have a bit more - even if not, I'm consulting doctors. This clearly falls under pre-existing as it will be within 6 months of arrival. The plans I've been reading exclude pre-existing for 6-12 months but then say prior coverage counts towards that exclusion (but how much?). So would the NHS wipe out that waiting period (I will have insurance from day of arrival in US)? Waiting period or not, once that is over, the ore-existing will be covered, correct? I understand certain conditions might never be covered (eg cancer) but I think cataract surgery isn't something that crops up again necessarily, or needs ongoing care.

Thirdly, wife and kids will likely visit the US on day 1 with me for a week or two but then disappear to Asia for a couple of months. Is it best to fork out for insurance even though they won't be there - possibly finding a policy with worldwide cover? I think travel insurance (from the UK) won't cover them as they would no longer be resident in the UK from the day they leave. They'd need medical cover whilst in the US for that initial week or two and, again, travel insurance probably wouldn't cut the mustard. Somebody asked a similar question a few weeks ago but I don't remember the consensus on travel vs health insurance, nor can I find the thread.

For my reference, this thread is proving useful:
http://britishexpats.com/forum/showthread.php?t=634062


Thanks.
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Old May 18th 2011, 1:06 pm
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Default Re: YAHIQ (yet another health insurance question)

BTW when I say "co-pay %" I mean "inpatient hospital" mostly, not Dr office visit co-pay. I'm hoping that mental care and chemical dependency types of things are less likely and can risk not worrying about them.
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Old May 18th 2011, 1:09 pm
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Default Re: YAHIQ (yet another health insurance question)

This is how ours works:

Your deductible is what you have to pay out of pocket before any insurance kicks in. So if your first hospital bill was for $100,000 you would pay $5,000 plus 30% of the remainder and all future bills until you reach your out of pocket maximum for the year.

You should read your policy as carefully as possible as there may be individual deductibles (say $500 pp) as well as a family deductible say ($1200) so you don't all have to meet your individual deductibles before insurance kicks in.

Also remember co-pays can vary for in-network/out of networks doctors, hospitals and even for different procedures and a prescriptions.

Minefield isn't it ? I haven't met a single person who fully understands their health insurance yet!
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Old May 18th 2011, 1:31 pm
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Default Re: YAHIQ (yet another health insurance question)

As your condition has been treated by the NHS your new insurance company should cover it. The following is from a member who no longer posts on BE (Tracym)...

"The HIPAA final rule:

http://www.dol.gov/federalregister/P...px?DocId=10270

The rule was changed to specifically include foreign government plans such as the NHS. Also, it specifically says that a a certificate of creditable coverage is NOT required - just some reasonable proof (e.g. national insurance card, letter from doctor, etc.)

Search the document for the word "foreign" for applicable text.

Shorter version - here is a comment from Blue Cross/Blue Shield, which specifically mentions that the the law changed to include plans such as the NHS as creditable coverage.

http://www.bcbsil.com/PDF/legislative_update_405.pdf

FAQs address the fact that a doctor's letter or some such can suffice if a certificate of creditable cover is not available:

http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

I have gotten this to work with a private insurer, and also for another person, it was accepted by a state high risk pool.

I believe it used to be a problem, but now the law has changed. Sometimes one has to point out the law, as not all insurers are aware of it (the state high risk pool wasn't) - but they were glad to oblige once it was pointed out to them.
"
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Old May 18th 2011, 1:31 pm
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Default Re: YAHIQ (yet another health insurance question)

As said, the deductible is what you have to pay before insurance will pay anything. Usually they will negotiate a rate so that $5000 as billed may only end up as $2000 of actual cost. That $2000 would be on you to pay. Once you meet the deductible your co-pay or coinsurance will apply.

The NHS coverage is creditable coverage but that usually only applies to group policies.
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Old May 18th 2011, 1:39 pm
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Default Re: YAHIQ (yet another health insurance question)

Originally Posted by ChocolateBabz View Post
you would pay $5,000 plus 30% of the remainder and all future bills until you reach your out of pocket maximum for the year.
Ah, I'd missed that bit! That makes it a bit more palatable.

Originally Posted by ChocolateBabz View Post
Also remember co-pays can vary for in-network/out of networks doctors, hospitals and even for different procedures and a prescriptions.
Yes, I was trying to keep it simple! I may well be travelling so I ought to find one that has wide in-network coverage.

Originally Posted by Jerseygirl View Post
As your condition has been treated by the NHS your new insurance company should cover it. The following is from a member who no longer posts on BE (Tracym)...

"The HIPAA final rule:"
I'd seen that post but was led to believe that HIPAA applies to group policies, not individual/family? But then also read that some honour it anyway - one of Blue Shield's policy wordings specifically stated prior creditable coverage waiting period waivers for an individual policy, for example. I realise I may have to argue with them to consider NHS coverage.

Thanks both.
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Old May 18th 2011, 1:41 pm
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Default Re: YAHIQ (yet another health insurance question)

Originally Posted by Duncan Roberts View Post
As said, the deductible is what you have to pay before insurance will pay anything. Usually they will negotiate a rate so that $5000 as billed may only end up as $2000 of actual cost. That $2000 would be on you to pay. Once you meet the deductible your co-pay or coinsurance will apply.
Thanks. Basically I should try to budget in the deductible right up front, worst case scenario.

Originally Posted by Duncan Roberts View Post
The NHS coverage is creditable coverage but that usually only applies to group policies.
Damn, back to square one!
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Old May 18th 2011, 1:53 pm
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Default Re: YAHIQ (yet another health insurance question)

Originally Posted by GeoffM View Post
Thanks. Basically I should try to budget in the deductible right up front, worst case scenario.
If you can yes, it's amazing how costs mount up. I had a mole removed at the beginning of the year (hadn't paid anything towards deductible yet) so had to pay the full $500.

Our annual out of pocket maximum is $6,000 so we actually have that stashed away 'just in case'. Of course if we ever had to use it we would have to find a way to save it up again for the following year's 'just in case'.

On the plus side some things (annual physical, pap smear, vaccinations) are covered 100% on our plan as they are seen as being 'preventative'.

Don't forget dental cover either, if you are anything like us at your first visit they will try to rob you blind!
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Old May 18th 2011, 2:23 pm
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Default Re: YAHIQ (yet another health insurance question)

Originally Posted by GeoffM View Post
I'd seen that post but was led to believe that HIPAA applies to group policies, not individual/family?
HIPAA is federal law - it applies to all aspects of health care including health care insurance... anywhere in the US in any form whatsoever.

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Old May 18th 2011, 4:38 pm
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Default Re: YAHIQ (yet another health insurance question)

I believe HIPAA protections for creditable coverage do apply to individual policies. But it's essentially a meaningless provision because HIPAA says nothing about the cost of individual policies that are willing to cover any and all pre-existing conditions one may have. In the group market, the provisions are meaningful because you are - obviously - paying the group rate rather than being rated as an individual.
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Old May 18th 2011, 8:55 pm
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Default Re: YAHIQ (yet another health insurance question)

Originally Posted by ChocolateBabz View Post
pap smear
Hopefully won't need one of those myself

Originally Posted by ChocolateBabz View Post
Don't forget dental cover either, if you are anything like us at your first visit they will try to rob you blind!
I dread to think. There's another horror thread today which includes dental costs. Our 3-year-old needs to go under for an extraction (highly embarrassing , bad parents; apparently milk formula when he went to bed with a bottle) which, of course, is covered under NHS. Myself, went for minor work recently and purely by coincidence a crown broke just two weeks later, only had to pay £150 instead of nearly double that because I'd recently had treatment - for a completely unrelated treatment! Can't knock that at all.

Originally Posted by ian-mstm View Post
HIPAA is federal law - it applies to all aspects of health care including health care insurance... anywhere in the US in any form whatsoever.
Ok, that clears that up.

Originally Posted by Giantaxe View Post
I believe HIPAA protections for creditable coverage do apply to individual policies. But it's essentially a meaningless provision because HIPAA says nothing about the cost of individual policies that are willing to cover any and all pre-existing conditions one may have. In the group market, the provisions are meaningful because you are - obviously - paying the group rate rather than being rated as an individual.
Hmm, I guess I'll find out when I request a full, formal quote with full declarations! I am hoping that, worst comes to the worst, I'll have to go back to the UK to take up residency in my parents' house and deal with any problems that way. At least this sort of condition is something that could take months to get worse rather than, for example, sudden heart attack. I did have "issues" with my previous private provider who stated a blanket "no eyes whatsoever" cover until I argued that was unreasonable for accidents or any other situation that had nothing to do with congenital conditions to not be covered. Not suggesting that US providers would be equally sympathetic - but I don't go down without a fight!

Thanks all. Any other comments about my other questions would be appreciated!
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Old May 18th 2011, 9:06 pm
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Default Re: YAHIQ (yet another health insurance question)

I suppose shopping around is the best answer. Time consuming and a pain, and I guess price comparison websites only show basic costs not the finer details, so you need to do the legwork yourself. Or use a broker maybe?

I agree with your comment about your eyes. I would also argue that not just eye accidents but anything else with the eyes not related to cataracts should be covered. There are several eye conditions that have no relation to cataracts. I bet the people doing the quoting are not medically qualified and this is the problem.

When I was reporting my pre-existing conditions to my travel insurance provider (who I admit covered everything except my depression even though I am diabetic and on lots of medication), I named a med called enalapril which is for high blood pressure but also protects the kidneys from the damage that diabetics can get. The guy at the call centre asked 'Are you waiting for a kidney transplant?' which shows how little they know.
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Old May 18th 2011, 9:50 pm
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Default Re: YAHIQ (yet another health insurance question)

Originally Posted by Squirrel View Post
even though I am diabetic
Not disagreeing with you, and nothing to do with this thread, but I've learnt over the last year that diabetes can affect the eyes badly - to the point that I had an ultrasound to check there was nothing wrong in the kidney area. As it was only a couple of weeks after SWMBO had her ultrasound for the baby, one couldn't help but think "is it a boy or a girl?"
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Old May 18th 2011, 9:54 pm
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Default Re: YAHIQ (yet another health insurance question)

Originally Posted by GeoffM View Post
Fet's say there is a deductible of $5000 and a co-pay of 30%, ... If I then had a catastrophic disaster and ended up with a $1,000,000 bill, I would have to pay 30% of that, ie $300,000, correct?
Not with my policy.

Double check the policy / proposal and you might find a limit on the co-pay. So it could be something like you pay the first $5,000 and then 30% above that with a limit of another $5,000. So the total cost to you in your example would be $10K.

Its a minefield for sure...good luck.
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Old May 18th 2011, 10:01 pm
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Default Re: YAHIQ (yet another health insurance question)

Originally Posted by Squirrel View Post
I suppose shopping around is the best answer. Time consuming and a pain, and I guess price comparison websites only show basic costs not the finer details, so you need to do the legwork yourself. Or use a broker maybe?
Bingo.

Geoff, it's customary for small business people to use an insurance broker. This is someone who is familiar with the lingo, and can shop several insurers for you. They're worth their weight in gold, and are an important partner in your business. They'll be able to help you with the other business & personal insurance needs too, not just health insurance.

Generally, the more policies you have with a given company, the more they will discount for you. A broker can sell you different policies from different companies too, but manage the whole portfolio for you. Believe me, it's just not the sort of thing that is easy to shop for yourself. A professional will save you a lot of time/heartache/money.
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