Another Health Insurance Question (Florida)

[Rush20]

Hi gang. I hope all is well. I haven't posted in awhile, however I have been checking in and reading updates, etc.

I'm hoping someone who has a similar pre-existing condition (artificial aortic heart valve) can help me.

I have been working in Corporate America my whole career and have particiated in group health insurance policies through the companies I've worked for. I moved from Chicago to Sarasota, FL in 2005 two years after my OHS and my aortic valve replacement.

Recently, the company I worked for was purchased and I lost my position (Channel Sales Director) due to the new company eliminating our department. Since then (July 2010), I have been consulting and purchasing group insurance (Cigna) through the Corbra plan, however it is set to expire at the end of this year.

I have been considering joining a small firm of consultants as I enjoy the idea of working for myself vs. a corporation, however the firm does not offer a health insurance plan due to its small size. Therefore, I need to know what type of insurance options I have once the Cobra insurance expires in December.

In the state of Florida, there are currently 4 major providers; (1) Blue Cross/Blue Shield, (2) Aetna, (3) Cigna and (4) Humana. I went on-line and completed one of those insurance quote requests and then received about 2-dozen phone calls from health insurance brokers. :eek2: I picked a few to call back and soon discovered that brokers cannot present a policy with a pre-existing condition such as my heart valve. I was informed that I would need to contact each insurance company directly, however it was highly likely they would refuse me. If, and that's a big "IF", the Obama health care plan does take effect, the pre-existing condition/non-refusal clause does not go into effect until 2014.

I was hoping I could secure a high, heart-related deductable and then obtain general health and dental policies for my wife/children, etc. I would hate to think that my career options will now be limited to corporations where group insurance is available.

I appreciate any suggestions, advise, etc. from those who may have walked this path already or from any health insurance professionals.

Thanks!

Allen

 

[dick0236]

If, and that's a big "IF", the Obama health care plan does take effect, the pre-existing condition/non-refusal clause does not go into effect until 2014.

I would hate to think that my career options will now be limited to corporations where group insurance is available.


Thanks!

Allen

Alan, I know and appreciate your problem. I received my valve fresh out of college, and was limited to large company group plans for almost all of my career. I am retired as a consultant of health insurance. As I remember COBRA, you have conversion privledges with the insurer that now carries your COBRA coverage, but it probably will be limited coverage and expensive. Look into an individual plan for your wife and kids. Either convert your COBRA plan to an individual plan on yourself or look into the Florida Hi-risk pool. Your problem is not unique....and I certainly hope the Obama plan is not repealed.

 

[ShezaGirlie]

The trials of finding health insurance..

The trials of finding health insurance..

Hi Rush,
Actually the Federal high-risk pool health insurance is currently in affect due to the Obama Healthcare Bill, so you're in luck there - but seems to qualify, a person must be without insurance for 6 months. Have a read of this article I found in the Tampa Times:

Floridians who opt into the new federal high-risk health insurance pool will pay pricey premiums
By Richard Martin, Times Staff Writer
In Print: Friday, July 2, 2010


--------------------------------------------------------------------------------

Help is on the way for people who are uninsured because of a pre-existing condition such as heart disease, diabetes, cancer or AIDS — if they can afford it.

Floridians can now apply for health coverage through a new federal pre-existing condition insurance plan, also known as a high-risk pool. It is one of the first programs to take effect under the new health reform law.

The plan is a temporary fix that's supposed to cover this high-risk group until Jan. 1, 2014, when more permanent components of the health reform law take effect. In 2014, insurers will no longer be able to exclude people with pre-existing conditions, and a new health insurance exchange is expected to offer more affordable premiums for them.

But even as the new program launches this week, many questions remain. It's unclear at this point whether the program will be able to accept everyone who applies, since no one knows how long the $5 billion set aside for the program will last. And there's concern that many will not be able to afford the premiums, which in Florida can be more than $900 a month, depending on your age and health condition.

Here are the basics:


What is a pre-existing condition?

It's a health condition, disability or physical or mental illness that you have before you enrolled in a health insurance plan.


Who can apply for coverage?

You must be a U.S. citizen or legal U.S. resident and have been previously denied insurance coverage because of a pre-existing condition. And you must be uninsured for at least six months before applying. State health officials estimate that as many as 760,000 Floridians meet the criteria.


How do you apply?

You can download and print out an application in English or Spanish at a newly created website, www.healthcare.gov. Applicants must include a copy of a letter from an insurance company denying coverage or excluding coverage for a medical condition. U.S. noncitizen nationals must include a copy of a document that confirms their status, such as a U.S. passport, and a copy of their immigration documents. You must mail in your completed application. But starting on Aug. 1, applications can be filled out online at the same website. If you don't have access to a computer, call (866) 717-5826.

Once your application is accepted, you will be notified by mail with information about your premium, and you'll also receive your first monthly bill.


How much will premiums be?

Premiums must be the same as the standard individual health insurance rates in each state. In Florida, that ranges from about $140 to $984 a month, depending on the type of plan and the applicant's age. Federal health officials estimate the premium for a 50-year-old in Florida will be between $552 and $675 a month for a plan that includes deductibles of $2,500 for in-network and $3,000 for out-of-network care. Once you meet the deductible, you are responsible for a $25 co-pay and 20 percent of in-network and 40 percent of out-of-network costs.

The plan will cover primary and specialty care, hospital care and prescription drugs.


How soon will coverage begin?

If you apply and are approved for enrollment by July 15, your coverage will begin Aug. 1. Generally, applications received on or before the 15th of the month will take effect on the first day of the next month. Those received after the 15th of the month will go into effect on the first day of the following month.


Will there be limits to the number of people who can enroll?

There are no plans to limit enrollment. But the law does give the secretary of Health and Human Services the ability to impose limits if necessary. Federal health officials expect the program to cover 200,000 people nationally at any given point.


How far can $5 billion go?

One of the biggest criticisms of the plan is that $5 billion will not be enough to cover everyone who is eligible and can afford the coverage until 2014. "The consensus of opinion is that it's underfunded," said Mary Beth Senkewicz, deputy commissioner for life and health with the Florida Department of Health.

Cost was a major reason Florida opted not to run its own high-risk pool plan, choosing instead to have the federal government run it. Twenty-one states have gone this route.

But Richard Popper, deputy director of a new insurance office at the federal Health and Human Services department, said $5 billion can be sufficient if managed properly. The federal government can work with states to adjust benefits and co-pays to their plans. And even though each state is allotted a share of the $5 billion (Florida's is expected to be about $351 million), money can be shifted from states where there isn't high participation, Popper said.

Richard Martin can be reached at [email protected] or (727) 893-8330. For the latest in health news, visit tampabay.com/health




For more information

To explore coverage options and to learn more about the pre-existing condition insurance plan, go to www.healthcare.gov or call (866) 717-5826.

[Last modified: Jul 02, 2010 07:22 AM]

 

[Luana]

When your COBRA ends, you can purchase an individual insurance plan with a pre-existing condition as long as you can say yes to the following 5 criteria:

• You have had at least 18 months of previous health insurance coverage without a break in coverage lasting 63 days or more;
  
• Your most recent period of coverage was under an employer-sponsored group plan, a church plan, or a government plan;
  
• You did not lose insurance coverage due to fraud or failure to pay premiums;
• You are ineligible for or have exhausted their COBRA coverage options or similar state continuation coverage;
  
• You are not eligible for any other employer-sponsored group plan, Medicaid, or Medicare.

Most major insurance carriers offer such plans; they are usually referred to as guaranteed-issue plans or HIPAA-eligible plans. A good broker should know about these and when you mentioned pre-existing condition, should have asked if you meet any of the above criteria. There is no medical review with these plans; you cannot be declined because of a pre-existing condition. This is not something new or part of the PPACA (Patient Protection & Affordable Care Act).

Premiums for HIPAA-eligible plans tend to be similar to COBRA and benefits are usually much better than the high-risk pools.

Many states have had high-risk pools before the PPACA was passed. They usually can only accept a certain amount of people and many have wait-lists to get on them. You probably would be better not to be without insurance for 6 months needed for the FL high-risk pool.

Also, is your COBRA now federal or from the state? If you're on federal COBRA now, you may have an additional 12 - 18 months of COBRA from the state. Check with the person who is in charge of the medical insurance benefits from the company you used to work for.

You can get more information for the state of Flordia here and also on the US Dept of Labor site here.

PS I am an insurance agent.

 

[Rush20]

When your COBRA ends, you can purchase an individual insurance plan with a pre-existing condition as long as you can say yes to the following 5 criteria:

• You have had at least 18 months of previous health insurance coverage without a break in coverage lasting 63 days or more;
  
• Your most recent period of coverage was under an employer-sponsored group plan, a church plan, or a government plan;
  
• You did not lose insurance coverage due to fraud or failure to pay premiums;
• You are ineligible for or have exhausted their COBRA coverage options or similar state continuation coverage;
  
• You are not eligible for any other employer-sponsored group plan, Medicaid, or Medicare.

Most major insurance carriers offer such plans; they are usually referred to as guaranteed-issue plans or HIPAA-eligible plans. A good broker should know about these and when you mentioned pre-existing condition, should have asked if you meet any of the above criteria. There is no medical review with these plans; you cannot be declined because of a pre-existing condition. This is not something new or part of the PPACA (Patient Protection & Affordable Care Act).

Premiums for HIPAA-eligible plans tend to be similar to COBRA and benefits are usually much better than the high-risk pools.

Many states have had high-risk pools before the PPACA was passed. They usually can only accept a certain amount of people and many have wait-lists to get on them. You probably would be better not to be without insurance for 6 months needed for the FL high-risk pool.

Also, is your COBRA now federal or from the state? If you're on federal COBRA now, you may have an additional 12 - 18 months of COBRA from the state. Check with the person who is in charge of the medical insurance benefits from the company you used to work for.

You can get more information for the state of Flordia here and also on the US Dept of Labor site here.

PS I am an insurance agent.

Thanks for all the replies so far. This really helps.

Part of my frustration is that I think many of these insurance brokers are not very well trained and are probably ex mortgage brokers who switched industries when the market crashed. None of them even metioned the five criteria points listed above.

I know my heart valve is a pre-existing condition, however with the exception of the valve and the 5 mg of coumadin I take every day, I am not on any other medication, my health is great, I'm a non-smoker and very active. I exercise 4-5 days per week (cardio + weights) and I'm within my correct weight target per my doctor. (6'2" - 200 lbs.) at age 47.

I'm hoping the valve lasts as long as I do (that's the plan anyway and the reason I chose the mechanical valve) so I'm also hoping my health record is taken into consideration.

 

[dick0236]

I'm hoping the valve lasts as long as I do (that's the plan anyway and the reason I chose the mechanical valve) so I'm also hoping my health record is taken into consideration.

I hope this is true for you and others in this situation. Unfortunately, insurers look at us as "claims about to happen" and place an unfair "dollar cost" on our eligibility for coverage.:thumbd:

 

[Luana]

Thanks for all the replies so far. This really helps.

Part of my frustration is that I think many of these insurance brokers are not very well trained and are probably ex mortgage brokers who switched industries when the market crashed. None of them even metioned the five criteria points listed above.

I know my heart valve is a pre-existing condition, however with the exception of the valve and the 5 mg of coumadin I take every day, I am not on any other medication, my health is great, I'm a non-smoker and very active. I exercise 4-5 days per week (cardio + weights) and I'm within my correct weight target per my doctor. (6'2" - 200 lbs.) at age 47.

I'm hoping the valve lasts as long as I do (that's the plan anyway and the reason I chose the mechanical valve) so I'm also hoping my health record is taken into consideration.

The way things are now in the insurance industry, I can guarantee you that with an AVR as part of your medical history, you will be declined if you apply for an individual health insurance plan that is not HIPAA-eligible. The AVR will trump everything else: normal weight, non-smoking, activity will mean nothing. The bottom line of insurance is risk. You are higher risk because the AVR, plain and simple. I can think of several; I'm sure an underwriter can think of more.

Please folks, no arguments on fairness; that's not the issue. I'm Sgt. Friday here, giving you just the facts. Folks may not agree with this, and that's fine, but it's the way things are now.

And, yes, the agents you talked to should have known about HIPAA-eligible plans. Shame on them.