AboutLinda Woolsteen Expertise I can help you with questions about health insurance. If you feel your insurance company is mistreating you. Are they telling you they are checking eligibity, pre-existing, etc. Or you just don`t understand how your insurance works or don`t understand what a PPO is.. I can help you.
Experience
Past/Present clients One company I worked for I was the underwriter for the Academy of Medicine of Cleveland and the Ohio Bar Association. I was also a supervisor of our customer service department.
Question I currently have Anthem-Matthew Thorton Blue through the company that I work for. I've been at the same company now for 6 years. I'm thankful that I have health insurance because two years ago, I injured my ribs and went so several different doctor's within the Anthem network. None of the doctor's were able to help me with my condition. I finally got my doctor to submit an out-of-network-referral to a different hospital (In Boston MA. I currently live in New Hampshire). The out-of-network-referral was approved, and I went to Boston MA to see a doctor. I ended up needing
surgery for my ribs. Before I had the surgery, I needed to have proof that there was no other doctor within network that was able to help with my condition. I proved this by submitting documents of phone calls that I had made to EVERY SINGLE HOSPITAL within network. I had the surgery, and the entire procedure was covered. I ended up needing a second surgery a year later, and the entire procedure was approved and covered. The surgery was 6 weeks ago, and I'm scheduled for a followup appointment in Boston at the
end of January.
My situation: My job has completely changed. The boss decided to do some "major reconstructing" and now, hours have been changed, positions have been changed, etc. My job is completely different than what it was before, and I'm miserable. The bosses have fired people left and right,
and I'm worried that I'll be next. I want so much to quit. I actually would quit, but, I don't want to be without health insurance for my last doctor's appointment at the end of January. What if the company gets rid of me before then? What if I can't stand it and quit before then? My
husband has an individual health insurance through Anthem because the company that he works for doesn't offer insurance. I've looked into COBRA, but it's so expensive! I don't think I could do it. Do you have any suggestions for me? Perhaps I could get individual insurance, just like my husband, but then I would have a deductable again, AND I would need to submit another referral for coverage for my last doctors appointment. I've heard of "FARMERS" insurance that has no network. Is that something I could look into? I don't know where to begin. Please offer me your advice. Thank you!
Answer Hi,
Yes, you are correct, COBRA can be expensive. Sometimes all they have to offer you is a similar policy as well like Hospital only and not the full benefits that you had.
Anyways, I would say to hang in there. Bite the bullet, let it roll of your shoulders, just do what you need to do to abide by time. BECAUSE....If you should go to an individual policy, you have to prove insurability. Which means you have to answer health questions. The new Insurance company will also check the MIB (Medical Information Bureau) then if there are any conditions that you were treated for, seen for or recevied medications for, they can either do the following: Deny you for the coverage altogether, issue the coverage to you with a rider on the policy, like for instance the rider may state "No Coverage for anything related to the back" which means you will have medical benefits for all other types of things but NOTHING will be covered for anything regarding your back. The rider's are usually permanent, unless they should state a specific time that it will be taken off or if in the future you should send in a letter for review, stating you have not had any problems or been seen for the condtion, say like in a year and they will review and see if they will remove the rider. OR, they can rate you up. Which means they will issue the policy to you but with a higher premium because they know beforehand that you are going to be incurring expenses for your back that they are going to have to pay claims on.
If you go to work for another employer.. usually if they have 20 or more employees health insurance is guaranteed issue which means you do not have to prove insurability.
Ok, all of that is about proving Insurability. There is also PRE-EXISTING. Let's say that your new individual policy doesn't have a problem with your back problems, issues you the coverage. The Pre-Existing time period in most Individual policies is 12 months/12 months which means "Anything that you were seen, treated or consulted for 12 months prior to your Effective date with them will not be covered until you have gone 12 months into the plan"
The Pre-Existing time period can vary, plan to plan. It could also be 6/12 which means again: Anything that you were seen for, consulted for 6 months prior to your effective date would not be covered until 12 months have gone by. Or is could read 24/24.
Now, if you should go to work for another employer and usually if they have 20 or more employees you do not have to prove insurability which means you may get the coverage issued to you without any riders or not be denied the coverage. BUT, it will still have a PRE-EXISTING time period on it. Now, when you leave your present employer, your health insurance company will give you whats called a CCC (Certificate of Creditable Coverage) it will say you had continous coverage for lets say 12 months with the insurance company (not your employer) if the new insurance companies pre-existing time period is 12 months waiting period then your CCC will take care of the waiting period and you will not have to wait for it to end. Meaning, they cannot deny your claims as PRE-EXISTING. If lets say, your present employer switched insurance companies and say within the last yr you had two carriers (carrier is the insurance company) so technically you would then be issued 2 CCC's one from the 1st insurance company and one from the 2nd Insurance company. To make it easier the first one is for 6 months and the second is for 6 months. You would send both of those CCC's to your new insurance carrier to show that you had back to back continuous coverage for 12 months which again, will eliminate your 12 month Pre-Existing waiting period. CCC's have some guidelines/rules ont them. Like you cannot have a break of some many months inbetween coverages. So, if you quit your job went lets say for an example 6 months without insurance coverage, got a new job and tried to use the previous CCC that you had 6 months ago, they may not accept it. Also, Individual plans do not have to accept the CCC's.
So.... that is why I say bite the bullet, stay put... Because it is not an easy world out here in the Indivdual health insurance world!! Premiums are high, once you have some condition noted, if you try to change plans for a cheaper premiums you are most likely going to be denied for the new coverage or receive it only with riders galore or higher, rated up premiums. God forbid if you have a stroke, heart attack or something major!! You will never get coverage and sometimes become stuck in the present Individual plan you may have obtained when you did not have any problems which will always have increasing premium increases. The only thing you can do is then increase your deductible. Some people nowdays, have catastrophic deductibles like $10,000 or $20,000.00. Meaning they have coverage to protect them for unforeseen, catastrophic type things but are unable to use it for everyday doctor visits.
I do not know what type of plans Farmers offers. I have Farmers for all of my other needs but obtained my own Individual Policy from Medical Mutual of Ohio and then had my Farmers agent signed up with them so he could get the commission.
Here is some other things. There are individual policies out there that do have office visit copays. The premiums are usually higher.
You did the right thing by having the out of network providers considered as in network beforehand. Good Job!
There are a lot of PPO networks out there. Some Insurance policies now have PPO networks that are national, not just local to your state. For example, MMO (Medical Mutual of Ohio) that I have... the PPO network is First Health. First Health is a National PPO network which means I will find providers nationwide that participate with them which means they are In-network and I receive better benefits if I stay in-network.
Referrals are different than in-out of network. Some policies do not reqire referrals and some do. What you asked for was a PPO network Exception it sounds like and they allowed it. Which means they will process your claims from the out of network providers, towards your in-network benefits but usually they are subject to R/C (Reasonable and Customary charges) so sometimes there may be an amount over and above the R/C amount that you will still be responsible for... but all in all it is still better than the claims being processed toward your out of network benefits.
Ok, I hope you understand all of that. If you still have questions, let me know. I really like to help people out. I personally would just stay put as long as you can. The Exconomy is not very good right now. Finding a good job with good benefits is not easy and you probably don't want to rack up a lot of uncovered medical expenses. Just my personal opionion.
