Health Insurance & why you need to take serious time to understand it

[jacklpalmer]

Okay, so full disclosure - I'm a health and life insurance broker. So I suspect I'll be spending a decent amount of time rummaging through this sub-form and helping people understand how health insurance works. I'm okay with that. I signed up to do this for a living, so bring it on.

Before I start, though, let me preface this with a caveat. I know there's people on both sides of the fence about the ACA ("Obamacare"). I get it. I talk about it all day. But whether or not you like the ACA isn't the point of this thread. Save your support or distaste of it for another thread, please.

Here's the deal, guys. You HAVE TO understand at least the basics of the health insurance/health care relationship. I couldn't possibly count how many times I've gotten that call. Other insurance brokers will feel me on that one, regardless of which insurance field they work in. Something wasn't covered, because they didn't understand their policy, and now they're out hundreds-to-hundreds-of-thousands of dollars.

So hit me. Ask your questions. There's only one type of dumb question - it's the one you don't ask.

I've worked in Health Insurance for over 15 years. It's basically the only career I've ever had. I worked in nearly every facet of the industry you can think of, from eligibility to customer service to claims adjudication to medical stop loss.

I may ask for documents to better assist you, such as your SBC (summary of benefits & coverage.) So be prepared for that.

Seriously. Talk about it. Learn everything you can. How much coverage do you need? How can you get covered now even though it's not Open Enrollment? How can you get coverage for catastrophic events only to save money and not have any of the extra fluff?

Health care costs are too expensive and being ignorant of how your coverage works can be devastating to you.

Do it. Ask that question. I double-dog-dare-you.

[TexasHusker]

I think a lot of this is a moot point for folks: As I understand it currently, Obamacare is the law. You don't have alternatives. It is mandated. And what you save in out-of-pocket costs, you pay for in extra premiums.

I don't see how a health insurance salesman is useful when the whole thing is required by law and is purchased directly through the gubmit's portal.

If I am in the business of selling cars, but every American is required by law to buy essentially the same car ("oh do you want that with no tires? OK, we'll knock $400 off the price"), what use is the salesman?

[disneysteve]

I think a lot of this is a moot point for folks: As I understand it currently, Obamacare is the law. You don't have alternatives. It is mandated. And what you save in out-of-pocket costs, you pay for in extra premiums.

I don't see how a health insurance salesman is useful when the whole thing is required by law and is purchased directly through the gubmit's portal.

I know how you feel about the ACA but this simply isn't true. You have many alternatives. At my practice, we worked with an insurance broker and every year at renewal time he would come in with proposals from a dozen different companies and plans and we would go over the numbers and coverage options and decide which plan each of us would take that year.

Even at my current job, there are several options for me to choose from. It's not as wide open as when we were buying our own coverage but it's also far, far cheaper so I'm okay with that.

[disneysteve]

Also, to OP's point, most people simply don't understand their coverage. When they are deciding what plan to buy, they tend to focus on the wrong thing: the premium. What they should be focusing on is the details of the coverage. Obviously the premium matters but sometimes the more expensive plan will actually cost you a lot less over the course of the year because it covers things the cheaper plan doesn't.

[Smallsteps]

Everyone's situation is different and although more then just premium should be considered we did not need any visits at all last year I am glad we chose by low premium, at least for last year.
Now people with on going issues should focus on what is covered but in my opinion they should also consider the company issuing the policy. Some (even very large players in health insurance) are very unethical. I worked in the industry for years and was disgusted by what I saw.
I have had plenty of policies throughout my life that all though the policy stated things were covered they fought on any little point NOT to pay. Take for example children covered under more then one parent, The insurance rule was parent who had birthday first in year was primary but EVERY bill I had to fight one crappy company (big name in health insurance) to get them to pay. EVERY single time even after talking to supervisors and stating their OWN rule back to them. Why not note in file so this was not another argument at the next bill. all together while I was covered by that company spent HOURS on phone over same issue because they knew many would not bother.
I truly believe that many companies deny stuff just because they know that a certain percentage will not argue over it and the more they make you jump through hoops even more will drop pursuing it.
NOT because the consumer did not know what was covered.

[TexasHusker]

I know how you feel about the ACA but this simply isn't true. You have many alternatives. At my practice, we worked with an insurance broker and every year at renewal time he would come in with proposals from a dozen different companies and plans and we would go over the numbers and coverage options and decide which plan each of us would take that year.

Even at my current job, there are several options for me to choose from. It's not as wide open as when we were buying our own coverage but it's also far, far cheaper so I'm okay with that.

The possibilities are endless when we are talking a group plan. They aren't mandated by ObummerCare. When you get into the individual market, it's a whole different story.

[jacklpalmer]

The possibilities are endless when we are talking a group plan. They aren't mandated by ObummerCare. When you get into the individual market, it's a whole different story.

Group Health Policies were very much affected by the Affordable Care Act. You're right in that there are less options on the individual market, I'll give you that. But there are still options. Most people will gravitate to the premium of a plan without regard to the plan as a whole.

While yes, I'm a technically a salesperson, in practice I work much more like a consultant. I'll review your financial and medical needs to find the plan that is going to protect you and result in the lowest healthcare costs. And I'll keep doing that - year after year and renewal after renewal. And I do it for the beans that the insurance carriers gives me to do it with. That's what we do. That's why I call myself "Your Insurance Lifeline," not "Your Insurance Salesperson." I do the same thing with Health Share Ministries.

[jacklpalmer]

Also, to OP's point, most people simply don't understand their coverage. When they are deciding what plan to buy, they tend to focus on the wrong thing: the premium. What they should be focusing on is the details of the coverage. Obviously the premium matters but sometimes the more expensive plan will actually cost you a lot less over the course of the year because it covers things the cheaper plan doesn't.

Exactly. This is why I do what I do. Most people (not all people, most) jump on the price tag. Then get frustrated with a $6,300 deductible when they go in to get that surgery. You didn't "save" any money by doing that. Or don't understand why they can't see a PCP with a copay because they enrolled in a HDHP without even knowing what it means. It's a complicated game.

[jacklpalmer]

Everyone's situation is different and although more then just premium should be considered we did not need any visits at all last year I am glad we chose by low premium, at least for last year.
Now people with on going issues should focus on what is covered but in my opinion they should also consider the company issuing the policy. Some (even very large players in health insurance) are very unethical. I worked in the industry for years and was disgusted by what I saw.
I have had plenty of policies throughout my life that all though the policy stated things were covered they fought on any little point NOT to pay. Take for example children covered under more then one parent, The insurance rule was parent who had birthday first in year was primary but EVERY bill I had to fight one crappy company (big name in health insurance) to get them to pay. EVERY single time even after talking to supervisors and stating their OWN rule back to them. Why not note in file so this was not another argument at the next bill. all together while I was covered by that company spent HOURS on phone over same issue because they knew many would not bother.
I truly believe that many companies deny stuff just because they know that a certain percentage will not argue over it and the more they make you jump through hoops even more will drop pursuing it.
NOT because the consumer did not know what was covered.

Sounds like this company has a severe training issue with Coordination of Benefits. I feel that pain. I used to work for a claims TPA for self-funded companies and it felt that we got that very simple concept wrong more often than we got it right. I'd be curious to know what company that was, though. Major insurers should know better.

More to your point, however, choosing a reputable company is important. You're not wrong about that. I'm not going to call out any names of the bad ones (like Cigna or Health Net,) but customer service can be just as important of part of your health coverage as the benefit chart. If you can't get anywhere with the company, there wasn't much of a point in paying for the premium, was there?

[Thrif-t]

I always try to understand my plan but sometimes I get stumped anyway!

I had a routine Colonoscopy when I turned 50 in Nov 2016. As I understood it, if I went to a facility in our plan and used a doctor in our plan it was 100% covered even if it turned into a diagnostic procedure, instead of routine. So I drove about 35 min away from home to get to a 100% covered facility.

Turns out I had 2 polyps but they were benign and it was still considered routine and I owed nothing.

Fast forward to March 2018, my DH is 54 and had his first routine colonoscopy. We did the same thing went to the 100% covered facility (my DH works in govt and they contract with this hospital so if we go there everything 100% covered).

He has 2 polyps they remove, also beinine but his procedure is coded diagnostic and we owe $245. WTH!! Tried talking to them, nothing, disputed the claim they studied it, still say I owe it was coded correctly diagnostic. I tried to get them to tell me why was mine not coded diagnostic 2 years earlier, yet his was same results 2 years later? Who knows. I paid the $245

[Smallsteps]

Sounds like this company has a severe training issue with Coordination of Benefits.

The company with the fight was Aetna.
I really wish I could dismiss the items and practices I have seen as a "training issue" but just typing that made me laugh. That IS what they were trained to do.
Other people I worked with had same issue but did not follow through making the numerous calls. Unless other coverage fought it they paid out of pocket.
Just signed up for insurance with husbands new job and the first thing insurance company sent was is there ANY possible coverage for either of us to try to find a way out of paying … We got that 1 day after we got our cards. we have not even used insurance yet. seriously on form the word ANY was capitalized.
If I had a dollar for every minute spent fighting this type of BS I would be very wealthy. There is little training as these customer service positions have huge turnovers probably because what they are told to do.
I once worked for a regional blue cross provider that wrongly marked a person as female when he was male /he sent in MANY requests ( including documentation and actual pictures proving his point on the 6th try LOL) to get fixed after refusal to pay for prostate exam.
I wondered why they did not simply fix the clerical error issues but they were waiting for him to just pay for it then correct the error. Seriously no joke.
This is the health insurance industry. I hope when you sell insurance you really know what happens after the claim is submitted.

[TexasHusker]

Just signed up for insurance with husbands new job and the first thing insurance company sent was is there ANY possible coverage for either of us to try to find a way out of paying … We got that 1 day after we got our cards. we have not even used insurance yet. seriously on form the word ANY was capitalized.

Your insurance company is a business. They are in the risk business. It isn't exactly a fair expectation for you to sign up for their insurance today, and immediately start sending them claims for things that occurred before they were taking the risk.

I don't call that B.S. More like common sense.

If you think insurance companies are dishonest, try dealing with the ignorant - and often blatantly dishonest - policyholders.

If you think insurance companies are dishonest, try dealing with hospitals that are sending you bills for $5000 MRIs that cost them maybe 150 bucks, or a $50,000 implant that they marked up from $5,000.

Plenty of blame to go around, but I would say there is less blood on the insurance company's hands than ANYONE, not because they are such good guys, but because they are so heavily regulated. Hospital pricing is completely UN-REGULATED. It's the wild west and insurance cos are having to deal with it.

Crooked and lying policyholders are also unregulated.

Source: Myself. I've worked in healthcare finance on the provider and insurance company side. I've pretty much seen it all.

[jacklpalmer]

The company with the fight was Aetna.
I really wish I could dismiss the items and practices I have seen as a "training issue" but just typing that made me laugh. That IS what they were trained to do.

The cause really is much more likely that it was a training issue. I know it's natural to get upset about this things - and you should be - but playing the run-around game with their members doesn't actually save insurance companies any money, contrary to popular belief. Healthcare providers are very good at forcing insurance companies to cut through the bureaucracy and pay them anyway. Only now the carrier lost a lot of money in staffing because of the issue.

Just signed up for insurance with husbands new job and the first thing insurance company sent was is there ANY possible coverage for either of us to try to find a way out of paying … We got that 1 day after we got our cards. we have not even used insurance yet. seriously on form the word ANY was capitalized.

Verifying coordination of benefits is a standard procedure for insurance carriers. If you have any insurance on yourself, your coverage would be primary, making the husband's insurance secondary. The insurance carrier would stand to lose a lot of money if they didn't know about your other coverage and paid as primary.

I once worked for a regional blue cross provider that wrongly marked a person as female when he was male /he sent in MANY requests ( including documentation and actual pictures proving his point on the 6th try LOL) to get fixed after refusal to pay for prostate exam. I wondered why they did not simply fix the clerical error issues but they were waiting for him to just pay for it then correct the error. Seriously no joke.

It's hard for me to say what exactly happened there. But it seems like a simple corrected HCFA should have solved the issue.

This is the health insurance industry. I hope when you sell insurance you really know what happens after the claim is submitted.

I'm fully aware of what happens. As I mentioned, I used to work on the inside of the health insurance field, too. I've actually processed those claims. I've seen a lot of mistakes, but I'm remiss to think of a time when I deliberately denied a claim and made it difficult for someone to get there money back because "that's what I was trained to do." More often then not, something was processed incorrectly by mistake, or the provider made a mistake. And, being one of the most heavily regulated industries in the country, they have to be fixed a certain way. Most providers and patients don't want to do it that way. It is what it is.

[Smallsteps]

Your insurance company is a business. They are in the risk business. It isn't exactly a fair expectation for you to sign up for their insurance today, and immediately start sending them claims for things that occurred before they were taking the risk.

Don't know what you are reading but we have NOT USED any insurance so zero claims have come to them. I know it is common practice to coordinate benefits, but as we FILLED out on the Application that NO OTHER coverage was in place and we have not used it AT ALL but they send us a form asking if we have other coverage is at best overkill.
This seems to be a bit much to me maybe some people like being asked the same thing over and over. I can see that if a claim happens we will yet again be asked if I have any other coverage. That is reasonable, not sending a form directly after processing the form we sent saying NO other coverage.

We all have had various experiences but I HAVE worked for and with more then one company and the many things I SAW and heard first hand happened. I know it was a simple fix to change a clerical error I also know why they put it off I was there when supervisor said it. I know the steps needed to fix some issues take time but I also know bad practices when I see them or hear them.
only positive is redundant forms keeping postal system working.

[TexasHusker]

Don't know what you are reading but we have NOT USED any insurance so zero claims have come to them. I know it is common practice to coordinate benefits, but as we FILLED out on the Application that NO OTHER coverage was in place and we have not used it AT ALL but they send us a form asking if we have other coverage is at best overkill.
This seems to be a bit much to me maybe some people like being asked the same thing over and over. I can see that if a claim happens we will yet again be asked if I have any other coverage. That is reasonable, not sending a form directly after processing the form we sent saying NO other coverage.

We all have had various experiences but I HAVE worked for and with more then one company and the many things I SAW and heard first hand happened. I know it was a simple fix to change a clerical error I also know why they put it off I was there when supervisor said it. I know the steps needed to fix some issues take time but I also know bad practices when I see them or hear them.
only positive is redundant forms keeping postal system working.

First of all, it is very likely that your husband's insurance company is his employer: His employer is probably self insured (or partially self insured) and pays an insurance company (Aetna, Cigna, Blue Cross, etc.) to administer the plan and provide reinsurance for large claims. If the employer has 100 or more employees, it is extremely unlikely that it is not a self-insured plan, because a fully insured plan like Obummercare is way too costly for employers: They would be out of business entirely, paying that sort of jack. So that evil insurance company is likely also the entity writing your husband's paycheck. Regardless, a group plan is going to ask for a letter of "credible coverage" not to rip you off, but to keep you from ripping the plan off. They want to know who was handling the risk the day before they took you over, and what liabilities there could be. For example, an ongoing cancer claim would fall under the previous risk taker's responsibility.

The plan is protecting itself, and in the end, its policy holders as well. If you have not had previous employer coverage, the new plan will likely have a significant waiting period before coverage begins, or a limitation of benefits, again to protect the plan.