Individual Medical Insurance

Off Topic
#1

Does anyone have insurance not through an employer? I was laid off earlier in the year. I have to decide whether to move to Cobra coverage at $650 a month or purchase a less expensive policy. I’m having a hard time deciphering the polices and commitments online.

I have found $350 a month policies but cannot determine if they include yearly preventative (cholesterol checks, annual physicals, etc.). I’m very healthy, haven’t been sick in years, don’t need prescription copays, and just looking for catastrophic coverage until I regain full-time employment.

Thanks for your feedback…

#2

Unless they rolled that part of ACA back i thought yearly checkups were required? Idk, I’d try and call and ask.

#3

I agree, my understanding is that preventive checkups are covered at no cost to the patient. However, if you get a prescription or any other form of treatment, then it’s not preventive and you can be charged. For example, a screening colonoscopy is no cost to the patient. If they see a polyp and remove it, that is treatment and can be charged.

#4

The policy docs should outline what’s included and what’s not. Check with the broker for the policy booklet - if they can’t provide it that’s a big red flag.

Here’s what I’ve done when I’ve been faced with COBRA. You don’t have to pay the premiums right away, I think it’s 90 days? If you do take it, though you have to pay back-premiums to the beginning, at least that’s what I’ve always been faced with. It’s basically a gamble while you try to find other work or other coverage. If nobody on your policy gets sick, decline COBRA on the last possible day and pick up a new policy. If someone gets sick you do the math on whether it’ll cost more to pay cash or pay the back premiums plus your out-of-pocket part of the coverage (copay/deductible/coinsurance).

It all makes sense logically, but the last time I had to roll those dice, we had a preteen and a teenager in the house, and every cough or sniffle had my mental calculator churning.

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#5

The Feds have issued clarification: polyp removal and testing are an integral part of a preventative/screening colonoscopy and are therefore covered. Same for anesthesia. I had mine this year after turning 50. Polyp-like thingy removed out of abundance of caution, tested, no charge. (And test was negative. Next test in 10yrs!). However, Blue Cross wouldn’t pay for anesthesia…I had to call and remind them of the 2015 ACA ruling to get it covered (wonder how many people have paid that bill not knowing they were covered?) Feds Tell Insurers To Pay For Anesthesia During Screening Colonoscopies

Colonoscopies are important. My mother in law died of it in her 80s because she refused to be tested. Now will flag myself for off topic.

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#6

While the COBRA plan may be more expensive, it is probably the better plan overall. I had kept mine for the max 18 months. Of course I was older, 59 1/2 so wider coverage was more important. But ACA was in effect then and policies were a lot more expensive (mine would have been $950). So if you are younger and generally in good health,you may do fine with other policy. Today the deductibles and all make them all expensive.

Hard decisions, and everyone case is different. Give me a PM and I’ll give you the name of the broker I’ve been using. He asked me what I wanted/need - then tried to match that.

#7

There are more and more practices that work on a membership basis, e.g. ~50 application fee, then ~$80/month for which you can go in for all the typical day-to-day, month-to-month, year-to-year things (ear aches, physicals, fevers, chronically recurring chlamydia, etc.). Even some emergency care like a broken bone, I think.

But you have to pay for some supplies (depending) and prescriptions (still way expensive). Care for catastrophic stuff (cancer, major car accident) is not covered…which I gather is what you are generally concerned with? Not sure…

#8

For BCBS, at least for PPO, if the facility is in-network, BCBS will pay the out-of-network anesthesiologist at the in-network rate and the facility is responsible for the balance if the anesthesiologist pursues it. You sometimes have to call the facility and remind them of this part of their contract, they seem to forget it often. And yeah it helps to call BCBS customer service to get them to remind the facility as well.

#9

Understood. Thanks for the advice. When I called to schedule, I did verify in-network, coverage, cost and that staff not employed by facility (pathologist, anesthesiologist) were covered. Facility got it right. Anesthesiologist got it right. Blue Cross didn’t. I’m paranoid after the nightmare that was my late husband’s medical billing.

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#10

@Clayton,
Totally get where you are coming from. I’m sure you have already looked into https://www.healthcare.gov/

Cobra is another alternative, and often expensive. But, the ACA plans are often expensive as well.

My friend Mario works for US Health Advisors and can walk you through coverage options on the ACA market and outside ACA of the market. He is the kind of guy to get you exactly what you need including those catastrophic only plans.

Mario’s number is 469-766-6054. If you want me to have him give you call, just PM me your phone number and I’ll get him to give you a ring.

Also, if you want more than my opinion on him, you can reach out to Ross Dusenbury and old DMS member that does a lot of gig work and needed health coverage quick. Mario knocked him out in less than 24 hours. Just PM me and I’ll give you Ross’ cell to chat with him.

Glad to help a maker.

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#11

Thank you for updating me. I have heard complaints about that in the past, but not recently. Sometimes I think insurance companies deny things hoping that patients will just pay it and not complain. It is unfortunate that medical billing is so complicated. Hopefully, it will change for the better in the near future.

Colonoscopies are extremely important. They prevent enough cancers to pay for everybody to have one. The prep required to safely perform one is a literal and figurative pain in the tush, but the actual procedure is easy due to the anesthesia. They are as important a screening test as pap smears and mammograms which are extremely important as well.

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#13

I had to send a medical provider a link to the State’s Civil Statues and Codes for a bill that came over two years after the service?!

Sec 146.002 (b)(2).

Sec. 146.002. TIMELY BILLING REQUIRED. (a) Except as provided by Subsection (b) or ©, a health care service provider shall bill a patient or other responsible person for services provided to the patient not later than the first day of the 11th month after the date the services are provided.
(b) If the health care service provider is required or authorized to directly bill the issuer of a health benefit plan for services provided to a patient, the health care service provider shall bill the issuer of the plan not later than:
(1) the date required under any contract between the health care service provider and the issuer of the health benefit plan; or
(2) if there is no contract between the health care service provider and the issuer of the health benefit plan, the first day of the 11th month after the date the services are provided.

It was a six figure bill.

source: https://statutes.capitol.texas.gov/Docs/CP/htm/CP.146.htm

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