Explain health insurance to me

General Questions
#1

I have health insurance through my employer, and just signed up for coverage for next year as well. My deductible this year is $1000 (I have been to the doctor a grand total of twice this year, so nowhere near it), and JUST signed up for a plan next year with a $2200 deductible.

I have just been diagnosed with HIV, and medical costs are going to bury me. My prescription plan only pays 80% of the cost of drugs, leaving most treatment regimens between $300 and $400, and at a $2200 deductible, I’m going to be paying a LOT out of pocket for healthcare costs.

Having said all of that, am I precluded from purchasing another insurance plan from something like ehealthinsurance.com? I haven’t priced it out yet, but I imagine I could get away with paying a lot per month in order to have it balance out with all the labwork I’ll need done.

So the actual GQ(s): am I wasting my time? Is anyone going to accept a member with HIV? I found one plan that specifically stated that there was a waiting period for pre-existing conditions - is that universal? And does anyone in the same boat have any specific recommendations for plans/websites I should check out?

(There is payment assistance available through the Arkansas AIDS Foundation, but not a whole lot for drugs. I’m in the process of getting on the waiting list though.)

#2

I am a health (and life) insurance agent, but I am not licensed in the state of Arkansas. The laws with which I am familiar usually transcend state lines, but not always. Most importantly (for my legal ass-covering), you should take nothing I say as a solicitation of any sort.

Your options with health insurance are now as follows:

You have insurance through your employer. On a group plan, you will never be “individually underwritten” and can never be excluded from coverage based on any pre-existing condition. Should you be fired, laid off, or otherwise lose your job you’ll be eligible for COBRA. Through COBRA, you’ll be able to maintain your group health insurance on an individual basis for 18 months. After those 18 months, you will be able to go through Assignment and be placed into an individual plan. Play your cards right, and you’ve got nothing to worry about as far as being ineligible for health insurance.

In the individual market, you’re not going to be able to get true coverage anywhere. There will be plans available to you - mini-meds and limited benefit plans that are “guaranteed issue” but which have significant holes in coverage. Going to ehealthinsurance.com is not an option for you.

Do not waste your time in the individual health insurance market. Waiting periods for pre-existing conditions do exist, yes, but these will not apply to you: your condition will be an automatic decline with every major medical insurance company in the individual market.

Your group coverage is the best you’re going to get.

You need to check the following things:

  1. Are your medical and prescription deductibles integrated? That is, do you have a $2200 medical deductible but a separate prescription drug deductible? Does this 80% coinsurance apply to both medical and prescription costs?

  2. Is there a prescription drug maximum (an annual cap)?

  3. Your drug regimen will almost certainly have at least a few “Level Four” drugs, and some insurance companies treat L4 differently than L1-3. Make sure that drug treatment is uniform.

If you would like, I would be happy to sit down with you over the phone and talk about your options. Again, I am not licensed in the state of Arkansas, I cannot sell you a policy, I cannot and will not represent you as your health insurance agent, and I cannot and will not solicit your business in any way. I just know that you’ve probably got a lot of questions, and I’ve got a lot of answers. PM me and we’ll set up a time to talk.

#3

This is one thing that makes this great. Thank you, soul, from all of us.

#4

For my particular prescription co-pay plan I had when I had insurance, I still had to pay the full price at the pharmacy. The insurance company had to send me back money for only their portion or both their portion and my co-pay after I was past the detectable. I hope your policy isn’t this way as you can need thousands of dollars in your possession to cycle through purchasing prescriptions and getting the money from the insurance company. Definitely shop with different pharmacies, because the insurance companies have different price structures with different pharmacies. Also the insurance company may have a better deal for you if you use a online pharmacy they partnered with.

#5

Something scary I (we?) learned from a previous similar thread is that COBRA is not available if the employer goes out of business. The day the company closes its doors all the employees are out of the group market, period.

I’m not competent to vouch for the accuracy of the above, but IIRC there was a cite to a government FAQ page which was pretty unequivocal. Soul?

#6

If the employer goes out of business, cancels the group health insurance plan, or even just changes the group insurance plan to a different carrier then COBRA does go away. However, in that event, you’re then eligible to go through with Assignment to an individual plan. Assignment works differently in every state, but in Georgia you basically choose one of four or five plans and get settled into it once COBRA runs out (for any reason - 18 months are up or the plan evaporates).

For more official FAQs, check out the following links:

http://patientcharity.com/ (very Georgia-centric, but a great site nonetheless; run by another agent I know here in Atlanta)

http://www.gainsurance.org/ConsumerService/FAQ_Health.aspx (FAQs about insurance from the Georgia Department of Insurance - some answers are true across state lines, and the federal resources linked from here apply as well)

http://www.georgiainsuranceoptions.com/2009/02/cobra-health-insurance/ (Article about COBRA on my own website)

http://www.cobrainsurance.com/COBRA_FAQ.htm (Extremely thorough COBRA FAQ)

http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.HTML (Slightly less thorough COBRA FAQ, but with a few different questions and DOL resources)

#7

(Sorry for the double post)

This is true in many cases. United Health is especially bad about having you pay the full cost upfront and then reimbursing you down the line.

If you don’t have a prescription copay, but instead have to meet that $2200 deductible before any benefits kick in whatsoever then it’s very important that you do two things:

  1. Clarify with your insurance company how prescription drug reporting is handled. Will filling a prescription automatically count towards your deductible, or will they wait to see a reimbursement form from you before applying the costs?

  2. Learn to shop pharmacies, as Harmonious Discord said. Don’t be afraid to call around to twenty different pharmacies to check the price on a prescription. Also, don’t be afraid to have twenty different prescriptions at twenty different pharmacies. Inconvenient? Yes, very much so. But if it saves you a significant amount of money, then it could be worth it - only you can say where the break-even point is between running around to fill your prescriptions and saving money on them.