Health Insurance

I’m pretty clueless when it comes to medical care. I had some injuries when I was younger, and a couple of minor medical things like cat-scratch disease and a cyst removal. Other than that, it’s been a physical every two years when I was an active pilot. I’m one of the people (thank the gods) that has been paying into the ‘system’ for years, but who has taken very little out of it. And then I tried to get a flu shot…

In the past, I’ve worked for large companies where the shots came to the employees. A fin or a sawbuck, and you get your shot. Now I work for a non-profit with a bit more than a dozen people in the office. I have to get a flu shot on my own. Since I don’t know how, generally, to get medical care, I called my insurance company. I was told that I must get the shot from my primary care physician if I want to be covered. There would be a charge for an office visit, and a charge for the shot. I think I’d be responsible for all of it, as I haven’t paid anything on a deductible. Or I could pay out-of-pocket anywhere I like. A further complication was that my PCP does not have any vaccine. Too bad. If my PCP doesn’t have vaccine, then I must go out-of-network at my own expense. I ended up paying $25 at Walgreen’s for a seasonal flu shot.

I asked what would happen if I were in a crash and was unconscious. Would I be covered for the ambulance ride? Apparently, not necessarily. I would have to make the decision as to whether it’s medically necessary – which I couldn’t do, since I’m not a doctor and I’m hypothetically unconscious. I was told that unless I’m in danger of dying, an ambulance ride is not ‘medically necessary’. I was told that if I broke my leg I’d have to hire a cab to get to the hospital.

My impression is that insurance providers (mine, anyway) will allow you to pay for coverage, but you’re not allowed to use it. At least, it’s so limited that one might as well say it can’t be used.

In the American system, one has virtually no choice of insurers. You take what your employer offers, or you’re wealthy enough to pay the full premium for the plan that will actually allow you to use the coverage if you need it.

This isn’t right. If I’m sick, I should be able to go to a doctor. Not just the one who is my PCP, but any doctor. Things like flu shots should be covered anywhere. It’s a matter of public health. How many people will not get flu shots, just because their insurance is too restrictive? How many people will they infect? And how many people will they infect? Why should I be writhing in agony waiting for a cab, and be transported by a presumably non-medical cabbie, when I have broken bones? It all seemed so much easier when I was on CHAMPUS. That ‘government insurance’ worked well for me when I was a kid and had athsma, and when I broke my arm.

I want fully-portable medical coverage that doesn’t depend on my job, and that will allow me to get treatment if and when I need it.

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I’ve been reading through this off and on all day.

I want to be able to get insurance for my older kids (out of college but under 27 yrs of age), and I want for my sister to be able to get coverage despite the fact that she’s under treatment for a mental illness.

I have my fingers crossed that we’ll get that. And you might get your portability, too.

There are plans that do not require a PCP. Apparently your employer has chocen a plan that requires a PCP - one of the disadvantages of having health insurance tied to employment.

You can get your own insurance, which will be portable, and have much more control over what the policy conditions are. It will be very expensive, though. Another disadvantage of having health insurance tied to employment. Either individual control or government-supplied would be better, IMO.

I could do… if I was wealthy, or if I wanted to stop paying my mortgage and bills, and if I didn’t mind not being covered if the insurance company finds out I had a wart once.

Yeah, I only said it is an option, not that it is a very good one.

Part of the problem is that small companies and non-profits can not possibly afford to compete with big ones to get good, affordable coverage for employees. The bigger the company, the lower their cost per employee, so the cost TO the employee is better, too.

My partner works at a huge bank that even has Domestic Partner coverage. We get more services than anybody I know, at great rates. She’ll have to stay there forever, though, as I’ll never get coverage again, due to “pre-existing conditions” (depression).

The current system sucks. I’d pay more to know that EVERYBODY was covered.

I sympathise.
Here in the UK, I’ve paid for the National Health system through taxes.
I therefore get for no further payment:

  • doctor consultation
  • medical treatment (including flu innoculation)
  • cholesterol + diabetes check
    etc

Yikes - your insurance coverage sounds REALLY crappy. No ambulance ride if you’re unconscious??? I’d have to say “unconscious” = “real risk of being dead soon”, in my mind.

Sorry about the flu shot thing - that’s a big part (I think) of why flu shots clinics at Wal-green’s etc. are so popular. Cheaper to spring for the 25 bucks there than to pay for an office visit. And I’m coming at that from the standpoint of having a primary care doc, and they offer “walk in and get a shot” slots. Really, anyone is better off getting the shot from the drugstore unless they have a need to visit the doc for something else.

I hope portability and affordability improves. We’re lucky that I have fairly good insurance through my work; Typo Knig’s company offers insurance but it’s crappy, limited doctors, high copays etc. So he gets coverage through my job.

It has to be ‘medically necessary’. So, according to the rep, an ambluance ride wouldn’t be covered if I was unconscious and it turned out it wasn’t ‘medically necessary’.

I have Regence/Blue Shield.

Not always - we have an HSA with a high deductable policy. It’s cheaper than my hubby’s insurance through work, and it works perfectly for us. We are not wealthy by anyone’s calculations.

Not right for everyone, that’s true. But perfect for our family. Unfortunately, it looks like it will become impossible under this UHC plan.

Great…

Welcome to the “best medical system in the world” at only twice the price with pooer outcomes than all the rest (in the developed world). I live in Canada and would move to the US if I could get decent medical insurance (or were qualified for medicare).

No doubt about it, an employer-based health care system has it’s pluses and minuses.

I happen to work for a large company that has relatively good coverage, but the employee-side cost will be going up next year. To defray some of the extra cost employees can pledge to stop smoking or lose weight and they can earn dollars that are then put against their share of the cost. It’s a win-win, but most employees just pay the increased portion or suffer with the higher deductible.

As far as flu shots go, in my case I was able to make an appointment with my Primary Care Physician for a seasonal flu shot (H1N1 isn’t available yet where I live). It only cost me $10 for the office visit. That’s cheaper than going to Costco ($20) or the local drug store ($25). I agree that it makes more sense to give the shot away free, and my county has free shots available for people who are most likely to get the flu (not me).

Find out if you can opt out of your company’s plan and instead find a local HMO in SoCal, such as Kaiser Permanente. I have used Kaiser in the past and have nothing but good things to say about them. My wife had abdominal surgery last year and it didn’t cost me a penny. Flu shots were always free and my office co-pay was only $15. My out of pocket cost was low and the level of coverage was good. Just a thought…

I would say you insurance is trying to “scare you” into doing the right thing.

The ambulance, clause is to prevent people from using it as a medical taxi. Even if you don’t get prior approval, it doesn’t mean they won’t pay. They will pay if it was deemed a medical necessity. If you THINK you’re having a heart attack, they’re gonna pay whether you call or not.

The idea behind those clauses is to prevent, as I said, the “medical taxi” thing. People will sprain an ankle and call an ambulance. You don’t need an ambulance for that.

As for doctors, you have to be pushy and you have to be pro-active. I’ve had doctors when I’ve been sick with the flu or something, that can’t fit me in for a week. If your doctor can’t see you today or at worst tomorrow, then you need to find another doctor, long before that happens.

My doctor for example, will see you the day you call, if you insist, but you must wait. He’ll say “I am very busy and you may have to wait a few hours, but I’ll sqeeze you in.” And sometimes you wait maybe a few hours, which is fair because other people are scheduled first, but he’ll get you in, even if it’s when he closes, he’ll stay after.

A lot of primary care doctors, I’ve had have been lousy. I had one I never saw at all prescribe me antibiotics over the phone for a cold. I never even went to his office.

Insurance is very frustrating, but the key to working it is simple. GO find a GOOD doctor before trouble. This can be frustrating, 'cause a lot of doctors have no “bedside manner.” It takes a long time to find a good one you can “click” with.

I can see why insurers do the flu shot thing. It makes sense to them. The insurers get money from the flu shot (which you get for free) and you pay for an office visit. Since a flu shot is definately a scheduled thing, there’s no reason why you can’t schedule it far in advance and make yourself the first appointment of the day so you’d get right in. Again, if you perfer convenience, then go to Walgreens and pay for the convenience.