NOTES
05/19/2010

 

 

AGE:

 

At 64 years old, it is virtually impossible to get individual coverage (BC& BS is an exception, they will provide coverage past 65.).  Also, when setting up coverage for older families, make the youngest spouse the primary on the policy, because the younger spouse will be on the policy longer than the other spouse who may roll over to Medicare at 65.

 

COBRA:

 

You should get off of Cobra as soon as you can, because, should you acquire a serious medical problem while on Cobra, you may not be able to get individual health care.  In this case you would have to go to the State Pool to get coverage, which is very expensive.

 

Cobra is for companies with 20 or more employees.  Employees have a 63 window to sign up for Cobra.  Companies have 30 days to notify an employee of their option for Cobra.  If a company has less than 20 employees the employees have to use. State Continuance insurance.

 

In Missouri, as in many other states, your health insurance options are somewhat dependent on your health status. Even if you are sick, however the laws protect you in the following ways.

 

Coverage under your group health plan (if your employer offers one) cannot be denied or limited, nor can you be required to pay more, because of your health status. This is called nondiscrimination.

 

All group health plans in Missouri must limit exclusion of pre-existing conditions. There are rules about what counts as a pre-existing condition and how long you must wait before a new group health plan will begin to pay for care for that condition. Generally, if you join a new group health plan, your old coverage will be credited toward the preexisting condition exclusion period, provided you did not have a long break in coverage.

 

Your health insurance cannot be canceled because you get sick. Most health insurance is guaranteed renewable.

 

If you leave your job, you may be able to remain in your old group health plan for a certain length of time. This is called COBRA or state continuation coverage. It can help when you are between jobs or waiting for a new health plan to cover your pre-existing condition. There are limits on what you can be charged for this coverage. If you lose your group health insurance and meet other qualifications, you will be federally eligible. If so, you are guaranteed the right to buy an individual health plan from any insurance company that sells such plans in Missouri. Insurance companies must offer you a choice of at least 2 plans. However, they may charge you significantly higher premiums due to your health status, age, or other factors.

 

If you lose your group health insurance and meet other qualifications, you may be able to buy a conversion policy. You will not face a new pre-existing condition for benefits covered under your prior plan. There are no limits on what you can be charged for a conversion policy and the benefits may be as generous.

 

 

You can buy insurance from the Missouri Health Insurance Pool (MHIP) if you have had difficulty obtaining affordable health insurance from private companies because of your health condition. In this case you may face a new pre-existing condition exclusion period. There are limits on what you can be charged for an MHIP policy.

 

If you are a small employer buying a group health plan, you cannot be turned down because of the health status, age, or any factor that might predict the use of health services of those in your group. All health plans for small employers must be sold on a guaranteed issue basis.

 

If you are a small employer buying a group health plan and you have between 3 and 25 eligible employees, there are limits on what you can be charged due to the health status, age, or other characteristics in your group.

 

If you have low or modest household income, you may be eligible for free or subsidized health coverage for yourself or members of your family. The Missouri Medicaid program offers free health coverage for pregnant women, families with children, elderly and disabled individuals with very low incomes. MC+ For Kids (part of the Medicaid program in Missouri) offers free or subsidized health coverage for some uninsured children.

 

WHAT ARE THE LIMITS ON MY PROTECTIONS?

 

As important as they are, the federal and state health insurance reforms are limited. Therefore, you also should understand how the laws do not protect you.

 

If you change jobs, you usually cannot take your old health benefits with you. Except when you exercise your federal COBRA or state continuation rights, you are not entitled to take your actual group health coverage with you when you leave a job. Your new health plan may not cover all of the benefits or the same doctors that your old plan did.

 

If you change jobs, your new employer may not offer a health insurance plan. If an employer offers a health insurance plan to its employees, the employer may not consider factors related to health status in determining whether to offer coverage under the health insurance plan.

 

If you get a new job with health benefits, your coverage may not start right away.

Employers can require waiting periods before your health benefits begin. HMOs can impose affiliation periods.

 

Even if your coverage is continuous, there may be a pre-existing condition exclusion period for some benefits if you join a group health plan that covers benefits your old plan did not. For example, say you move from a group plan that does not cover prescription drugs to one that does. You may have to wait up to one year before your new health plan will pay for drugs prescribed to treat a pre-existing condition. 

 

In Missouri, your access to individual health insurance may depend on your health status. Private insurers are not prohibited from turning you down, charging more, or limiting coverage due to your health. If you are federally eligible, insurance companies may only offer you a choice of 2 policies.  Once you obtain coverage, your ability to switch plans may be limited as well. While you have protections when you move from an individual policy to a group plan, neither federal nor Missouri law protects you from the imposition of pre-existing condition exclusions when you move from one individual plan to another, even if you had prior continuous coverage. Furthermore, you are not assured the right to buy another individual policy.

 

If you work for a non-federal public employer in Missouri, such as such as a state agency or a municipal government, not all of the group health plan protections may apply to you.

 

 

Collection or Denial of Unpaid Claims (What to do):

 

1. Use the Appeal Process and try to get a letter from your Physician.
2. Clerical errors and/or omission – Information provided is incorrect due to clerical errors, etc.
3. Make sure the plan that you purchased covers what is in dispute.  If not, there is not much we can do.
4. Amount charged is more than the expected and reasonable charge.  You may have to take this issue up with your Physician.
5. Unnecessary or not routine tests.  If the Physician tells you that something is covered and it is not, you need to take this up with your Physician.  You may need to tell the Physician that you will not pay this and that you will take this up with the Medical Examining Board.
6. Try to resubmit the claims, because errors happen.  More times than not, it is due to errors and not the insurance company.
7. When dealing with the insurance companies, try to get the names and departments that handle these issues, and send claim to their attention.

 

 

 

 

 

Complaint Ratio Report:

 

Can be ordered from Insurance Departments.  The have a wealth of information about insurance companies.

 

 

Diabetes:

Per Chris, “If you take Diabetes Meds, you are Diabetic” and qualify for SNPs.

 

 

Group Insurance:

 

Have Guaranteed Coverage no matter what pre-existing problems there are.

Teamsters Group Insurance is a strong plan.

 

 

HSA – Health Savings Account:

 

A tax benefit that is 100% tax deductible on premiums, money in account.  It is similar to 401k and IRA plans.

 

 

 

 

Individual Insurance:

 

According to State Law, neither Individual or Group Insurance can be canceled because of over usage.

Limits:

 

There are limits even to a Group Plan

 

LIS;
LIS people can switch plans monthly per Chris
LIS people pay less because the Plan B premiums are usually paid for.

 

 

rescriptions:

Benefits for covered expenses include the generic version of a prescription drug on brand names (if no generic exists).  If you wish, you may choose the brand name drug even if a generic exists, but you must pay the difference in cost and the brand-name copay.

 

 

Medical Codes
ICD9 Code 250 is Diabetes.

ICD9 Code 428 is Heart Failure

 

 

Pre-Screening An Application:

 

You can call the underwriters to see what the chances are to get coverage.  We do this so we do not get a Turndown to avoid it going to MIB.  We can get the underwriters to tell us before it goes to acceptance or turndown.  We can pull the application ion before then.

 

Scheduled Benefit Plans:

 

This is where you have X amount of dollars for each medical issue, not an aggregate of 1 or 2 million like you would have with BC&BS, AMS, etc., that would cover everything.  We do not sell Scheduled Benefit Plans. 

 

 

State Continuance:

 

See COBRA above.  Kansas is for 6 months and Missouri is for 9 Months.

 

State Insurance Pool:

 

Kansas State Pool – KHIA  (800) 290-1368  Has a $7,500 deductible available

Missouri State Pool (800) 843-6447  Deductibles can not exceed $5,000.

To get coverage, you need to be turned down by 2 insurance companies.

BC&BC and Health Midwest are two companies most used for State Pool insurance.

 

Some of these state plans have a annual caps on them, make sure you advise your clients of this.