Health Insurance and Access to Care in the U.S.

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candystripper -> Health Insurance and Access to Care in the U.S. (11/13/2008 9:36:31 AM)
Here in the United States, health insurance is provided in one of three basic ways: Government programs, such as Medicaid. Government programs which have been semi-privitatized, such Medicare. Traditional Indemnity Insurance, such as Blue Cross/Blue Shield. Health Maintenance Organizations, which are a cooperative of hospitals and other providers, along with an insurance company 'back office' and limited to a certain geographical area. Most people don't realise that, if they are receiving Medicare, their Social Security checks are being debitted about $100 every month for Medicare Part A coverage. This is evidentially something you must 'opt out' of. Note: If you have not done so, you need to opt-out for 2009 between Nov. 15th and Dec. 31st, 2008 by calling Medicare at 1-800-Medicare. Medicare is also reachable at medicare.gov. If you applied an additional $50 a month to the $100 you may be paying for Medicare Part A coverage, you'd have enough to shop in the marketplace for a health insurance indemity plan (or HMO if you live somewhere one is available). If you decide on an insurance company only to be told 'we only sell to companies' call your state's Secretary of State and register a 'dba' or trade name, then call back and give the 'company name' -- your company will have one employee -- you. There are three criteria for choosing a health insurance company. First: will they pay claims? Beware of lifetime caps on coverage, etc. Read the POLICY -- not the ancillary materials. DO NOT rely on your insurance agent to explain it to you. Of course you want the maximum coverage you can get. Most people need hopitals, MDs, and prescription drug coverage. To find a quality insurance 'admitted' to do business in the state where you reside, go to ambest.com. Look at the company's financial strength as well as it's market conduct rating. An 'A' rated company is most desirable. Note: do not buy health insurance from an insurance company which is not 'admited to do business' in your state. Certainly never, ever buy insurance from a company located outside the United States. Insurance Companies, like banks, are financial instutions, but there is only regulatory control at the state level, nothing at the federal level. For further assistance, look at the National Association of Insurance Regulators at naic.org. They have a Consumer Hotline but more importantly, they have many materials meant to inform consumers about the condition of the market in their states as to any line of insurance. It's a good site to bookmark if you live in the U.S. Another other resource to use is the American Bar Association's Health and Disability Insurance Law Committee. Try abanet.org. Note: the home page for the ABA offers the consumer of legal services a means of finding a lawyer qualified to handle his matter via martindale.com. While Martindale-Hubbel does do some 'due diligence' on lawyerly folks before it allows them to advertise, that's all it is --adverising. Comparatively, any member of the ABA's Health and Disability Law Committee can probably help you. Most such lawyers are probably not living in your state. They tend to be clustered in the larger metro areas, like NYC and DC. I know it's anxety-provoking to hire a lawyer who is not local, but businesses do it all the time. It's safe, not that you should ever suspend your own good sense of whether your legal matter is being properly handled. Remember: an Insurance Company sells a contract to pay claims in the event you fall ill, and you pay good money for the coverage. If you are not happy with how a claim or cascade of claims is being handled, you are entitled to litigate the matter. If you are facing dire consequences as a result of an insurance company's failure to perform, etc., see a lawyer skilled in handling such matters. I hope this is of assistance to someone in the U.S. (Don't you folks in Canada, Great Britian and Australia feel sorry for us poor U.S. folks, LOL?) Peace out, peeps. candystripper [sm=pole.gif]

CalifChick -> RE: Health Insurance and Access to Care in the U.S. (11/13/2008 10:42:51 AM)
quote: ORIGINAL: candystripper Note: If you have not done so, you need to opt-out for 2009 between Nov. 15th and Dec. 31st, 2008 by calling Medicare at 1-800-Medicare. Medicare is also reachable at medicare.gov. If you applied an additional $50 a month to the $100 you may be paying for Medicare Part A coverage, you'd have enough to shop in the marketplace for a health insurance indemity plan (or HMO if you live somewhere one is available). Please, for the love of all that is holy, do NOT make any changes to your medicare coverage without speaking to someone knowledgeable about Medicare and what is available in YOUR area, and what the consequences of making those changes are. Medicare Part A covers facility charges (such as hospital charges) and for many people, Part A is FREE due to their work history. For more information on Medicare, here is the official 2009 "Medicare and You" booklet: http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf Cali

meatcleaver -> RE: Health Insurance and Access to Care in the U.S. (11/13/2008 10:59:26 AM)
quote: ORIGINAL: candystripper I hope this is of assistance to someone in the U.S. (Don't you folks in Canada, Great Britian and Australia feel sorry for us poor U.S. folks, LOL?) Well I don't think there are many people in countries with national health services that would swop systems with an America. That being said, there are people who would but my guess is they've never tried it. My brother lives in America and loves all things American but....you guessed it, he thinks the American health service, cover, whatever it is, sucks.

BlackPhx -> RE: Health Insurance and Access to Care in the U.S. (11/13/2008 1:04:46 PM)
The problem with your plan Candystripper is that most people who are on Social Security and in these forums are on Disability. this means they have pre-existing conditions and the MAJORITY of Insurance Companies will refuse to take them on as clients if they are eligible for Medicare. While they get the Medicare premium, and in some cases an additional premium from the client, they also recieve the Medicare payment for the proceedure if there is one, AND have negotiated special reduced costs for the proceedures for the medicare clients they handle. They WANT you to stay with Medicare plans through them..they lose so much less on your health that way. I explored going with Blue Cross Blue Shield back when the Advantage plans were first authorized as their plans gave me the same coverage for far less in premiums...they wouldn't even discuss it. Don't cut Medicare before you KNOW you have something in it's place. poenkitten

sirsholly -> RE: Health Insurance and Access to Care in the U.S. (11/13/2008 1:36:42 PM)
quote: ORIGINAL: CalifChick quote: ORIGINAL: candystripper Note: If you have not done so, you need to opt-out for 2009 between Nov. 15th and Dec. 31st, 2008 by calling Medicare at 1-800-Medicare. Medicare is also reachable at medicare.gov. If you applied an additional $50 a month to the $100 you may be paying for Medicare Part A coverage, you'd have enough to shop in the marketplace for a health insurance indemity plan (or HMO if you live somewhere one is available). Please, for the love of all that is holy, do NOT make any changes to your medicare coverage without speaking to someone knowledgeable about Medicare and what is available in YOUR area, and what the consequences of making those changes are. Medicare Part A covers facility charges (such as hospital charges) and for many people, Part A is FREE due to their work history. For more information on Medicare, here is the official 2009 "Medicare and You" booklet: http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf Cali i agree...a social worker is a good one to start with.

candystripper -> RE: Health Insurance and Access to Care in the U.S. (11/13/2008 2:12:54 PM)
quote: ORIGINAL: BlackPhx The problem with your plan Candystripper is that most people who are on Social Security and in these forums are on Disability. this means they have pre-existing conditions and the MAJORITY of Insurance Companies will refuse to take them on as clients if they are eligible for Medicare. While they get the Medicare premium, and in some cases an additional premium from the client, they also recieve the Medicare payment for the proceedure if there is one, AND have negotiated special reduced costs for the proceedures for the medicare clients they handle. They WANT you to stay with Medicare plans through them..they lose so much less on your health that way. I explored going with Blue Cross Blue Shield back when the Advantage plans were first authorized as their plans gave me the same coverage for far less in premiums...they wouldn't even discuss it. Don't cut Medicare before you KNOW you have something in it's place. poenkitten O, yr quite right Black Phx. It was an introductory Op, not a seminar in the Law or Business of Insurance. Bear in mind though, that insurance companies could not make any money if they turned away any applicant who was not in perfect health (as if such folks exist). My advice is not to get off Medicare Part A unless and until you have found another carrier. However, if you locate an insurer and all seems well, you must still check around your community for a local hospital and family MD who accepts the policy. When applying to a private insurance company, simply say you are self-employed. It's no one's business where you get your revenues from. candystripper [sm=pole.gif]

corysub -> RE: Health Insurance and Access to Care in the U.S. (11/13/2008 8:17:49 PM)
quote: ORIGINAL: BlackPhx The problem with your plan Candystripper is that most people who are on Social Security and in these forums are on Disability. this means they have pre-existing conditions and the MAJORITY of Insurance Companies will refuse to take them on as clients if they are eligible for Medicare. While they get the Medicare premium, and in some cases an additional premium from the client, they also recieve the Medicare payment for the proceedure if there is one, AND have negotiated special reduced costs for the proceedures for the medicare clients they handle. They WANT you to stay with Medicare plans through them..they lose so much less on your health that way. I explored going with Blue Cross Blue Shield back when the Advantage plans were first authorized as their plans gave me the same coverage for far less in premiums...they wouldn't even discuss it. Don't cut Medicare before you KNOW you have something in it's place. poenkitten I don't believe you can opt out of Medicare. I think once you reach 65 years of age it is mandated that you get Medicare, and any other insurance you might have from an employer or personal will be your "secondary" insurer. The problem arises then that Medicare becomes your "gatekeeper" and if medicare disallows something your secondary won't pay it either. Please correct me if I am wrong on this....

DomMeinCT -> RE: Health Insurance and Access to Care in the U.S. (11/13/2008 10:16:16 PM)
A few points on the original post: There are many more variations on the types of insurance coverage products than those listed, and more being created all the time. One of the most common is a PPO - preferred provider organization - which can combine "traditional insurance" (deductibles, copays, coinsurance) and allow an insured to see any provider/hospital, but which will pay a higher proportion of expenses if the insured goes to a specific providers who have contracts with the insurance company. Beware of lifetime caps on coverage, etc This is a little misleading. Few policies are now being written with unlimited lifetime caps, even in the case of very rich group policies. If you are not happy with how a claim or cascade of claims is being handled, you are entitled to litigate the matter. You may be entitled to litigate matters, but litigation is rarely the first option. Many states require insurance companies to offer insureds multiple levels of appeals and specific processes designed to avoid litigation. During these levels of appeals, the insurance company may be required to have outside medical experts review claim denials, which provides unbiased review. A state's Department of Insurance is a great resource to consult first, without having to use an attorney and involve unnecessary litigation (which is another reason for our high healthcare costs in this country).

tweedydaddy -> RE: Health Insurance and Access to Care in the U.S. (11/13/2008 11:57:34 PM)
I am emigrating to the US in the next few years and quite frankly both the state of healthcare there and the universal American war on the poor are the two things that bother me most. It strikes me as bizarre that a country as wealthy as the USA spends more money on the health of other nations than it does on its own. I do have the utmost sympathy for you over there, the NHS has it's faults, but health care that is free at the point of need should be a Universal human right. If the US could ever unbend from it's fear of Socialism or Socialist inspired policies then it should at least invest in an NHS of it's own. If tax dollars were spent on the well being of your own people instead of other countries, it could only be a benefit to you all. As you point out, health insurance firms are financial institutions, and we know how they are doing at the moment. Would it be so bad to spend all the money being wasted on sending metal into outer space, or in mothballing fleets of aircraft and ships you will never use to provide a few more clinics? If we make it work, in however flawed a manner, surely you can.

candystripper -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 12:02:38 AM)
quote: ORIGINAL: corysub quote: ORIGINAL: BlackPhx The problem with your plan Candystripper is that most people who are on Social Security and in these forums are on Disability. this means they have pre-existing conditions and the MAJORITY of Insurance Companies will refuse to take them on as clients if they are eligible for Medicare. While they get the Medicare premium, and in some cases an additional premium from the client, they also recieve the Medicare payment for the proceedure if there is one, AND have negotiated special reduced costs for the proceedures for the medicare clients they handle. They WANT you to stay with Medicare plans through them..they lose so much less on your health that way. I explored going with Blue Cross Blue Shield back when the Advantage plans were first authorized as their plans gave me the same coverage for far less in premiums...they wouldn't even discuss it. Don't cut Medicare before you KNOW you have something in it's place. poenkitten I don't believe you can opt out of Medicare. I think once you reach 65 years of age it is mandated that you get Medicare, and any other insurance you might have from an employer or personal will be your "secondary" insurer. The problem arises then that Medicare becomes your "gatekeeper" and if medicare disallows something your secondary won't pay it either. Please correct me if I am wrong on this.... The Medicare Part B coverage is primarially for hospitals. It is embedded in your eligibility to draw Social Security, whether you retired due to age or disability. There is no charge to you for Medicare part B coverage. Medicare Part A is optional, and this is what the $100 debitted from your Social Security check is paying for. It covers MD visits and I'm not sure what else. Medicare part D, which has been privatized, is coverage for prescription drugs. However, there is an annual cap of $2,700 and the copays made by you are incuded in the measurement of the cap. Rather than doing business with the government and it's contractors, who are not all insurance companies and who seem to provide horrendous customer service and claims handling, you could consider spending your health insurance dollars on private insurance. To be honest, I don't know what Medicare A and B actually cover. Perhaps they're a better 'deal' than private coverage. I'd never spend the money for a 'Medicare Supplement policy' myself. They are chronic malfeasors, concentrating people who fall ill into groups and raising their rates horrendously - a practice known as back-loading. Concentration of risk is a violation of sound insurance company practice. candystripper [sm=pole.gif]

candystripper -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 12:37:29 AM)
ORIGINAL: DomMeinCT A few points on the original post: There are many more variations on the types of insurance coverage products than those listed, and more being created all the time. One of the most common is a PPO - preferred provider organization - which can combine "traditional insurance" (deductibles, copays, coinsurance) and allow an insured to see any provider/hospital, but which will pay a higher proportion of expenses if the insured goes to a specific providers who have contracts with the insurance company. DomMein, a Preferred Provider Organiztion can come to resemble a Health Maintenance Organization, but most are no more than indemnity plans which 'capture' the purchaser of the policy in a particlar network of hospitals and MDs. Like any other form of insurance product, there's no substitute for doing the 'due dilligence' on such plans. Beware of lifetime caps on coverage, etc This is a little misleading. Few policies are now being written with unlimited lifetime caps, even in the case of very rich group policies. That was not my point. But there is a difference between a $5 Million lifetime cap and a $1 Million dollar one. If you are not happy with how a claim or cascade of claims is being handled, you are entitled to litigate the matter. You may be entitled to litigate matters, but litigation is rarely the first option. Many states require insurance companies to offer insureds multiple levels of appeals and specific processes designed to avoid litigation. During these levels of appeals, the insurance company may be required to have outside medical experts review claim denials, which provides unbiased review. A state's Department of Insurance is a great resource to consult first, without having to use an attorney and involve unnecessary litigation (which is another reason for our high healthcare costs in this country). Sometimes it's useful to pursue an appeals process offered by an insurance company; other times it is not; and a few times these appeals are so procedurally complex you may need a lawyer to navigate them. Some state insurance regaulators offer alternative dispute resolution processes, but in the main, they are limited to an HMO which denies care. It s not the business of insuarnce regulators to provide an alternative to the courts for dispute resolution. That is not to say they cannot help; every state has a Unfair Trade Practices Act which governs the conduct of insurers. However, typically the regulators won't send the lawyers to court to litigate malfeasnace by a insurance company without some evidence that a vile business practice, affecting insureds generally, is present. Bear in mind too, the lawyers who work for regulators are not 'your' lawyer. You will have no say in whether they case is settled without requiring restitution to the injured insureds. I would never discourage anyone from trying to resolve their own problems without the aid of a lawyer. But if you are faced with denial of access to care or servere financial hardships, sometimes a lawyer can force the company to act responsiblity. candystripper [sm=pole.gif]

CalifChick -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 7:16:55 AM)
quote: ORIGINAL: corysub I don't believe you can opt out of Medicare. I think once you reach 65 years of age it is mandated that you get Medicare, and any other insurance you might have from an employer or personal will be your "secondary" insurer. The problem arises then that Medicare becomes your "gatekeeper" and if medicare disallows something your secondary won't pay it either. Please correct me if I am wrong on this.... Actually, you can elect to have a Medicare Replacement Plan. These are often known as "fee for service" plans, and any regular Medicare provider is required to accept them. So if you choose a Blue Cross Senior Advantage Plan (which is a fee for service), then you can go to any doctor who accepts regular Medicare. You can also get additional insurance to cover what Medicare does not pay. This would be an individual plan or a group plan (for instance, from a job you retired from). The third option is a Medicare Supplement plan. Similar to the second option. AARP is the most well-known and largest provider of Medicare Supplement Plans. They have different plans for different needs and financial situations. Some only cover the Medicare deductible, some cover the deductible and the copay. Generally, with any insurance, you have to follow the rules of the primary carrier (in this instance Medicare) in order for the secondary to pay. Howevever, if it is a benefit of the secondary but not Medicare (such as biofeedback), then generally the secondary will go ahead and pay. You must educate yourself on what each plan covers. And that education really needs to come from an expert in the field, not a tax attorney. Cali

sirsholly -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 8:46:36 AM)
quote: ORIGINAL: CalifChick quote: ORIGINAL: corysub I don't believe you can opt out of Medicare. I think once you reach 65 years of age it is mandated that you get Medicare, and any other insurance you might have from an employer or personal will be your "secondary" insurer. The problem arises then that Medicare becomes your "gatekeeper" and if medicare disallows something your secondary won't pay it either. Please correct me if I am wrong on this.... Actually, you can elect to have a Medicare Replacement Plan. These are often known as "fee for service" plans, and any regular Medicare provider is required to accept them. So if you choose a Blue Cross Senior Advantage Plan (which is a fee for service), then you can go to any doctor who accepts regular Medicare. You can also get additional insurance to cover what Medicare does not pay. This would be an individual plan or a group plan (for instance, from a job you retired from). The third option is a Medicare Supplement plan. Similar to the second option. AARP is the most well-known and largest provider of Medicare Supplement Plans. They have different plans for different needs and financial situations. Some only cover the Medicare deductible, some cover the deductible and the copay. Generally, with any insurance, you have to follow the rules of the primary carrier (in this instance Medicare) in order for the secondary to pay. Howevever, if it is a benefit of the secondary but not Medicare (such as biofeedback), then generally the secondary will go ahead and pay. You must educate yourself on what each plan covers. And that education really needs to come from an expert in the field, not a tax attorney. Cali the lady knows of which she speaks...[:)]

CalifChick -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 9:11:00 AM)
quote: ORIGINAL: candystripper The Medicare Part B coverage is primarially for hospitals. It is embedded in your eligibility to draw Social Security, whether you retired due to age or disability. There is no charge to you for Medicare part B coverage. Medicare Part A is optional, and this is what the $100 debitted from your Social Security check is paying for. It covers MD visits and I'm not sure what else. This post just proves that you should never take advice on insurance from a tax attorney, because all of this information is wrong. Not sorta wrong, kinda wrong, sometimes wrong... FLAT OUT WRONG. Candy, please give up this new obsession. God help anyone who thinks that your information is correct. Cali

sirsholly -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 9:19:47 AM)
quote: ORIGINAL: CalifChick quote: ORIGINAL: candystripper The Medicare Part B coverage is primarially for hospitals. It is embedded in your eligibility to draw Social Security, whether you retired due to age or disability. There is no charge to you for Medicare part B coverage. Medicare Part A is optional, and this is what the $100 debitted from your Social Security check is paying for. It covers MD visits and I'm not sure what else. This post just proves that you should never take advice on insurance from a tax attorney, because all of this information is wrong. Not sorta wrong, kinda wrong, sometimes wrong... FLAT OUT WRONG. Candy, please give up this new obsession. God help anyone who thinks that your information is correct. Cali Cali is correct...this is WRONG!!!!! Candy...where in the hell are you getting this MISinformation??

CalifChick -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 9:39:22 AM)
quote: ORIGINAL: candystripper Sometimes it's useful to pursue an appeals process offered by an insurance company; other times it is not; and a few times these appeals are so procedurally complex you may need a lawyer to navigate them. Once again, this information could be terribly damaging if someone were to take it at face value. If your plan is an ERISA plan, then NOT following the appeals process means you forfeit the right to litigate. That is federal law. As an attorney, I would think you would have access to information on dozens and dozens of cases that were thrown out of court due to not following the required appeal process... even as a layperson I have seen it. The majority of plans (not including Medicare) are ERISA plans. ERISA is a set of federal laws, and it applies to all plans obtained thru an employer, and many plans obtained thru any kind of group. Some insurance companies have helpfully started putting the notation "ERISA=YES" in the fine print on the insurance card. In virtually all non-ERISA plans, when you sign up for the coverage, you agree to the appeal terms, and if you don't follow them, then you cannot litigate. Cali

sirsholly -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 9:47:58 AM)
quote: ORIGINAL: CalifChick quote: ORIGINAL: candystripper Sometimes it's useful to pursue an appeals process offered by an insurance company; other times it is not; and a few times these appeals are so procedurally complex you may need a lawyer to navigate them. Once again, this information could be terribly damaging if someone were to take it at face value. If your plan is an ERISA plan, then NOT following the appeals process means you forfeit the right to litigate. That is federal law. As an attorney, I would think you would have access to information on dozens and dozens of cases that were thrown out of court due to not following the required appeal process... even as a layperson I have seen it. The majority of plans (not including Medicare) are ERISA plans. ERISA is a set of federal laws, and it applies to all plans obtained thru an employer, and many plans obtained thru any kind of group. Some insurance companies have helpfully started putting the notation "ERISA=YES" in the fine print on the insurance card. In virtually all non-ERISA plans, when you sign up for the coverage, you agree to the appeal terms, and if you don't follow them, then you cannot litigate. Cali another good post, Cali [sm=applause.gif]

windchymes -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 10:12:27 AM)
quote: ORIGINAL: CalifChick quote: ORIGINAL: candystripper The Medicare Part B coverage is primarially for hospitals. It is embedded in your eligibility to draw Social Security, whether you retired due to age or disability. There is no charge to you for Medicare part B coverage. Medicare Part A is optional, and this is what the $100 debitted from your Social Security check is paying for. It covers MD visits and I'm not sure what else. This post just proves that you should never take advice on insurance from a tax attorney, because all of this information is wrong. Not sorta wrong, kinda wrong, sometimes wrong... FLAT OUT WRONG. Candy, please give up this new obsession. God help anyone who thinks that your information is correct. Cali Wow. It's been a few years since I did billing, but a few years ago, Part A was for in-patient hospital coverage (among other things) and Part B was for out-patient services, and there WAS a monthly premium to carry Part B coverage. I think I'm going to mix up a blender of strong margaritas, hang a dart board on the wall, and then start giving the world legal advice . [8\|]

DomMeinCT -> RE: Health Insurance and Access to Care in the U.S. (11/14/2008 1:11:01 PM)
quote: ORIGINAL: CalifChick quote: ORIGINAL: candystripper Sometimes it's useful to pursue an appeals process offered by an insurance company; other times it is not; and a few times these appeals are so procedurally complex you may need a lawyer to navigate them. Once again, this information could be terribly damaging if someone were to take it at face value. If your plan is an ERISA plan, then NOT following the appeals process means you forfeit the right to litigate. That is federal law. As an attorney, I would think you would have access to information on dozens and dozens of cases that were thrown out of court due to not following the required appeal process... even as a layperson I have seen it. The majority of plans (not including Medicare) are ERISA plans. ERISA is a set of federal laws, and it applies to all plans obtained thru an employer, and many plans obtained thru any kind of group. Some insurance companies have helpfully started putting the notation "ERISA=YES" in the fine print on the insurance card. In virtually all non-ERISA plans, when you sign up for the coverage, you agree to the appeal terms, and if you don't follow them, then you cannot litigate. Cali Thank you. You beat me to the response on this one. Many state Departments of Insurance have Ombudsmen who can shepherd someone who is unhappy with a claim payment through the appeals process, and avoid litigation and attorney expenses. Insurance companies can work just as cooperatively with DoI as they can a for-profit attorney.

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