Frugal Wife

Dear Frugal Wife,

The employer is not required to pay you anything for the favor of skipping their health plan.  The HR person was right, though perhaps a bit rude to point out the windfall the company would be getting.

Now that you know you won’t get any extra pay for leaving their plan, you might want to re-think your strategy.  Joining your husband’s plan may cost more than staying on your employer’s plan.  If you plan to quit working to have a family, you can drop off your employer’s plan when that happens.  You don’t need to be on your husband’s plan before then.  (Your husband’s group plan will pick you up when you lose your other coverage for “family status changes”, such as when you quit the job or have a baby.)

In the meantime, feel free to subtly hint to your employer that you expect a very nice wedding gift.

Still Uninsured

Dear Still Uninsured,

In 2014, the federal health reform will require companies with 50 or more full-time employees to offer a plan to pay a penalty. Part-time employees count as fractions of full-time; so, two half-time employees equal one full-timer.

Seasonal employees who work 120 days or less per year do not count as full-timers and do not have to be offered a plan. Likewise, part-timers do not have to be offered a plan even though they “count” toward the 50-employee mark.

The process of counting employees is a bit technical, but for most companies, the 50-employee threshold is easy to figure out.  It is even trickier is figuring out whether a particular employee “regularly” works at least 30 hours per week.  Employers are shifting schedules in 2013, since that is the period that will be looked at to determine who is full-time and who is not.

If you do not get a plan at work, you are still required to have coverage.  You will be able to buy your own plan on the insurance exchange.  More information about these will be available in the fall of 2013.

Breathless

Dear Breathless,

Yes the plan can stop covering a drug in mid-year though it should still cover something comparable or cover your medicine with a higher co-pay. Before you switch to another medicine, find out if the plan will still cover your medicine with a prior authorization. Your doctor would submit information to the plan and the plan would decide whether to approve it.  If they decide not to approve it, you can appeal their decision. “Appeal” means that you ask them to reconsider it.

If the drug is simply no longer covered and the other options are not appropriate for you, go to the drug manufacturer’s website and look for their patient assistance program. Some manufacturers will give you a steep discount on the medicine, if you qualify.

Not Sure Where To Turn

Dear Not Sure Where To Turn,

It depends what state you live in. In some states, insurers have to offer you a plan though they may be able to charge you more. In other states, the insurer can refuse to sell you a plan.  Here is a list of states and their rules on “guaranteed issue”.  If you are turned down for health insurance, contact your state’s insurance regulatory bureau to find out whether you qualify for a high risk pool or other program for people who are considered “uninsurable”.

In 2014, all insurers will have to accept you as a customer.  Until then, you may have to work a little harder to find a plan.  If your illness is preventing you from working, you should file for Social Security disability.  You may qualify for these benefits, which would help you pay for health insurance until you qualify for Medicare.

Crone Free

Dear Crone Free,

The pre-existing condition problem only arises when you change health plans.  And it’s only a problem until January 2014, when health reform prohibits insurers from charging more and from denying claims for pre-existing conditions.

Until 2014, a pre-existing condition is any illness that you have received treatment for in the six months before you join a new health plan. The new plan will look back at the six months before you joined to determine whether you had any treatment.  (Whether you expect to have more treatment is not important to the insurer.)

Now, suppose you did have some treatment – an office visit or a test – during those six months.  The insurer still has to pay your claim if you had no gap in your health insurance coverage.  The first time you submit a claim, you will probably get a notice from the insurer — looking for proof of your previous coverage. This is called a “letter of creditable coverage”. It is a form that you would request from your plan; or it may have been sent to you when you ended your coverage.

Downhill in Colorado

Dear Downhill in Colorado,

The agent should give you the letter from the insurer with the reason for the rejection, even if he is now pressing shirts.  If you cannot reach the agent, you could contact your state’s insurance regulatory bureau.  In Colorado, that is the Department of Regulatory Agencies Division of Insurance.   You can even e-mail them your question.  They will be able to help you get a copy of the rejection letter.

You will need the rejection letter, if you want to apply to CoverColorado, the state’s program for people who have been turned down for health insurance because of their health.

In any case, this is a temporary problem: insurers will not be able to reject customers in 2014.  Health reform requires insurers to offer a plan to all comers.

On Edge In Maryland

Dear On Edge In Maryland,

The insurer could cancel your policy only you committed fraud on the application. This was part of the health reform law of 2010, limiting the insurer’s ability to end a person’s coverage. So, for example, if you lied about being married to someone on your application for family coverage, they could cancel your policy.

In Maryland, insurers are allowed to charge people more or turn you away based upon their health.  This is true until 2014, when this practice is prohibited.  If you cannot find a willing insurer, you can apply to Maryland Health Insurance Plan (MHIP); this is specifically for people who can’t get insurance because of their health.

Once you have a new plan, you should be all set for having your pre-existing condition covered – as long as you do not have a gap in your health coverage of 63 days or more.  You will probably have to show the new plan that you had uninterrupted coverage, as soon as you get a service for your pre-existing condition.  When the insurer gets a claim for an ongoing (chronic) illness like diabetes or depression for a new member, they will ask you to send them proof of “creditable coverage.” This is a form that you would request from your previous insurer.  Once they have that form, they will be able to pay the claim (assuming you had no gap).

Stitched Up

Dear Stitched Up,

Yes, the insurer will pay for your care as long as you had coverage on the date of the surgery. It does not matter that in the month after the surgery, you ended your coverage.

With many surgeries, the fee covers follow-up visits.  So, even though you no longer have the insurance, your visit to the doctor may already have been paid for.  Call your doctor’s office and ask.

Mom To Be

Dear Mom To Be,

In 2010, the cost to deliver a baby ranged from $2,000 for a normal, vaginal delivery at a birth center to $23,000 for a cesarean section with complications at a hospital. If you are in a low-income household, you may qualify for Medicaid.  Medicaid has special rules for pregnant women.  So even if you have applied before and were turned down, try again.  Ask your doctor or a billing staff person at the hospital where you will deliver.  They can help you get in touch with the right agency and get the application forms.

If you do not qualify for Medicaid, explain your situation to your doctor (and the hospital).  They may have other ideas for you, and at the very least, could offer you a payment plan.

Good News, Bad News

Dear Good News, Bad News,

Yes she should tell Medicaid about her daughter’s new plan.  And no, she will not get into trouble.  People are allowed to have both Medicaid and a private health plan.  So, her daughter will not have to give up Medicaid.

The Medicaid plan will pay after her father’s plan pays. This means that the doctor (or hospital or other service provider) will bill his plan first; then they will send the private plan’s explanation of benefits to Medicaid. You don’t need to worry about this part — the billing people already know how to do this.

If the father’s plan does go poof, she will still have Medicaid – as long as she and her mother still qualify for it.