A Couple of Benefit Questions

marymary · 10-15-2006, 08:03 PM

These benefit matters really stress me out, I'm sure you all have been through the same or similar struggles.

We are evaluating small Group coverage with Blue Cross (PPO w/ $30 co-pay), this would be through husband's employer.

There is a pre-existing conditions clause, as follows:

"If an employee or dependent applies for coverage within 180 days of terminating coverage in a group health care plan, Blue Cross will credit the time enrolled IN THE PREVIOUS PLAN toward the preexisting condition waiting period"

My question is, what if you were enrolled in a succession of plans, never experiencing a lapse in coverage? Would the preexisting condition waiting period still be waived? In my situation I was enrolled in Health Net through two separate employers (going from most recent backwards) One (1) month in new plan with the new employer; Three (3) months of COBRA coverage with the old employer, and a year + with the old employer.

Also, does anyone know if Blue Cross PPO covers Gamma Knife treatment?

Basically I am finding that the PPO option is quite costly, with a $ 4,000 Annual Out-of-Pocket Maximum. Since we are already in October, that would basically mean $ 4,000 in 2006 and then again in 2007. Add to that the premium cost, of which the employer would pay 50%. I have not yet received the premium cost. I will learn that tomorrow.

This employer does not offer an HMO feature. I'm not sure that Medicare would be any less expensive, however. I am currently only enrolled in Medicare Part A (the part you can't turn down), due to my current enrollment in a Health Net HMO. I honestly don't know very much about Medicare coverage.

I am feeling guilty and sad that my husband's acceptance of this job offer is hinging on my need to be in an HMO. We are both feeling the stress today.

Any comments and feedback is welcome from all you benefit gurus out there.

Thanks.

Mary

Lolly · 10-15-2006, 08:22 PM

Mary, I used to have BCBS of Oregon. The benefits and costs most likely vary depending on what region, but I do remember that according to my benefits plan if you enroll in a BCBS plan within 3 months of year-end, they roll over the amount you've paid towards your out-of-pocket maximum into the next year. Is there a Customer Service number in the info packet you have? If not, call Information for their number and ask Customer Service your questions. In my experience with BCBS, their people were without fail polite, very helpful and very knowledgeable.

Colleen007 · 10-16-2006, 04:26 AM

My background is in employee benefits. It should not matter that you've been covered by a succession of plans...just that you've been covered for the previous 180 days with no breaks in coverage. You should have received a HIPAA Certificate from each of the prior plans that shows the dates you were enrolled (as you will probably need to prove at some point that you had continuous coverage). If you do not have copies of them, you should start contacting the prior plan administrators now to get copies (I believe they are legally oibligated to provide them to you).

Regarding your other questions, you should follow Lolly's advice above and contact the plan's Customer Service number to get your answers.

Sheila · 10-16-2006, 10:03 AM

Mary
I have BCBS of Illinois, PPO, and it has been wonderful as long as I go to a PPO Provider and Hospital...you can call or go on their web site and find out what Dr's etc are "on the list" as PPO Providers. The most I ever Pay is a 15.00 co-pay. Hope this helps. Oh, and the important thing is as long as I am going to a PPO provider, I have NO lifetime max on insurance bills...that is a big relief.

marymary · 10-17-2006, 09:25 AM

My husband just accepted the new job offer, although much if not all of the increased salary will go to Blue Cross in the form of high yearly out-of-pocket-maximums. These are $ 4,000 per year per enrollee.

The phone rep. put me on hold, then came back and said Blue Cross covers Gamma Knife "if it is medically necessary". OK, so that piece was just plain irritating. We're not having cosmetic surgery here.

I still have a few questions. The new Blue Cross policy is small group. Medicare, if I had it, would therefore be primary. Right now I only have Medicare part A. Should I sign up for Part B to help defray the OOPM's? I'm guessing my husband's change in employment might be considered a qualifying event (even though the new employer offers insurance). It might be an administrative nightmare since Medicare would be primary payer. I'm guessing the answer is no but I hate to guess on these things.

Other question, he only just became eligible for insurance in October at the job he is leaving. We have received new i.d. cards from Health Net but they have yet to deduct a premium (clearly this was a mistake). I'm not positive if they have to offer us COBRA continuation coverage since he will not be employed throughout the month of October. Our former COBRA policy is set to expire this coming Wednesday. No pressure here.

Just got back from Washington and have been glued to spreadsheets, the net etc. since Sunday. Today it's off to San Francisco for Herceptin. The good news: I just received the third and final vaccine. Let's hope these things work, we need some miracles. Thank you so very much for your feedback; I've noticed all breast cancer survivors tend to be insurance experts.

Love,

Mary