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Preparing to be Uninsured and Beyond - Part Three

Doris' Blog
By: dorisjdickson

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Posted: Aug 4, 2009 13:28
  • Preparing to be Uninsured and Beyond - Part Three

    Part Three


    I spent several months not knowing when my COBRA was going to run out.  I thought it was the end of May or June but was not sure.  Every time I went to the pharmacy, my insurance was still active and they were able to fill my test strip prescription.  Why rock the boat?  They were cashing the checks, which is a binding contract and could not by law demand I reimburse them for claims paid.  I did not receive any information from the employer, third-party COBRA administrator or BC/BS until Friday, July 21st. 


    The letter came from BC/BS and was dated July 17, 2009.  It stated that my COBRA was about to run out or had run out and gave me an 800 number to call for information about new plans.  Therefore, I called the 800 number and chose the individual plan option.  I spoke to Matt and, honestly, was in a particularly negative mood about what I anticipated being told.


    First, I asked about the letter I had received.  I was annoyed that the insurer was the player in the game to adviser me of the cancellation.  I was even more annoyed when he said they received notification on July 17th to retroactively cancel my insurance back to June 1st! 


    Later that day, I was even more annoyed to find out the third-party administrator had cashed the June payment on July 24th.  I was then infuriated the employer refused to do their job (as the customer of the 3rd party vendor) and inquire as to when I would be reimbursed the $445 payment that never should have been cashed in the first place and HAD been cashed AFTER the insurance had been cancelled retroactively.


    Back to the discussion with Matt at BC/BS - we discussed the variety of plans available as an individual and if there was any price/plan difference if I chose the self-employed option.  There were no differences.  We discussed my needs as a diabetic who is strong-willed at making medical decisions without “permission” from a primary care physician.  We discussed the cost replicating the recently terminated plan.  The premium would be $774 per month for the PPO I had with the deductibles I had.  Ouch. That was currently out of the question.


    So on to the other options.  Based on our detailed conversation he suggested and emailed proposals for two options:  HMO with a deductible of $500 and PPO with a deductible of $1,000.  The costs, based on zip code and age, are $452 and $435, respectively.  The contract term is one-year. 


    The major differences between the HMO and the PPO, other than deductible are:  HMOs require referrals (but it is a much easier process these days), the inability to seek non-Massachusetts medical care (for example if you get a particular form of cancer that Massachusetts physicians are ill-equipped to treat) and services under the deductible differ.  Under the HMO option, office visits are NOT subject to the deductible. 


    I decided to call back and ask a few more questions including what the cost of the HMO with the $1,000 deductible is.  It is $405.  Mathematically, it is more beneficial to not expose myself to the additional $500 deductible with either the HMO or the PPO.  Even the HMO premium difference of $45 (x 12) is only $540 total (just slightly more than the difference in deductible), which I would prefer to pay monthly, rather than owing medical providers.  There is no question one doctor’s visit will cause me to blow right through the $500. 


    Therefore, after laboriously researching several sources of individual and self-employed plans, including the Small Business Administration, the Commonwealth Connector, and Blue Cross/Blue Shield Massachusetts Direct Pay, I had to make a decision.  Fortunately, I live in Massachusetts and do not face pre-existing conditions clauses.  Therefore, the fact that the employer and third-party vendor blew by the notification of termination of coverage and thus, the 63 days of continuation of coverage mandates required by HIPAA were not going to be an issue.  My deadline was July 31st in order to have coverage for August 15th (the start date of all plans under BC/BS Massachusetts Direct Bill).


    The biggest question was HMO or PPO.  I absolutely do not like the concept of HMO’s and managed care.  I do not like large deductibles in conjunction with such high premiums.  Something suffers along the way.  At least with these plans, there is no prescription deductible, limited prescription formulary or limited physician list.  Most physicians take HMO Blue. 


    Therefore, I begrudgingly and with much apprehension called Matt at 8:30 Friday morning and faxed the application having chosen … HMO Blue $500 deductible.  My thought process is changing back to a PPO once I find full-time work.  In the mean time, it is important that I have prescription coverage (stock piled insulin or not) and that I can see a physician. 


    But is the process complete … not really.  Stay tuned for Part Four to find out what else this choice means and how this stressful this entire process has been.

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