Questions about insurance and being "uninsurable"

[workjw]

We are in a mess with our insurance, and I'm just wondering if anyone here has some ideas. DD is on state insurance, and it's causing us some trouble. DH has individual insurance (he's self employed, so no group option) and right now I have no insurance, but I'm having some medical problems and need to get coverage. We have been told that if I get insurance it gives us family coverage. Sounds great, except the insurance company is saying that they may or may not cover DD, but if they do, they won't cover anything pre-existing... which basically means they won't cover anything. The state says that it doesn't matter that they won't cover anything, she will still be classified as insured, so they will drop her.

I know she doesn't qualify for disability, but based on what the doctors have told us, we think that if we put down every possibility of what could be wrong (she doesn't have a formal diagnosis) that the insurance will deny her and she would be considered uninsurable. I think she has to be denied by 2 insurance companies to qualify. Has anyone been down this road? Are there any reasons we should avoid the label of uninsurable? If she is classified as uninsurable, the state will continue to cover her regardless of our other circumstances, but I don't want to end up making things worse if I can help it. Also, if we apply and the indiv policy does accept her... well I don't know what that would mean?!?! I know we don't have to accept the insurance, but I can't figure out if that would affect our current standing with the state, and our caseworker has been less than helpful.

Any ideas or suggestions?

[Wild Lupine]

Originally Posted by workjw

We have been told that if I get insurance it gives us family coverage.

I would question this assumption. It is possible that you have he option to cover the family if you want to, but don't necessarily have to. I've never heard of a plan that forces family coverage; it is significantly more expensive that way, even through an employer.

[workjw]

That makes sense to me, but for some reason I don't think it was more expensive to add the kids? It seemed like we had 2 options which were single coverage or family coverage, but maybe I'm just really confused. I'll call our agent again in the morning.

[workjw]

So I finally had a chance to sit down with our insurance agent and I was right, we only have the 2 options... individual or family. They won't cover anything pre-existing with the family plan, but we do have another option where they will cover pre-existing after 18 months. Only problem is that it has a $5,000 deductible and costs an extra $500 a month. So, to cover our family and actually have useful insurance, it will cost us almost $18,000 a year (plus all dr visits, meds, tests, etc for the next 18 months). That's more than 1/2 of our income.

Either way, according to the state, she would have access to insurance, so they would take her off state insurance.

I spoke to a number of agents at other insurance companies, and most were less than helpful, but I did find one lady that was great. She sent in some of dd's basic info to see if any of the providers would deny her, but she said that over the last few years that a lot of companies were accepting people with an 18 month month period and high rates for pre-existing. She did say I might be able to get insurance somewhere else individually, but I'm not sure how the state will see that since they already know we can get family coverage with dh's insurance.

I'm just so frustrated about it all. To top it all off, dh's business is starting to do well, and we may have to actually start turning clients down because we can't make any more money to still qualify for state insurance, b/c we certainly wouldn't be making enough to pay 20k a year for private (worthless for 18 mos) insurance. I just feel like I'm chasing my tail.

Thanks for reading if you made it this far. Apparently I needed to vent. Anyone have any advice?

[cdahlgrd]

Do you have a Children's hospital nearby? We paid $18,000 a year for insurance for several years. The year we couldn't afford that plus the cost of my ds's hearing tests, equipment, we got a scholarship from our Chilren's hospital.

I totally understand where you are. It is extrememly difficult.

Can you contact the state about disability and Medicaid for your little one? (if you go this route, get a laywer to help you apply. It is really tricky and they deny deny deny coverage unless you know the "tricks").

[KatWrangler]

I so hate insurance.

[khaoskat]

Originally Posted by workjw

So I finally had a chance to sit down with our insurance agent and I was right, we only have the 2 options... individual or family. They won't cover anything pre-existing with the family plan, but we do have another option where they will cover pre-existing after 18 months. Only problem is that it has a $5,000 deductible and costs an extra $500 a month. So, to cover our family and actually have useful insurance, it will cost us almost $18,000 a year (plus all dr visits, meds, tests, etc for the next 18 months). That's more than 1/2 of our income.

Ok, your child is covered by State Insurance. Your child is currently insured and has coverage. Pre-existing only comes into play when your child has not had any insurance in the 18 months previous to the plan going into effect. So, basically if she has been insured for 18 of the 18 past months, there is no waiting period. If she was covered 12 of the last 18 months (unless she is less than 18 months of age) there would be a 6 month waiting period.

[khaoskat]

Oh, and here is another possible solution to your situation.

Get two individual plans. Go through a different agent, or get quotes yourself.

Basically what you are looking at doing right now, is adding yourself to your husband's existing plan.

[Liba613]

Originally Posted by khaoskat

Ok, your child is covered by State Insurance. Your child is currently insured and has coverage. Pre-existing only comes into play when your child has not had any insurance in the 18 months previous to the plan going into effect. So, basically if she has been insured for 18 of the 18 past months, there is no waiting period. If she was covered 12 of the last 18 months (unless she is less than 18 months of age) there would be a 6 month waiting period.

100%

There are no waiting periods or exclusions for pre-existing conditions as long as there is continuous medical coverage, including medicaid, with no break of 63 or more days.

[KatWrangler]

Originally Posted by khaoskat

Ok, your child is covered by State Insurance. Your child is currently insured and has coverage. Pre-existing only comes into play when your child has not had any insurance in the 18 months previous to the plan going into effect. So, basically if she has been insured for 18 of the 18 past months, there is no waiting period. If she was covered 12 of the last 18 months (unless she is less than 18 months of age) there would be a 6 month waiting period.

No, I don't think thats right. The state will drop her because both Mom and Dad will have insurance. But no new insurance policy will cover her child because of pre-existing conditions.

[workjw]

Originally Posted by KatWrangler

No, I don't think thats right. The state will drop her because both Mom and Dad will have insurance. But no new insurance policy will cover her child because of pre-existing conditions.

That is the way I understand it too Anne. They still require an 18 month wait period even though she has been insured by the state for the last 2 years. I know that with group insurance pre-existing isn't an issue if you have had continuous coverage, but I guess private insurance is a different beast.

We actually got one preliminary denial letter today from one of the insurance companies we talked to last week. They said "Because she has more surgeries pending, we cannot be of service."

At this point I don't know if that is good or bad!

We've talked about getting my insurance through another company, but I believe there is a rule about both parents being insured and the children not being. Not sure if it's because of cost or what, plus I'm afraid that it may cause some problems b/c our caseworker knows that we can get family coverage with our current company by adding me. They tried to drop the kids when dh got insurance and we had to file a bunch of paperwork from the insurance company to keep them covered. I had an appt scheduled with our caseworker this week, but she had to cancel and I'm still waiting to hear from her so I can get some more info.

Thank you for the suggestion of the Hospital scholarship, I will definitely look into that if we can't get something worked out soon.

[queencarr]

Maybe this is naive of me but why can't you just "decline" to put her on the family policy? If they don't have her personal info, there is no way that she could be on it. Then, you could keep her state insurance. I think it is weird that they only either have a single or family policy, but just because she is eligible for it doesn't mean you have to put her on it, right? She is not automatically covered without any info given to them about her, yes? For example, when our third child came along, I had to specifically add him to our dental plan, even though we had family coverage--until I added him, he was not covered even though me and my other 2 kids were. Does that make sense?

As far as specifically getting her declared, uninsurable, I wouldn't do that. It might make it difficult for her down the road to get her own insurance once she is over 18. I do understand how difficult it can be wtiht the whole state insurance thing--we qualify for chips $$ but because my dh is retired military, we automatically have tricare. Which is actually pretty decent, but doesn't cover some of the things we are looking at needing for my youngest. Chips does, but because he has insurance, he cannot get it and there is no way to disenroll him from tricare without losing all of his other benefits, too. (and even then, not sure how to do it).

[workjw]

Originally Posted by queencarr

Maybe this is naive of me but why can't you just "decline" to put her on the family policy? If they don't have her personal info, there is no way that she could be on it. Then, you could keep her state insurance. I think it is weird that they only either have a single or family policy, but just because she is eligible for it doesn't mean you have to put her on it, right? She is not automatically covered without any info given to them about her, yes? For example, when our third child came along, I had to specifically add him to our dental plan, even though we had family coverage--until I added him, he was not covered even though me and my other 2 kids were. Does that make sense?

It does make sense but unfortunately it's not that easy. It doesn't matter if we actually use the insurance, only that she has access to it. If she has access to insurance (no matter how crummy) they can drop her from state insurance. I think that there is also some type of restriction about both parents having insurance, which I think is also b/c of access issues, but I'm not sure what the exact rules are. I'm still waiting to talk to our caseworker.

I am concerned about having her declared uninsurable, and hope it doesn't come to that. We have only done basic inquiries with no name or social or anything. Just enough basic info on her medical conditions to see if they would accept or deny her if we applied. I also need to find out what the specific rules are but I think the state considers her uninsurable if she is denied by 2 insurance companies. I need to find out exactly how that would follow her.

[mrsfru]

arghh....deleted b/c I forgot about the difference b/t applying for group thru work vs. private.....BTDT, too! GL OP!

[khaoskat]

Originally Posted by KatWrangler

No, I don't think thats right. The state will drop her because both Mom and Dad will have insurance. But no new insurance policy will cover her child because of pre-existing conditions.

Check your State's Requirements.

In Ohio, it is the child has to have insurance, regardless of the parents insurance status. If both DH and I have a policy, as long as the children are under 200% of the Federal Poverty level for our household size, then they are covered. If insurance is provided for the children, I believe they have to be at or below 150% to have both insurances available and to be used.

It is not that insurance is available to the family, if that were the case, it would deny everyone, because anyone can go purchase a policy.

Also, when your State Insurance coverage terminates you get a Certificate of Coverage. Pre-existing has an 18 month exclusion on it, if you did not have prior existing coverage at the time you get private, and you get a 1 for 1 credit (ie 1 month for 1 month, so if you had 12 months coverage, you get 12 months off the pre-existing exclusion; if you 18 months, then you get 18 months off the pre-existing exclusion).

[workjw]

Originally Posted by khaoskat

Check your State's Requirements.

In Ohio, it is the child has to have insurance, regardless of the parents insurance status. If both DH and I have a policy, as long as the children are under 200% of the Federal Poverty level for our household size, then they are covered. If insurance is provided for the children, I believe they have to be at or below 150% to have both insurances available and to be used.

It is not that insurance is available to the family, if that were the case, it would deny everyone, because anyone can go purchase a policy.

Also, when your State Insurance coverage terminates you get a Certificate of Coverage. Pre-existing has an 18 month exclusion on it, if you did not have prior existing coverage at the time you get private, and you get a 1 for 1 credit (ie 1 month for 1 month, so if you had 12 months coverage, you get 12 months off the pre-existing exclusion; if you 18 months, then you get 18 months off the pre-existing exclusion).

I guess it must differ from state to state, b/c it does not matter that dd has had coverage, our private insurance still requires the 18 month waiting period. There are no credits. But either way, we could never afford $18k a year for it, even if it kicked in after 6 months. The other 2 private companies we have talked to have already said they will not cover her period.

As for the availability, in our situation, if I get coverage, we automatically have a family plan and therefore she is technically covered at no additional cost (even though they won't cover anything pre-existing) which means she would be dropped b/c she has access to insurance.

[LynnS6]

It must vary from state to state.

A colleague of mine was just ranting about this today - her child has been deemed 'uninsurable' by the insurance industry (despite three appeals) because he was once on Risperdal. She and her husband have private insurance (she doesn't work full time so she doesn't get insurance from my university, and her husband is an ER doc and so doesn't have group insurance). The private insurance won't insure their son, but the state will.

Does the state have a solution for your 18 month waiting period?

OP: It's a pain but how much $ would it cost for you to pay out of pocket for the medical procedures you need?

[workjw]

As far as I know, there is no solution for the 18 mos, but I'm still waiting to see our caseworker. Last I talked to them (by phone) they didn't care about WHAT the insurance would cover, just whether or not she had it.

As for out of pocket, I don't really see how we could do it (unless maybe we hit the lottery! ). We might be ok for a while paying for her follow ups and testing, but we know she needs at least 2 more surgeries over the next couple of years, and maybe more depending on how those go. We've been really lucky at how well she's done the last year, but after her first year I'm honestly terrified of going without insurance for her.

If you don't mind my asking, has your friend had any problems from their son being deemed uninsurable (other than not getting private ins)? Do they think this will cause problems for him long term as well?

[AbbieB]

Just throwing another option out there for you...

We have decided to keep the $18,000 a year (using your figure as an example, ours was just slightly less) in our own pockets and pay cash.

DS has Down syndrome. We went through all of the testing and doctors visits the first year that everyone else does. Wasn't I surprised to learn that when you visit a cardiologist and tell them up front that you are self pay that the fees for all of the testing which normally costs in the 3K to 5K range cost me less than $300. Same story with everyone else. The pedi is not so generous but we do not do well baby exams so not so big a deal (even so $75 to $125 dollar office visit is less than $1000 month premium for family coverage.)

My family doc has the same deal. I was shocked to find that a test (I have regular blood work done due to a chronic condition to monitor hormone levels) that cost me $150 plus copays back when I was working cost me only $5.

Similar story with prescription drugs. Copay was $30 for 30 day supply. Self pay at Target I was paying $25 for a 30 day supply.

We went from looking at paying out $12,000 a year plus co pays with my preexisting condition being not covered to paying less than $2000 a year out of pocket.

Obviously I worry about ER visits or something very serious like a heart attack or cancer, and would like to have some kind of coverage for that, but for daily, routine stuff self pay has been much more economical.

Something to think about.

I forgot to mention we have a healthy savings account now to cover things like the surprise $2000 fee for sedation at the dentist, or minor emergencies. We just pay ourselves rather than the insurance company.

[workjw]

Thanks AbbieB, that is actually very encouraging information. When reading your post, I realized that LynnS6 was also talking about paying for the procedures I need and not the ones for dd.

I'll have to look into the cost of the procedures without any insurance. It's a surgery, but it's outpatient so it might be reasonable. I haven't had insurance since dd was tiny, but it hasn't been much of an issue until last month when I was having chest pains and needed an EKG. Luckily the EKG results were fine (and not horribly expensive) but it got me worried about what could happen.