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Old 02-16-2010, 02:39 PM   #1
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question about coverage

I have insurance through my husband company and they are changing providers effective march 1st. I have a mammogram appmt tomorrow for an annual check, I hope everything is ok as it's has been for the past 10 years in a row but if something was to happen (say they find something or whatever) do the new policy with the new provider will cover whatever comes from this? any input would be appreciated.

 
Old 02-16-2010, 05:20 PM   #2
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Re: question about coverage

It should. I assume you are concerned about any pre-existing conditions. As long as you go from one group policy directly to another and the original policy certifies to the new one that you were on it and had coverage (which I am sure the company is making sure they do), then you'd be covered. It's called "credible coverage."

 
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Old 02-16-2010, 07:08 PM   #3
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Re: question about coverage

thank you titchou for your answer

 
Old 02-16-2010, 10:17 PM   #4
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Re: question about coverage

Titchou is correct. The mere decision of your husband's employer to change insurance carriers does not create any pre-ex issues.

The only thing that can change is which doctors, hospitals, and providers are in-network. In fact if the changes take effect 3/1/10 ther may already be a website that employees can go to in order to see what doctors and providers are in-network.
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Last edited by SpineAZ; 02-16-2010 at 10:18 PM.

 
Old 02-17-2010, 10:25 AM   #5
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Re: question about coverage

You are right Spine, there is a website that we can check the list of doctors in and out of network, I have to register yet. By the way which part of Arizona are you in? I live in Mesa.

 
Old 02-17-2010, 10:49 AM   #6
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Re: question about coverage

I'm in North Central Phoenix (Moon Valley area). My aunt and uncle from Iowa spend 3-4 month per year in Mesa).. Since I was having back surgery 02/03 we knew we'd not see them after since I'm relatively home bound so we met them for lunch 02/01 at Mimi's Cafe off Alma School.
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Last edited by SpineAZ; 02-17-2010 at 10:53 AM.

 
Old 02-23-2010, 08:13 AM   #7
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Re: question about coverage

Oh I know Mimi's Cafe, my husband works at a company off of Alma School and Mc Kellips.
Well I got a call today that I have to go back to get my mammogram again, the radiologist wants to see more pictures, needles to say I'm terrified, and just now that we are changing carriers!!!! I just hope is nothing, had this happened a few years back and it was nothing. Wish me luck!

 
Old 02-23-2010, 01:50 PM   #8
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Re: question about coverage

New develpment. I need to go back to get extra images and an ultrasound, when I asked at the hospital what was going to be my copay they say my deductible, which is 1500, now my insurance is changing next monday and they say to do it with the old one because the new one may deny me because is a new provider, how can that be possible is the reason I'm having a new provider is because the employer decided to change it? I don't know what to do, I don't want to pay my deductible which is only going to be good for just that because of the fact that my coverage ends this end of the month? any advice please, I'm beginning to freak out here!!! They say they saw a nodule that looks not cancerous but they need to see they don't miss anything, that's why the ultrasound.

 
Old 02-23-2010, 02:32 PM   #9
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Re: question about coverage

Whatever you do BEFORE your insurance changes is processed under the current insurance. Whatever you do AFTER your insurance changes is processed under the new insurance. If you can cram it in this week, then yes, do it so you don't have to do it nder the new insurance which is when your deductible and out of pocket reverts back to zero.

Employers can choose any 'Plan Year'. So if your plan year runs 3/1 to 2/28 of each year then your insurance costs (deductible , out of pocket max, etc) starts over every 3/1. While the majority of employers run the plan year 1/1 - 12/31, having workedd in the industry, I've seen all kinds of plan years
For example:

If your insurance is to change 3/1/10 and your procedure/treatment is to take place 3/5/10, the insurance you have on 3/15 is the insurance that the claim will be processed under.

If your insurance is to change 3/1/10 and your procedure/treatment is to take place 2/28/10, the insurance you have as of 2/28 is the insurance that the claim will be processed under.


As for deductible:

Again, an example:

If your insurance is to change 3/1/10, but your mammogram is to occur 2/28/10, then the claim is processed under the insurance in effect on 2/28/10. If you have a $1500 deductible and have not met the deductibleat alll, then the provider has to figure out how much you owe them. So let's say your insurance is currently Aetna and under Aetna a mammogram costs $950. This is the contracted amount between Aetna and the provider that will be doing the treatment. So the radiology center contacts your current insurance and finds out that you have a $1500 deductible and have had $0 in claims toward the deductibe. Then the mammogram center can come back to you and say you must pay us the $950 as your deductible has not been met.

The first thing you should do is contact your current insurance company. Ask what your annual deductible is. And, of that amount, what portion has already been met. The radiology facility should be doing the same thing.

Once you change insurance companies you start your deductible all over again.

As another example which may be part of what is going on, let's say your current insurance is Aetna and that will end 2/28/10. Under Aetna you are allowed to go to Simpson Medical Imaging and Jones Medical Imaging for mammograms. But on 3/1/10 your insurance is changing to Cigna. And Cigna only contracts with Brown Medical Imaging and Cordes Medical Imaging. [Examples only, not indicative of true names of facilities, just used for example purposes only]

You have to go only to THE facilities that your insurance will cover. So if your additional images will be done 3/1 or after then you may need to go to a different imaging facility.


Here's what I had as my problem.

My deductible is $300 and my annual out of pocket is $1500. I aimed to get my back surgery done under 2009 insurance as I had already met both the deductible and the out of pocket maximum, but no such luck.

So in January I had a bunch of stuff scheduled: brace making (custom), EKG, cardiac stress test, and pre-op admission practices. ALL happening within the same week.

However, I had not yet met my $300 deductible. So EACH entity wanted the $300. I ended up paying it to the brace orthotic company as I saw them first. But they had a delay in processing the claim (I checked with my medical insurance site on line every day to see what was processed). So when I went to the hospital they also checked with my health insurance and saw the $300 had not been met. It was then I realized I had to pay the $300 again. THEN,whatever entity had the claim processed first would keep the $300. I've since called the brace place and they said they don't know what the delay was but it does appear they will have to refund me my $300. But they wait until claims have been processed. I had to prepay all facilities a total of $1500 based on deductible and estimated 10% co-pay for all services.

I hope this helps, let me know. If you can get in all the tests before 3/1 it will be under your current insurance and likely cost you less if you've met your deductible already.
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Old 02-23-2010, 05:57 PM   #10
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Re: question about coverage

Thank you for you input SpineAZ.
I understand what you say whatever I do before the 1st of march would be under my old insurance company and after that would be after the new one. My concern is that this lady at the hospital administration told me that it was going to be a pain in the b.... with the new insurance company, that they might not cover whatever procedure would come from this next mammo-ultrasound, I guess she's not aware of the certificate of creditable coverage?
Sadly I didn't meet my deductible this year but I call my actual insurance company and they told me that this follow-up test should be under a Diagnostic category and therefore I should not have to pay for anything. Also call BBBS, my new insurance from next monday and they told me if I get a letter of pre-existing conditions with the new paperwork not to panic and ask my old insurance to get me a letter with the certificate of creditable coverage and send it to BBBS.

 
Old 02-23-2010, 06:44 PM   #11
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Re: question about coverage

It is true that sometimes when an employer changes insurance companies they also sometimes change benefits. For example, they may decide to exclude breast reductions in the new plan with the new carrier. While under the former carrier that was an approved procedure (this is one I see commonly change when employers change carriers or simply seek to add some exclusions of treatment).

It's also possible that the lady you are speaking with deals with insurance companies daily and does find some to be more helpful and easier to deal with than others. My gut feeling is if what you are having done is a diagnostic procedure based on the outcome of a mammogram, then it will likely be covered by the new carrier. But the new carrier can ask to see the results of the mammogram first. Ideally the transition is smooth in cases like this for relatively "routine" tests and procedures.

My surgeon's medical assistant,when talking about scheduling my surgery, asked me "who is your health insurance?" and when I told her who it was she said "Oh, they are easy to deal with and this should go through smoothly".

So you could experience some bumps in the road along the way, and if so ask that your doctor contact the new insurance company to explain what is needed. The new insurance company has no real history on you and may wonder why a certain procedure or treatment is needed. It does make it tough on the hospitals/doctors/facilities as sometimes they have to take a step back and say "here's why this is needed". And it also can make it hard on you as you have to be your own LOUD advocate ;-)

If you have a contact number for the new insurance company you can call them and give them a general idea of "I'm in the middle of an evaluation for XYZ and have thus already had this test and that test,. What do I need to do to help make the transition from Old Ins Co to your company smooth?"

Also, if needed you can get your husband's HR/Benefits involved in any thing that isn't working well. Sometimes they can help smooth stuff over.

I will tell you that my employer decided to drop all insurance carriers except one (the one I was on) as of 1/1/10. It was a bumpy road as there was a problem with eligibility data being transmitted to the new carrier and I did hear of some people who had stuff schedued for the first two weeks in January had to make sure they were heard, had to get their doctors and HR/Benefits involved, etc. So be prepared to be your own advocate. If you've had any recent tests that are leading to more tests/procedures make sure you get a copy of the findings of every test/procedure done recently. So if the new carrrier wants informatino you can fax it over
ASAP. It's not the "credible coverage" that is the issue, it's the possibility of the new insurance carrier has different criteria for certain treatments (for example, they may require more tests before a knee replacement than the prior insurance company did).

Ideally it should all go smoothly, and unless your current medical issue is unique you should be able to move along with what you need. Let me know if you need any guidance along the way. (Isn't this fun? NOT)
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C5-C7 foraminotomy 08

 
Old 02-24-2010, 02:09 PM   #12
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Re: question about coverage

THank you for your information, it makes me feel better already
I called my insurance today and asked for the letter of creditable coverage to have it with me in case i needed, hope I don't, they also told me that this ultrasound and extra images they need now is a diagnostic procedure related to the preventive mammogram and it is covered, so pfufffff!!! big relief there!!

 
Old 02-26-2010, 01:05 PM   #13
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Re: question about coverage

Had my ultrasound and didn't have to pay for anything and everything went well,, so I won't have to deal with the insurance any time soon.

 
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