Medica Insurance question for people in US.

[Whisper]

Hi.

My husband has been offered a job in the US but we are concerned about how the medical system works. Right now, we are in Canada and everything is covered.

If we were to move to NY or NJ, then how would his medical coverage come into play? Would my 'condition' even though I have no diagnosis of anything specific be classed as a "pre-existing condition"?

Also, he has high blood pressure (controlled with meds) and was just diagnosed with Diabetes last year (controlled with diet and exercise).

Any info you could provide, would be greatly appreciated. If you need more info (I only have limited) feel free to ask.

Thanks,
Lorraine:)

[nikki79]

It all depends on the company he is working for and the contract they have with the insurance company. Some companies do not have the pre-existing exclusion in their plans and others do. Sometimes they won't cover a pre-existing illnes for a number of months or years and sometimes there isn't a waiting period at all. Usually (but not always) if you can prove you have had continual insurance coverage, the pre-existing exclusion clause does not apply. People seem to have better luck with coverage for PE illnesses if they are working for a very large company.

[Whisper]

It all depends on the company he is working for and the contract they have with the insurance company. Some companies do not have the pre-existing exclusion in their plans and others do. Sometimes they won't cover a pre-existing illnes for a number of months or years and sometimes there isn't a waiting period at all. Usually (but not always) if you can prove you have had continual insurance coverage, the pre-existing exclusion clause does not apply. People seem to have better luck with coverage for PE illnesses if they are working for a very large company.

Thank you for your information. I appreciate it. I don't know how I would find out what insurance company they have. I was sent a benefit package (via email) but no mention of insurance company there. Only the cost to us for certain medical procedures...(I have no idea how to interpret it).

Anyway, thanks for your reply.

Lorraine:)

[PattiLee]

Insurance is regulated by individual states, so check state regulations. Most states now have laws that prevent discrimination for pre-existing conditions. One state may require that employers provide OB insurance for everyone, others say that you can skip it for a woman in menopause or one who has had a hysterectomy.

Good news: Medical care here is a lot more readily available. It took me twenty minutes to get an appointment for an MRI after a doc decided that I might need one.

Most meds have deductible, as do doctor's visits. I spend eight dollars to see my doc, and 10 on a script. On the other hand, if I wake up on Monday morning with a medical issue, my doc is usually available before the day is over. A specialist may take a couple of days longer, but maybe not. Most policies even include eye glasses.

BTW: hospitals must treat anyone entering an emergency room, so it's a bit of a misnomer that people here can't get medical care. They can. You just have to sit in an emergency room for a few hours if you're not insured.

Your question is: do you have insurance? If you do, you probably don't need to worry about a thing.

[renee]

Assuming you can choose companies do NOT touch any HMO with a ten foot pole.

[BBS1951]

I second that. Turn down any HMO offer. Usually big companies have more than one choice. HMO will be the cheapest plan for you, but often the worst plan for a variety of reasons.

Try for a PPO plan, where most of the doctors and hospitals in that area of the state are a PPO provider (PPO Means preferred provider organiz). When the doc signs up or hospital signs up as a PPO provider, it means they will charge the patient only what thte insurance allows them to charge ("allowable"), which is cheaper than their usual fees. A great PPO plan will also limit your copay for visits to a smaller amount (insurance picks up rest), and small copay for drugs (Insurance picks up rest), and a low deductible.

Deductible means how much money you have to spend before the insurance starts to pick up the tab. "Catastrophic insurance" usually has a high deductible such as >$1500. SO you shell out the first 1500, and after that insurance picks up all or part of the fee (often 80%). Then, after you spend a total of $5000, many catastrophic plans then pick up 100% of the fee as long as you use "in network" providers and hospitals.

In Network means that the doc or hospital is on the PPO list.

If you use an out of network doc or hospital, often insurance will pay (after you meet your deductible), but often at a lower rate, such as only 60% of the allowable fee--then you are stuck with not only the other 40% of the fee, but also the difference between the allowable fee and the actual fee that the doc/hospital charges----- because, remember, if the doc is "out of network", he can charge his entire fee, not the "allowable" pre-set fee by the insurance.

Clear as mud? Why leave Canada?

[TexLady21]

[QUOTE=BBS1951;357638]I second that. Turn down any HMO offer. Usually big companies have more than one choice. HMO will be the cheapest plan for you, but often the worst plan for a variety of reasons.

I wouldn't necessarily do this. We've been with an HMO for over 5 years now. When we got on it I had already been diagnosed with MS. It has been an excellent plan IMO.

[Whisper]

WOW, wonderful helpful replies all! Thanks.

BBS, leaving Canada was not planned. A company from NY called my husband (he's known a few people there) and they want to hire him. It's a higher position than here and one that he could likely advance at (he's kinda 'stuck' here). More opportunity for him, and looking like more money. Plus our children are grown now.

We just want to make sure it will be the best move for us. Money is not everything and I actually hope my husband will retire completely in about 6-8 years. (he already retired from the Canadian Military 9 years ago).

Would anyone please mention a few names of insurance companies (if allowed). I do not know the names of insurance companies there. They sent a 'benefit' package to us via email but I don't understand the 'options'. It does say something about HMO but I have no idea if other insurance companies are listed.

My husband is quite a 'safety' person so he ALWAYS takes the best insurance even if it costs us a bit more. Anyway, thanks again for the help...and it IS very helpful.

Lorraine:)

[renee]

I'd cruise the net for insurance companies, compare their plans and patient reviews. Which state you choose to live in may make a difference in price, hassle-factor or quality of care.

A friend has Blue Cross of northwestern NY coverage but receives most medical care in northeastern NY.
Blue Cross of nw NY may be a different company from BC of ne NY....
Reimbursement schedule is lower. Messy.

If you are offered an HMO read the info very, very carefully. Anticipate what care you could ever possibly need and the ways the contract could deny you care, or choice of procedure options.
The same goes for all companies.

[Agent]

I'm licensed and have been focusing in on Health Insurance. While it is true that Insurance is regulated by individual State, there is a loose National group of the State's Commissioners called the NAIC, so they kinda set National policy.

One thing to look into is HIPAA laws for your rights. If you have had "Credible Coverage", your Pre-existing condition has to be covered in 12 months. This is not a Gray area. Your plan is either Credible or not.

You need to find out if HIPAA considers your Canadian Insurance "Credible" for the conversion. This applies to Individual and Small Group plans, mainly. True Group (over 100 employees) usually takes all comers and underwrites the entire group based on past Claim Experiences.

While 12 months seems unfair, before HIPAA, there was no such time frame that they had to cover you.

And then there's the fact that Individual policies may not take you, to begin with. My best policy has no riders, but MS is a DECLINE, so the point is MOOT. My Guaranteed Issue product will take me, but there is the 12 month HIPAA to deal with.

So I am stuck with a less than perfect Unicare Policy. Last year, a new neuro ordered a big set of MRI's for me. I told her "NO" unless it was covered 100%. I was told a few times by the Doc and the Hospital, it was covered 100%.

Well, it covered 100% of $250 for "Lab Work". :(

It was definitely an OOPS moment for me (Out-Of-Pocket SURPRISE!) and I'm supposed to know this stuff!

On another note, it is interesting to see how some companies are Underwriting these days. I find it quite clever that one company just looks at your Rx history. Genius.

[Whisper]

Is Aetna PPO or PPS considered an insurance company?
The company that wants to hire him says this:

"Comprehensive medical coverage through Aetna PPO, POS or choice of HMO".

I am assuming that Aetna is an insurance company. The PPO is what BBS was saying earlier...what is POS? Any ideas? Do any of you know if this is a decent company?

Thanks again.
Lorraine:)

[TexLady21]

Aetna is an insurance company. I know those that have used them down in here in Texas really love the company.

Here is their site. http://www.aetna.com/index.htm

[Whisper]

Aetna is an insurance company. I know those that have used them down in here in Texas really love the company.

Here is their site. http://www.aetna.com/index.htm

thank you so much.
Lorraine:)

[Frog42]

This website may give you a better idea of what you should choose: http://www.agencyinfo.net/iv/medical/types/hmo-ppo-pos.htm

We have the Aetna PPO plan and considering how often I see the neuro, it's been a very positive thing for me. Hope this helps!

[Whisper]

This website may give you a better idea of what you should choose: http://www.agencyinfo.net/iv/medical/types/hmo-ppo-pos.htm

We have the Aetna PPO plan and considering how often I see the neuro, it's been a very positive thing for me. Hope this helps!

Thanks Vicky.
Lorraine:)