Health Insurance companies hate them! 6 companies to lower medical bills
June 20, 2023 7:08 PM Subscribe
Please explain to me how I can get a policy with one of *these 6 health insurance providers* without going through my state's health connector system! Assume I am a loudmouth 12 year old with only basic computer skills. If I have to go through VT Health Connect, any tips?
I recently lost my health insurance :( Silver lining, I can now choose my new insurance to ensure that it will pay for me to see a specialist surgeon in another state. His office has told me that the following companies play nice with them: Blue Cross, Blue Shield, Blue Cross/Shield (combo), Signa, HealthNet, and Anthem. I don't care at all which of these I get, my #1 priority is to get my surgery covered, and after that I can change my insurance in the next selection period or whatever. I don't understand anything about how health insurance works, to be totally honest. My surgeon's office was very clear to avoid HMOs, whatever those are.
I have a consult scheduled with my surgeon for next Tuesday, June 27th. It would be cool to have this consult covered by my new insurance, but I can pay out of pocket if I have to. What's more important is getting insurance by mid-July so I have time to get all my ducks in a row to get pre-authorized for surgery in September.
Data Points:
- My surgery cost before insurance will be exorbitantly high, so whatever the policy's out-of-pocket maximum is, I will end up having to pay that this year. As such, low out-of-pocket maximum is a priority
- I live in VT, my surgeon is in California
- I am self-employed as an independent contractor, my business is also based in VT
- My wife has Harvard Pilgrim Health Care through her work. I could join her policy if I wanted, but this will likely not work with my surgeon's office. Is there a chance I would be forced to join her policy rather than get my own?
- I am good at being the right amount of pushy to get what I want by calling doctors, offices, etc. I'm a good self-advocate
- I am very bad at filling out online forms. (I have ADHD, often these systems don't work for me because of past name changes and other weirdness with verifying my identity)
- I have tried to go into a local hospital where they have assistants to walk you thru the process (this is how I got my health insurance previously) but this service seems to have been discontinued during COVID
Let me know if I can provide any additional info to help you help me! I honestly don't know what's relevant and what isn't. Any ideas or tips would be welcome.
I recently lost my health insurance :( Silver lining, I can now choose my new insurance to ensure that it will pay for me to see a specialist surgeon in another state. His office has told me that the following companies play nice with them: Blue Cross, Blue Shield, Blue Cross/Shield (combo), Signa, HealthNet, and Anthem. I don't care at all which of these I get, my #1 priority is to get my surgery covered, and after that I can change my insurance in the next selection period or whatever. I don't understand anything about how health insurance works, to be totally honest. My surgeon's office was very clear to avoid HMOs, whatever those are.
I have a consult scheduled with my surgeon for next Tuesday, June 27th. It would be cool to have this consult covered by my new insurance, but I can pay out of pocket if I have to. What's more important is getting insurance by mid-July so I have time to get all my ducks in a row to get pre-authorized for surgery in September.
Data Points:
- My surgery cost before insurance will be exorbitantly high, so whatever the policy's out-of-pocket maximum is, I will end up having to pay that this year. As such, low out-of-pocket maximum is a priority
- I live in VT, my surgeon is in California
- I am self-employed as an independent contractor, my business is also based in VT
- My wife has Harvard Pilgrim Health Care through her work. I could join her policy if I wanted, but this will likely not work with my surgeon's office. Is there a chance I would be forced to join her policy rather than get my own?
- I am good at being the right amount of pushy to get what I want by calling doctors, offices, etc. I'm a good self-advocate
- I am very bad at filling out online forms. (I have ADHD, often these systems don't work for me because of past name changes and other weirdness with verifying my identity)
- I have tried to go into a local hospital where they have assistants to walk you thru the process (this is how I got my health insurance previously) but this service seems to have been discontinued during COVID
Let me know if I can provide any additional info to help you help me! I honestly don't know what's relevant and what isn't. Any ideas or tips would be welcome.
It looks like there’s at least one BCBS plan through the Vermont exchange. Will your doctor take that specific plan? Ask the plan (this is where an assister comes in.)
posted by chesty_a_arthur at 4:41 AM on June 21, 2023 [1 favorite]
posted by chesty_a_arthur at 4:41 AM on June 21, 2023 [1 favorite]
1. Get help with the forms.
2. Is there a chance you will have to join your wife's insurance? Yes. No insurance company wants to take on a new customer who already has a surgury scheduled. I don't know exactly what means of preventing this you may run into. I think some scheme that comes down to much higher premiums is the most likely.
posted by SemiSalt at 5:06 AM on June 21, 2023
2. Is there a chance you will have to join your wife's insurance? Yes. No insurance company wants to take on a new customer who already has a surgury scheduled. I don't know exactly what means of preventing this you may run into. I think some scheme that comes down to much higher premiums is the most likely.
posted by SemiSalt at 5:06 AM on June 21, 2023
Health insurance in the US is so complex and profit-oriented, not patient-centered; it's no wonder you're at loose ends. You are highly unlikely to have an insurance policy by next Tuesday--unless you were to start a job tomorrow that came with first-day insurance coverage. You really could benefit from a trained local person to explain your options. Please do try the Assisters listed in another response.
In short, these are the main options for getting health insurance if you're self-employed:
- Your partner's/spouse's employer. Almost all employers that offer this will only allow you to join your partner's plan within a certain time window of a "qualifying life event" meaning a person in the employee's family has a change in their need for insurance, such as loss/change of your job, marriage, birth/adoption of a child, etc.
- You pay through the nose for an individual policy as a self-employed person. The people I know in these situations, typically sole proprietors and artists, all pay through the nose (eg $1800/month) and found their policies through insurance brokers.
- A state exchange that came about through the ACA/Obamacare. You may or may not qualify for this. Each state is different. And the Vermont Assisters will be able to help you. Be sure to tell them you intend to use a surgeon based in CA, and whether or not you intend to have the surgery in CA. The terms "in network" and "out of network" may be used a lot. Have them explain to you what that means in the case of the options you're presented.
Be aware that if you schedule a surgery date without knowing what your coverage will be, you may have to change your surgery date, surgeon, or surgery location. And there will be no way to know how much you will owe.
posted by ImproviseOrDie at 5:40 AM on June 21, 2023 [1 favorite]
In short, these are the main options for getting health insurance if you're self-employed:
- Your partner's/spouse's employer. Almost all employers that offer this will only allow you to join your partner's plan within a certain time window of a "qualifying life event" meaning a person in the employee's family has a change in their need for insurance, such as loss/change of your job, marriage, birth/adoption of a child, etc.
- You pay through the nose for an individual policy as a self-employed person. The people I know in these situations, typically sole proprietors and artists, all pay through the nose (eg $1800/month) and found their policies through insurance brokers.
- A state exchange that came about through the ACA/Obamacare. You may or may not qualify for this. Each state is different. And the Vermont Assisters will be able to help you. Be sure to tell them you intend to use a surgeon based in CA, and whether or not you intend to have the surgery in CA. The terms "in network" and "out of network" may be used a lot. Have them explain to you what that means in the case of the options you're presented.
Be aware that if you schedule a surgery date without knowing what your coverage will be, you may have to change your surgery date, surgeon, or surgery location. And there will be no way to know how much you will owe.
posted by ImproviseOrDie at 5:40 AM on June 21, 2023 [1 favorite]
Response by poster: Thanks for the answers so far everyone. I have tried to locate in-person assisters in my county but these are the programs I alluded to that never re-hired people to fill those roles after they left during COVID. I will try contacting more of the listings in my county, but the ones I have contacted don't currently offer the service, or only offer it to people seeking care at their facility. I will try to use the call-in service ASAP.
To clarify the situation, I am seeing a very boutique surgeon. I have had previous work done by a less experienced surgeon closer to me and he did a mediocre job which needs correcting. This is a serious quality of life priority for me, I and a group of other patients are considering legal action against our previous surgeon but in the meantime I would like to move on with my life. I have lot of money that I could hypothetically put towards this, potentially about 100k, but I would rather not go that far. 10-20k is a hard pill to swallow, but I would take that hit. I'm just trying to keep the bill as low as I can without sacrificing quality of care.
Thanks for your thoughtful consideration!
posted by Summers at 5:48 PM on June 21, 2023
To clarify the situation, I am seeing a very boutique surgeon. I have had previous work done by a less experienced surgeon closer to me and he did a mediocre job which needs correcting. This is a serious quality of life priority for me, I and a group of other patients are considering legal action against our previous surgeon but in the meantime I would like to move on with my life. I have lot of money that I could hypothetically put towards this, potentially about 100k, but I would rather not go that far. 10-20k is a hard pill to swallow, but I would take that hit. I'm just trying to keep the bill as low as I can without sacrificing quality of care.
Thanks for your thoughtful consideration!
posted by Summers at 5:48 PM on June 21, 2023
Best answer: I took a look a the Vermont Health Connect, which manages the affordable care act plans. As I read it, you only have a choice between HMO (only see doctors that work for them) and EPO (only see that doctors that are contracted with their extended network) Neither one is a PPO (preferred provider - cheaper price if you see a doctor in their network but will also cover out of network care). So, I don't think that will work.
So, I think your only option (outside of your wife's insurance) is to contact an insurance broker and see what they can find for you. The problem is that if you go for an individual plan, you need to make sure that it covers pre-existing conditions. (One of the benefits of ACA plans is that they have to cover preexisting conditions as long as you had proper insurance coverage prior to signing up.)
By the way, Blue Cross/Blue Shield is a network of state or smaller regional plans. So some plans will be just [regional name] Blue Cross, some just [name] Blue Shield and some are [name] Blue Cross/Blue Shield. Anthem is also a part of the BCBS.
The one that serves Vermont is called Blue Cross Blue Shield Vermont. So those four options collapse down to one.
You could try giving them a call (800) 247-2583 and asking them if they offer any PPO plans and if it covers pre-existing conditions. Tell them you are interested in a platinum plan (highest premium, best coverage including out of pocket max) If they have something, then ask them about the out of network coverage (the deductible, how much they pay after deductible is met, how much is out of pocket maximum). [Note that out of an excess of caution, I would not give my real information on this first call]
I don't know if cigna or HealthNet operate in Vermont - if you try to search of insurance on their website, they should ask for your zip code and tell if you if they have anything in your area as the first step.
posted by metahawk at 6:42 PM on June 21, 2023 [3 favorites]
So, I think your only option (outside of your wife's insurance) is to contact an insurance broker and see what they can find for you. The problem is that if you go for an individual plan, you need to make sure that it covers pre-existing conditions. (One of the benefits of ACA plans is that they have to cover preexisting conditions as long as you had proper insurance coverage prior to signing up.)
By the way, Blue Cross/Blue Shield is a network of state or smaller regional plans. So some plans will be just [regional name] Blue Cross, some just [name] Blue Shield and some are [name] Blue Cross/Blue Shield. Anthem is also a part of the BCBS.
The one that serves Vermont is called Blue Cross Blue Shield Vermont. So those four options collapse down to one.
You could try giving them a call (800) 247-2583 and asking them if they offer any PPO plans and if it covers pre-existing conditions. Tell them you are interested in a platinum plan (highest premium, best coverage including out of pocket max) If they have something, then ask them about the out of network coverage (the deductible, how much they pay after deductible is met, how much is out of pocket maximum). [Note that out of an excess of caution, I would not give my real information on this first call]
I don't know if cigna or HealthNet operate in Vermont - if you try to search of insurance on their website, they should ask for your zip code and tell if you if they have anything in your area as the first step.
posted by metahawk at 6:42 PM on June 21, 2023 [3 favorites]
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