STM and GAP Plans Discussion.

[kgmom219]

Thanks, it looks interesting but isn't offered in my states (Florida, Georgia)-they may be rolling it out gradually.

How do the rates stack up against STM in Texas?

Its less, but not THAT much less. In fact, I couldn't figure out why you would do this over an STM.

It does have a $5K maternity (with a 12 month waiting period, so at that point, just buy a damn ACA plan)

$200 wellness per year is a joke. It includes everything under the $200.

6 prescriptions per year, per tier. That's a nightmare to explain.

$60 Office Visits. Well, OK, but most UHC contracted rate at a doc is between 75-100, anyway.

You get 1 ER visit or Urgent care each year. Uhh...ok???

1 Xray or labwork at $100

I'd rather have access to the Choice Plus PPO discounts on an STM, with a 10K OOP.

I want insurance that is going to cover a catastrophic event. This isn't it.

 

[junkman]

Note that the UHC deductible is not included in the out of pocket on the STM. Adding supp acc with UHC is almost as expensive as simply buying a lower deductible.

But anyway, a $5,000 deductible 70/30 plan is a $10,000 OOP. A $10,000 deductible is a $15,000 OOP. I know 1 person that fell while unloading his truck and cracked his pelvis. The hospital couldn't do anything but let him stay 3 days until he could hobble out. Cost was only slightly more than $20,000. Consider the other exclusions of STM and add to the OOP and it likely only makes sense for old people that are healthy and trying to avoid the high premiums. There aren't enough dollars on the table for the young to make it worth the risk of STM.

 

[kgmom219]

Note that the UHC deductible is not included in the out of pocket on the STM. Adding supp acc with UHC is almost as expensive as simply buying a lower deductible.

But anyway, a $5,000 deductible 70/30 plan is a $10,000 OOP. A $10,000 deductible is a $15,000 OOP. I know 1 person that fell while unloading his truck and cracked his pelvis. The hospital couldn't do anything but let him stay 3 days until he could hobble out. Cost was only slightly more than $20,000. Consider the other exclusions of STM and add to the OOP and it likely only makes sense for old people that are healthy and trying to avoid the high premiums. There aren't enough dollars on the table for the young to make it worth the risk of STM.

I run all my STMs at $5K deductible and $10K OOP.

As far as the pelvic guy goes, great. How'd the PT go? Subsequent surgeries?

And since I'm sure he didnt pay the $20K, who did? The people WITH insurance. Just another reason Texas rates are so high...we've got a 20% uninsured rate.

A broken bone is NOT the issue. Its not even a catastrophic event, since people with insurance pay for all those who don't and the ERs are required to treat.

Its a catastrophic DIAGNOSIS.
Chemo is not an emergency.
A dark smudge on your MRI with all those headaches? Not an emergency.
A white mass on your mammogram? Sorry. Not an emergency.

Insurance isnt for runny noses and broken arms.

Insurance is if my baby needs chemo, I don't have to worry about the million its going to cost to keep him alive.

 

[FLM2]

I run all my STMs at $5K deductible and $10K OOP.

As far as the pelvic guy goes, great. How'd the PT go? Subsequent surgeries?

And since I'm sure he didnt pay the $20K, who did? The people WITH insurance. Just another reason Texas rates are so high...we've got a 20% uninsured rate.

A broken bone is NOT the issue. Its not even a catastrophic event, since people with insurance pay for all those who don't and the ERs are required to treat.

Its a catastrophic DIAGNOSIS.
Chemo is not an emergency.
A dark smudge on your MRI with all those headaches? Not an emergency.
A white mass on your mammogram? Sorry. Not an emergency.

Insurance isnt for runny noses and broken arms.

Insurance is if my baby needs chemo, I don't have to worry about the million its going to cost to keep him alive.

Every one of my STM policies is quoted with a $10K TrioMed AME/CI supplement so all of the accident/injury concerns are gone with my cases. I've always liked those policies and TrioMed is the successor to Assurant's Suite Solutions (GI, $10K max for each, about $53 for single, $79 for couple).

 

[junkman]

I run all my STMs at $5K deductible and $10K OOP.

As far as the pelvic guy goes, great. How'd the PT go? Subsequent surgeries?

And since I'm sure he didnt pay the $20K, who did? The people WITH insurance. Just another reason Texas rates are so high...we've got a 20% uninsured rate.

A broken bone is NOT the issue. Its not even a catastrophic event, since people with insurance pay for all those who don't and the ERs are required to treat.

Its a catastrophic DIAGNOSIS.
Chemo is not an emergency.
A dark smudge on your MRI with all those headaches? Not an emergency.
A white mass on your mammogram? Sorry. Not an emergency.

Insurance isnt for runny noses and broken arms.

Insurance is if my baby needs chemo, I don't have to worry about the million its going to cost to keep him alive.

The guy with the pelvis had and still has off-ex ACA coverage and paid whatever the premiums were at the time and the max out-of-pocket. There was no treatment in the hospital except x-rays and a couple of PT trips up and down 4 steps. He left as soon as he could walk out of the hospital. All except x-rays could have been done at home. He paid premiums, had insurance and the carrier sucked up everything over the stop loss. No one in this situation is sucking off the system unless you consider taking the max advantage of the insurance contract a form of sucking.

None of my individual clients consider insurance for runny noses and most chose the lowest total cost plans defined as premiums + expected claims available to them at time of enrollment. A few opted for a more expensive plan but all were shown the spectrum. Everyone at the end of the day makes their own decisions.

Many of my clients are only a few years before Medicare eligible and premiums this year became excessive even for those in the $100,000 to $200,000 income range. Additionally, Exchange carriers essentially split the state with Blue Cross taking the rural areas and Humana & Cigna splitting the metropolitan areas. The Humana & Cigna networks are barely acceptable only chosen because there are limited options. No carrier is paying any commission on new business. I sent all off-Ex clients to UHC which is really a self-funded plan with claims paid by Farm Bureau and administered by UHC - and, I understand that this contract can change mid-year if Farm Bureau's contract with UHC renews any time except 1/1/2018. FB was with BCBST for years with short excursions to other carries.

I received a notice from the Gubmt exclaiming how affordable coverage is because "most enrolled at an average of $75/month." We have changed who is being squeezed out of coverage from those with no money to those in the middle class without access to employer coverage.

Reality is, as my family is an example, that premiums are now high enough that the premium savings for enrolling in a crappy STM or underwritten non-ACA plan fits some people's situation. None of us have been in a hospital for years and are not likely to be there in 2017. Why do you think underwritten plans have lower premiums than GI plans - pre-ex limitations and the fact that someone healthy today is likely but not assured of good health tomorrow.

Is $20,000 in 1-year premiums worth it to me for a $5200 deductible, $6500 OOP? I can assure you it is not - especially when lesser premium options are available. How will I pay if one of us goes to the hospital? The same way I'd pay for a car - with a check AND I'm not looking forward to the increased liability of the lesser coverage.

I don't mind paying my share of the claims pool that is generated by health issues comparable to small group (which I had access to before ACA). I will not pay an exorbitant share of the claims that are driven only by adverse selection of the ACA pool. This year's renewal became exorbitant in my world. I estimate that at least 40% of this year's ACA renewal results from adverse selection. I base this on my small group data and also what underwritten rates are for comparable plans.

Houston, we have a problem. To be clear, the problem is adverse selection and unmitigated underlying procedure cost increase. I can't change either of those and will simply respond by choosing from available options.

Hopefully, I don't need Chemo or a car wreck or a bike wreck or, or, or but will deal with whatever too if/when it gets here.

 

[AllenChicago]

I'm by far NOT an expert in these things, but did you look at the Core Indemnity plans that UHC is rolling out? Would that work?

Just looked at the UHC Core Indemnity plans, KGMom.

Here's a link to the PDF Brochure: https://www.uhone.com/FileHandler.ashx?FileName=Brochure_Core_Access_1216.pdf

UHC must be relying on name recognition, because their "new" offering is pretty much the same thing that's been available from smaller insurers for many years..only UHC's is skimpiest I've seen with outpatient benefits. ($100 allowed for Outpatient tests.. LOL.)

 

[junkman]

I look at how many dollars net of commission and over rides are available to pay claims and have seen exactly 0 indemnity/hospital/surgical plans that make economic sense except in very narrow situations. They are normally sold by promoting the maximum benefit that "could" be received without noting that the benefit schedule has almost no relationship to what the actual charge is. They are not a viable possibility for a major med replacement. They are good for the agent - when sold in bulk at a group enrollment.

 

[AllenChicago]

I look at how many dollars net of commission and over rides are available to pay claims and have seen exactly 0 indemnity/hospital/surgical plans that make economic sense except in very narrow situations. They are normally sold by promoting the maximum benefit that "could" be received without noting that the benefit schedule has almost no relationship to what the actual charge is. They are not a viable possibility for a major med replacement. They are good for the agent - when sold in bulk at a group enrollment.

I sold scheduled benefit indemnity plan from Philadelphia American in 2011 that was too good to be true.

They went back 8 years...found that my client's physician noted that he had a liver issue from drinking, and denied his $20,000 hospital claim, because he didn't disclose "full" medical history.

We appealed. Didn't work, because some of their application questions ask, "Have you EVER...?". Some people don't remember everything that happened 5 years ago, let alone "ever" ago.

 

[junkman]

@Allen: Records not matching recollection has been a problem forever.

TN individual apps tend to go back forever. Doctors frequently minimize what they tell patients and might say "you have arthritis and can get a hip replacement if it begins to interfere with your normal routine. " The records read "severe arthritic joint deterioration. Probable joint replacement within the next 3-5 years".

Group apps only have a 5 yr look back which is much more reasonab. We are now back to the point where it pays to avoid a formal diagnosis if you know it isn't time to have work done. I know 1 person with an untreated hernia that isn't in the records. It will stay that way until time to let the Doc whittle on him.

It's a good idea to pull a copy of your own records before applying for anything.

 

[bluemarlin08]

@Allen: Records not matching recollection has been a problem forever.

TN individual apps tend to go back forever. Doctors frequently minimize what they tell patients and might say "you have arthritis and can get a hip replacement if it begins to interfere with your normal routine. " The records read "severe arthritic joint deterioration. Probable joint replacement within the next 3-5 years".

Group apps only have a 5 yr look back which is much more reasonab. We are now back to the point where it pays to avoid a formal diagnosis if you know it isn't time to have work done. I know 1 person with an untreated hernia that isn't in the records. It will stay that way until time to let the Doc whittle on him.

It's a good idea to pull a copy of your own records before applying for anything.

I encourage everyone to keep copies of all records