Insurance Agent Forum

[al3]

I'm working with a small company to get them a group health plan (With CalChoice). I need to have 70% participation so it is vital we get the vast majority of the the employees. I got the following last night. I sent it to my GA for an answer but I thought one of you might know. (I've written a lot of small groups, but this has never come up before.)

3) One of our employees currently has an individual health plan that she is signed up for and has been on for a while. When she signed up, they denied her coverage for "preexisting" conditions for six month, which she just recently cleared. She is concerned that if she converts over and signs up for our group health plan, she will have to go through a whole new, extended "waiting period" for any "preexisting" conditions.

QUESTION: If an employee who currently has individual
Coverage, and has cleared the waiting period under her existing plan for a preexisting condition, signs up for the proposed compoany plan, will she be penalized (as compared to sticking with her current, individual plan) by having to go through a new waiting period before any "preexisting" condition will be included in her coverage?

I'm going to guess that the woman will have to wait six months on pre-ex... which might torpedo the group unless there is a way to get get her to join with double coverage. But why would she want to pay 2 premiums (company is only paying 55% of a low-cost option.) We really need her to make participation ratio. Maybe company could "bonus" her the premium for 6 months... but if it gets out the other are going to be pissed.

According to the CalChoice UW guidelines:

Pre-existing conditions are excluded unless continuously
Insured for six consecutive months. A pre-existing
Condition is an injury or sickness for which the covered
Person consulted with a doctor, took medication or
Received medical care or advice within six months before
The enrollment date. Full portability will be given to all
Original employees and dependents that are currently
Covered under an employer sponsored plan (whether the
Prior carrier’s plan or another employer sponsored plan).


With most (all?) carroers in CA, coming off of group and on to individual coverage will not cause a pre-ex problem (if done in X days of leaving group.) But the other way around... leaving IFP for group WILL cause a pre-ex period? Is that right? Looks to be. It will probably kill the deal unless someone here has some magic.

Any ideas?

Thanks.

[Dave020]

I don't work with CC or KPC but Anthem allows for pre-ex credit whether coming off of group, individual or state-sponsored. They also use date of hire, not date of enrollment on the plan (if there is a waiting period).

Generally, group to group is 180 gap or less with full lookback for creditable coverage. If individual is in the mix, that goes down to 63 days. State program also use the 180 day group model, not the individual 63-day model.

I can't imagine why CC would be different. That being said, because CC, KPC, HSA yadda yadda that W&B own are pooled plans, they may impose different rules than the carriers directly. Check with your RSM for CC.

I have one now that KPC wanted to quote (getting desperate) and I had already run it through KP direct (so would Anthem but it's an SP with no payroll). They can't quote the group because the spouse is on Medicare. KP will of course allow as valid waiver and enroll at 1 ee. Needless to say, KPC will NOT get any of my cases.

[al3]

Thanks Dave. I too would rather just offer Anthem or Shield, but I get a lot of small group.. (I specialize in law firms because I speak their language and I'm anal they way they are!) and there is always one partner (or spouse) who has KP, loves it, and won't give it up.

I forget the ratios' but it is difficult to offer KP with another carrier unless you have a larger employee population. (I've read the Anthem and Shield UW guidelines a million times and can never figure out what the specs are.)

Lawyers really want "choice." For some reason they love being able to choose carriers... and have KP as an option. And they are willing to pay the higher rates. (Choice says they are getting their pricing under control and will be in the 8 to 12% higher range and not the 15 to 20 they are now in some areas.)

One thing with Choice is that they "give away" a dental discount and a vision discount and a hearing discount thing. It helps in making the sale, but not critical.

The big thing I find with Choice is that you don't have to go through a GA... their direct people in San Jose are really good and very accessible. They also play nice with Word and Brown (obviously.)

Yeah, I know that Choice groups look like low-hanging fruit to other brokers who would come along and say "I can save you X percent." But my groups don't buy health insurance... they (for better or worse!) buy ME. They know I'm here 24/7 to answer a question or help with a new hire, etc. just like I'm doing today with one of the partners.

Also, I believe that 10 groups of 4 or 5 enrolled EEs is better than one group of 40 or 50 because if that large group bolts (or drops coverage) say good-night to the payment on your BMW! (Of course if you've been in this biz as long as Dave F., you have a whole fleet of BMWs!! I still drive my crappy 2004 Civic... zero to sixty in about two hours!)

I just got an email from the senior partner who says the gal with the pre-ex wants an HMO... and there is no pre-ex with KP on Choice. So all is well that ends well. I don't even have to drive (100 mi) to San Francisco to enroll it as W&B will do it for me. If you own a nice suit, have a college degree (they always ask for some reason) and can speak in a full sentence, selling group to small law offices (with help from a good GA)... is a nice way to supplement your IFP and life income.

[Dave020]

I understand. I have found that "pooled" plans sometimes tend to have more restrictions than the individual carriers themselves.

KP allows more flex than KPC. CC does not work at all for spousal groups as BS is in the mix and is too restrictive with them.

I have also found that Wolfpack has rules that are more strict than Delta or VSP outside of that pooled plan.

[ABC]

This is really a carrier question. The carriers I use in my state will give creditable coverage for an individual policy if its been in place long enough. If it has not been in place long enough my carriers will give credit for how long its been in place.

If your able to get credit then you should have no problems.

Small group is a pain but it adds up quick and for every 12 groups you write one of them might become a 20 lives.

[Dave020]

Actually, in these cases it does not go back to the carrier. These CalChoice and KPChoice plans are pooled plans run by the GA, not the carrier. They can set different rules in these circumstances.