Pre-existing Condition Insurance

Mountains1day · July 2011

I am considering this PCI Plan the Obama Care is calling a "transitioning" plan until 2014 when it supposedly ends and a new open market begins where no one can be denied for a pre-existing condition. Oh, but I'm afraid it may be too costly, too risky and not so easily defined as a "step in the right direction" as some are calling it. Not available in all states yet however, I'm in Florida and as of July 1, 2011, the requirements are as follows: 1. US citizen 2. Not eligible for medicare 3. A doctor's written documentation describing your pre-existing condition 4. Uninsured for at least 6 months. No longer need to provide proof of being denied coverage, so nice of them to spare us that monumental task. Now if they could eliminate the 6 months rule of having no insurance......perhaps more people would sign up if they could afford to fore go treatment for that long. Risky endeavor I may add for the people who are sick and can't afford that risk. After all, this is insurance specifically designed for sick people who can't get and/or afford insurance in the first place. But that's just the tip of the iceberg.......

What I'm finding out as I explore this option is starting to make me wonder why the republicans are opposing this so much. Sorry, I don't want to bring politics into this so I will focus just what I am learning thus far. Grant you, after reading the plan outline at www.pciplan.comI think I'll need a lawyer just to be clear on many things. Like all the drugs, services, supplies and procedures that would be needing pre-certifications and who exactly are these government representatives making these decisions to approve or disapprove you and based on what conditions? It's one thing to have a contractual plan that say these things are covered but completely another thing when the time comes to receive these things.......oh, sorry, that's not going to be approved. Based on what? FDA regulations? Age? Scary thought.

Then there's a concern I have about what drugs I know I will need for the next 2 years. The same drugs I've been taking since my breast cancer diagnosis. I am currently on my husband's group plan but we pay a whopping $1500 per month and a high deductible and co-pays. Don't know how much longer we can do this that's why I am considering this Obama Care Plan for myself only since I'm the one with the pre-existing condition and this Obama Care Plan is supposedly designed to help people like me, right?

Just not so fast........I found out today that the drug "ZOLADEX" would be considered a "speciality" drug (among many cancer drugs) and this plan would require the recipient (after precertification and deductible) to pay total out of pocket expenses ($5,500) before they pay anything. Mind you the Zoladex injection cost anywhere from $1,600 to $4,500 and being most cancer patients need them every 3 months according to standard protocol, this amounts to a heck of a lot of money.

Oh and here's the part I need legal counsel on................all the fines and penalties for not doing this or that. Is this what Obama Care means for the sick, poor and uninsured? Is this going to get worse in 2014? Is is more cost effective to go without health coverage all together and have your doctors, etc. bill you for a reduce rate instead on a as needed basis? I would love to hear from anyone who has this plan in place already and can speak of anything positive about it. Thanks so much.

peggy_j · July 2011

You asked: Is is more cost effective to go without health coverage all together and have your doctors, etc. bill you for a reduce rate instead on a as needed basis?

Do your docs charge a reduced rate? Looking at the bills, I think people w/o insurance get charged the super high "rack rate." Getting insurance lets you get the network negotiated rate, which can be a big savings.

I haven't looked into ObamaCare plans but in my opinion we should buy insurance (any kind, car, home etc) for the worst-case scenario because they could potentially bankrupt us. So given a choice, you should opt for a plan with the lowest max out of pocket expenses per year (even if the deductible and co-pay are higher for "good years"), and go to a doc that's in-network and/or "contracted" with the insurance company. (it's not enough for them to "take" the insurance, they have to agree that the insurance company's payment is sufficient) You need to protect yourself on the "upside risk" of medical charges.

Is there any expert you can talk to about your specific case? In CA I called our gov'ts department that deals with consumer health care insurance issues. The guy I talked to was surprisingly helpful and willing to answer frankly.

I agree that our insurance situation is horrible, esp. needing that 6 month window w/o insurance. I could rant and rave about our politicians but..that would be another thread...good luck. Our health insurance system sucks. I try to console myself that at least Obama is trying to move it in the right direction and some of the changes are better (like removing the life time max)

Medigal · July 2011

One thing I would like to add that some people may not think about. It is not enough to just call the doctor you want to see and ask them if they accept your insurance. I have found that many will just say they do but there is a catch to this. Unless you call your particular insurance company and verify that the doctor is "in network", you will have to pay the much higher "out of network" charges which are not nearly as cheap as the negotiated rates you get when you stick with in-network doctors. I never see any doctor or go to any facility unless I get it verified by "my" health insurance that they are truly "in-network". Those negotiated rates can save us a lot of money on what we end up having to pay for our cost.

peggy_j · July 2011

Yes yes, I agree with Medigal. You need to make sure your docs are "in network." My insurance company suggested I ask the doc if they are "contracted with" the insurance company.

Pre-existing Condition Insurance

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