reply to post by IAMTAT
Well only work on the group policy end, but I do have a lot of people that get transferred to me by accident who a usually quite upset about their
indi. policy. From my knowledge working for BCBS, there are MANY (I apologize for not having a number) of indi policies being cancelled because they
do not offer mental benefits, such as, individual and family counseling. Many indi policies are also being cancelled because they do not offer
prescription drug and maternity either. I have to say that I was very surprised that so many insurance companies did not have to offer these things,
now they have too. Is this a bad thing? Well I guess that is up to one's own personal opinion.
Group policies however, are a different story entirely are are quite safe from being forced cancelled.
I will give several examples since I do deal with these over 40 hrs a week.
First there are a couple different types of group policies, depending on the company. There is what is called ASO groups, or groups that are
self-insured or partially insured. These groups can chose to opt out of certain federal and state mandates (examples to follow shortly).
Then there are fully insured groups that do have to follow state and federal policies unless they have a grandfathered clause ( but that my only be a
few groups and I can not think of any because I have not personally dealt with any).
Now on to some examples (and these,just to remind you have group policy examples and how they work with different state and fed mandates). I guess
this would be a good time to point out that I work for BCBS PA ( that is all I am comfortable saying online, I prefer to to specify which one).
Now one of the (if not the most) popular federal mandates involving "obamacare" is the women's health mandate. This mandate give women the breast
pumps, birth control with no "cost-sharing". Now "no cost-sharing" means that the woman will not have to pay any copays, deductibles or
out-of-pockets for these. There are some stipulations, breast pumps require the woman to get a prescription written for her (after the baby is born)
and it must be obtained from an INN (In Network) durable medical equipment supplier. Birth control has to be on their plans formulary list ( the list
of drugs that is covered by your policy and there are only two) and the womens mandate formulary list. Almost all birth control and birth control
devices are covered. All this is only so for fully-insured companies (companies choose to be fully or self insured by the way).
On to ASO groups. Aso groups and there are many of them have chosen not to participate and breast pumps and birth control still have copays and can
apply to your deductible. Not to much more I can say other than the company has chosen to not fully cover these things.
It is like Mandate 81 (which is a PA mandate for adopted babies and newborns). By law all babies are allowed to have coverage on the moms (or dads)
policy for the first 31 days of life without being officially added. However, if an ASO group has decided to not fully follow this mandate then that
baby is subject to all the same deductible and out-of pockets as the parent. With fully insured groups the baby's hospital bills would be 100% paid
The examples I have given above are to demonstrate how mandates work with group policies and how the employer, depending on what type of coverage the
opt for ( and no group policies are being forced cancelled to my knowledge) work. I have seen a lot of people talking about Major medical polices that
are being cancelled (indi ones). I would just like to say that several group policies have this type of coverage including the PA state police and
will be keeping it (at least for current members). On a PERSONAL OPINION note, these policies are complete and utter garbage and no one should ever
buy one. They cover nothing. I constantly have people yelling at me because they call in and want to know if it covers flu shots, immunizations,
preventative drs visit check ups and no no no no.
Sorry about that, but back to group polices and mandates. I guess one of the points I am trying to make about group polices is that when you get upset
about having to pay for something that you think should be coverage for or you should not have to pay for at all, check to see what kind of insured
company you work for, it could explain alot.
One excellent example that I can give to anyone who has a PA based policy (if your companies headquarters is in PA you have a PA based policy) is a
guideline (not mandate) that was enacted this past September that can be beneficial for both women and men as well as any dependents, but NOT A SINGLE
ASO GROUP has opted in to follow:
For this I am going to have to break down copays first. Most people know that when you go to the the Dr for an office visit, whether a family doc or
specialist, you can and usually do get charged a co-pay. The co-pay is the agreed (contracted) amount that Dr will receive upfront for his or her
services that is usually non-refundable (unless an ER visit where you were admitted Inpatient or they over charged). For example, my copay for a
family doc visit is $25 for a specialist it is $30.
Now on to the new PA BCBS guideline for physical medicine. Say you injured your back and or neck and now have to go see a chiropractor or even just to
to a physical therapist. If you were to call in and get me on the either line this is what I would explain to you if your company is a fully-insured
I would explain to you that sometime when you go in for chiropractic services or physical therapy services, when the claim (bill) is sent to your
insurance company there may be charges for both spinal manipulations (chiropractic) and physical medicine. I would then check your benefits for your
spinal manipulation copay and limits (ie visit limitation) as well as your physical medicine copay (and limits).
So for ease I will use my copays. For each spinal and PM my copay is $30 each per visit. Before September if I was to go to the chiropractor he/she
performed both spinal manipulations and physical medicine they could bill me a total of $60 dollars a visit! Which is insane, but with the new
guideline I am only allowed to be charged one copay!, awesome, right? Well not if you work for an ASO group because not a single one has opted for
I am aware I have covered a lot of information regarding how group policies work when it comes to mandates and such. I wish I knew more about
individual policies, but if anyone want me to clarify something or explain something more I will do my best. I will apologize ahead of time if you do
not answer super quick. I have been sick with a bad respiratory cold.