Topic: Individual PPO policy for 58 year old BC survivor?

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Posted on: May 21, 2011 07:03PM

Posted on: May 21, 2011 07:03PM

soccermom wrote:

Does anyone have or know of a good individual PPO health insurance policy for a 58 year old , 7 1/2 year BC survivor? The premium for my employee plan (Sharp HMO)  was going to go up 20%, then Sharp decided to drop us because I was the only one who wanted it. That leaves me with a choice of Kaiser ... And Kaiser...through my employer... Neither of which really work for me. So I am thinking about getting my own plan and opting out of employer coverage, or keeping the employer coverage but getting my own PPO plan for the things that I need that Kaiser wouldn't cover. Also want to look into HSA accounts.

On top of that I was just informed of Sharp being dropped and I have to decide by Weds. Ideas anyone? I live in the San Diego are in North county in CA.

A little background: Due my jerk ex H divorcing me in the middle of BC, I lost my excellent PPO health insurance and along with it access to all the doctors that kept me alive during my BC treatment. I would love to get back to a PPO because then I could get back to those drs. Even though they weren't covered by my new HMO insurance, I have kept going to my original breast surgeon, oncologist and state of the art mammography/MRI  center for my yearly checkups, and paying for it out of pocket even though I could NOT afford it- but I did not dare switch over to the HMO services for those critical yearly checkups.

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 21, 2011 07:06PM DiDel wrote:

I am self employed and have Aetna PPO. Knock on wood so far they have been great and my premiums are very reasonable. Under MD law they can not raise my rates based on my diagnosis...THANK GOD! I went through esurance.com and sort of designed my policy and then had a couple different providers to select from.


Good luck!

Diane

Dx 11/12/2009, IDC, Right, 2cm, Stage IIA, Grade 2, 0/8 nodes, ER+/PR+, HER2-, Surgery 12/22/2009 Mastectomy: Right Chemotherapy 3/16/2010 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Hormonal Therapy 8/14/2010 Dx 10/28/2015, IDC, Right, <1cm, Stage IA, Grade 1, ER+/PR+, HER2- Surgery 11/8/2015 Lumpectomy: Right Radiation Therapy 1/31/2016 3DCRT: Chest wall
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May 21, 2011 07:09PM Fearless_One wrote:

DO NOT DROP OUT OF YOUR EMPLOYER GROUP PLAN.    I cannot emphasize this enough.   The main difference between group coverage and individual is that the individual plan will drop you the minute you get sick.  Your group plan won't.   HMO, PPO, whichever.   Just so long as it's part of GROUP COVERAGE.

lump/chemo/rads/hyster-ooph/mastectomy/implants
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May 21, 2011 07:11PM diana50 wrote:

i have anthem blue cross; PPO, however, it is really expensive.  i had switched to individual prior to my initial diagnosis back in 2000 and at that time it was very reasonable.  (i am 59 yrs old)  my premiums have gradually gone up over the years; partly because of age and partly because of cancer. 

good luck*

Not today cancer. Nope. Dx 2/26/2002, IDC, 1cm, Stage IIIC, Grade 3, 10/12 nodes, ER+/PR+, HER2- Surgery 3/3/2002 Lumpectomy: Left; Lymph node removal: Left, Underarm/Axillary Chemotherapy 4/2/2002 Adriamycin (doxorubicin), Cytoxan (cyclophosphamide), Taxotere (docetaxel) Radiation Therapy 8/5/2002 Hormonal Therapy 8/9/2002 Arimidex (anastrozole) Dx 8/30/2012, IDC, 1cm, Stage IV, mets, ER+/PR+, HER2- Radiation Therapy 10/1/2012 Bone Chemotherapy 7/7/2014 Taxol (paclitaxel) Chemotherapy 5/6/2015 Ixempra (ixabepilone) Chemotherapy 10/4/2015 Gemzar (gemcitabine) Hormonal Therapy 4/12/2016 Faslodex (fulvestrant)
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May 21, 2011 07:17PM soccermom wrote:

WOW I didn't know that about getting dropped from an individual plan if you got sick, but I believe you- but isn't that against the law now with the new health care? Sooo confusing! 

Do you think it would work to maybe keep the employer-paid  group plan (Kaiser) and get a separate individual policy for the stuff they don't cover, assuming it wouldn't be too expensive? Anyone know about HSAs?

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 21, 2011 07:20PM soccermom wrote:

@diana50- so apparently they didn't drop you when you got sick? what is your premium?

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 21, 2011 07:21PM soccermom wrote:

@didel-- just curious did you have the plan before your diagnosis? if so then apparently they did NOT drop you when you got sick?

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 21, 2011 07:57PM soccermom wrote:

btw on top of everything else I am a single parent and low income- employed by non-profit law firm in a very low-paying position

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 21, 2011 11:45PM LisaAlissa wrote:

An individual policy will be much, much more expensive.  There are at least three reasons for that:

1.  As a member of the group, you get the benefit of a group rate (based on the underwriting for the entire group).  A non-profit law firm may be getting its insurance through a collective of similarly placed employers, which would spread the risk (for the insurer) even more, making the rates even lower.  As an individual, they're going to underwrite the risk they have on you, as an individual.  They may not be willing to underwrite an individual policy for you at all.  

2.  Many employers subsidize the underwritten rate for their employees as an employee benefit.  If you're paying anything less than $300 a month or so for an indivdual policy, they're probably subsidizing your insurance.  If you decline the insurance, they are unlikely to pay you the difference between the unsubsidized and the subsidized rate, you will simply be forgoing the difference.  If you have a so-called "cafeteria plan" where you get to choose which benefits you want to use your pre-tax dollars to pay for, you're still not paying "market" price for your coverage.

3.  Employer-sponsored group policies are paid for with employer dollars, instead of your "after-tax" income dollars.  So you will need to gross the price of the individual policy up by your tax rate to make a fair comparison with the unsubsidized group rate.

Finally, you may not be able to get an individually underwritten policy at all (I couldn't) so you would then have to look to either your state's high-risk pool, or (if your state has one) it's mandated cover group.  Qualification for the mandated cover group (at least in my state) usually is based on exhaustion of COBRA benefits, no group coverage & no lapse in coverage.

And by the way, my unsubsidized, employer sponsored policy (for me only) was $280/month.  My policy wasn't subsidized, but our clerical staff's was subsidized, so that they paid something between $25 and $50 for the same policy.  It's the loss of the employer subsidy that makes people think COBRA coverage (which is the same price as the unsubsidized policy + a 1% or 2% administative fee) is expensive.    

My mandated group cover policy (which is only oftered in a high-deductible policy) is $648/month.  That means my costs (for premium & deductible) are $13,000/year for insurance before the insurer pays anything.  

All that is another way of saying, please reconsider keeping your group policy! 

LisaAlissa 

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May 22, 2011 12:56AM soccermom wrote:

@LisaAlissa- very good points! Thank you so much. As far as the employer plans, now that my old plan is phased out I only have two choices: Kaiser Deductible HMO $30 ofc visit/ $1500 ded OR Kaiser $30. Copayment plan. First plan costs 484. per month, Second plan costs 571. per month LESS employer contribution of 428. per month.

So I guess on paper that isn't such a bad deal..and as you say, I may not even be able to get an individual policy...

but remember I have to go out of pocket if I want to see all my original cancer drs for my yearly checkups. Breast surgeon wants me to have MRI every other year and I have mammo/ultrasound , consult with breast surgeon and consult with onc once every year..none of which will be covered if I go to my original drs. I don't remember exactly what all that costs- I think without the MRI around 600. ish. Thats just for routine checkups-

IF God forbid there's a problem I'm really going to be torn having to use all new drs... 

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 22, 2011 02:02PM edwards750 wrote:

Agree with Fearlessone...stay with your employer group plan. One of the reasons they are more reasonable is more participants in the plan. We have BCBS which is pretty good. Our deductible is high - $5000 but we have already met that..no surprise with the medical bills - and now they are covering everything 100% which is a blessing. I have read posts from some ladies who have been taken to court because they cant pay the medical bills. You can negotiate the balance with a provider. Some ladies have done that and ended up paying half of the total charge. You need to pay on the bill for a few months but after that make them an offer. All they can do is say no. I have never really been sick until now so the medical charges have been a real eye opener. At least with BCBS if you use one of their providers they have a set amount they can charge and in my case it has been as much as 50% less than the original charge. Is it no surprise why a lot of people who need to go to the doctor, dont? Now with the price of food and gas rising almost daily, you arent left with any options...do you eat, drive to your job or go to the doctor? It really galls me when you schedule a surgical procedure and they are all over you the day before telling you what you have to pay to be admitted? One of my friends got such a call and they told her she had to pay $500 and she said sorry dont have it...they said okay $100...go figure...Keep us posted. diane

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