Topic: Any insurance experts here? Nervous about switching plans

Forum: Employment, Insurance, and Other Financial Issues — Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: Feb 18, 2019 12:14AM

Posted on: Feb 18, 2019 12:14AM

adymaria wrote:

Hello all,

I currently work for a consulting firm. Our largest client asked my boss to become an employee which he's agreed to and wants to take me with him. The problem is, I think this client (my potential new employer) has a self-funded health insurance plan. I've been researching it online and it sounds like self-funded plans do not offer the same protection/benefits ACA offers to cancer patients through normal insurance. Sounds like these self-funded plans only benefit employers and screw over an employee when they become seriously ill. I read that self-funded insurance companies have a stop plan and the stop plan can deny coverage leaving cancer patients paying their own medical claims. My current insurance company could not deny me coverage.

I am so sad after reading all the bad things i'm reading about self-funded plans. I was really looking forward to working with this client. This was such a great opportunity and now it may not happen (if what I read is true about self-funded plans). Even worse, I will end up losing my current job and my current insurance through my consulting firm since my boss is leaving to go to the client. My current insurance is a high deductible plan but at least it covered the over 100k in medical costs I have per year. For the first time since my diagnosis, I'm scared for my future.

If anyone is an insurance expert, can you tell me if what I'm reading about self-funded plans true? Am i not protected under the ACA and could be denied coverage? Should I be worried? I don't know who else to ask/talk to about this so I would very much appreciate responses/any advice.

Thank you,


Dx 5/15/2018, IDC, Right, 6cm+, Stage IV, metastasized to bone, Grade 3, ER+/PR+, HER2- Hormonal Therapy 6/5/2018 Zoladex (goserelin) Targeted Therapy 6/12/2018 Ibrance (palbociclib) Hormonal Therapy 6/30/2018 Femara (letrozole) Hormonal Therapy
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Feb 18, 2019 11:29AM vlnrph wrote:

I am not an expert but have sent complaints to my state insurance commissioner's office. Have you tried asking them about self-funded plans? I would also be concerned from what I've heard regarding their operation. In general, group plans do not resort to individual underwriting so would not know about your condition or be able to discriminate. Maybe a broker could offer insight. Keep in mind that they are basically salespeople.

However, since you have metastatic disease and probably have enough work credits, you may qualify for social security disability income. The Compassionate Allowance program will fast track your claim. (Mine was approved in ten days in early January). Then there is a five month waiting period. After receiving benefits for two years, Medicare starts. Cobra coverage is available until that point, via special arrangement.

Of course, under SSDI there are limits to earnings or you lose out. It sounds like retirement is not your preference right now but perhaps a free lance position or becoming an independent consultant yourself might be a possibility. Obtaining an affordable health care policy then becomes the big question. Good luck!

Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Feb 18, 2019 02:00PM Runrcrb wrote:

i am not an insurance expert. I work for a company that funds its own health insurance. Anthem administers it but my employer pays the bills. I have had no issues. I switched from my husband’s employer plan to my employer one day prior to my last chemo. My husband had a very expensive last year of life and we didn’t have insurance issues.

Most health insurance mandates through ACA apply based on size of the company not self insured.

When you get an offer, ask for details on the health insurance- there are plan documents they should be able to provide you.

Dx 6/27/2016, IDC, Right, 1cm, Stage IIB, Grade 1, 4/10 nodes, ER+/PR+, HER2- Dx 6/27/2016, ILC/IDC, Right, 2cm, Stage IIB, Grade 1, 4/10 nodes, ER+/PR+, HER2- Surgery 9/22/2016 Lymph node removal: Right; Mastectomy: Right; Reconstruction (right): Tissue expander placement Chemotherapy 10/31/2016 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Radiation Therapy 2/9/2017 Whole breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 4/23/2017 Aromasin (exemestane) Surgery 12/13/2017 Reconstruction (right): DIEP flap
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Feb 21, 2019 08:53PM pajim wrote:

Lots of companies self-fund their insurance. Usually they're big companies so they can spread the risk around. Or they're hospitals.

Before accepting or turning down an offer ask a lot of questions. As Runrcrb says, they should be able to provide you with the plan documents which say what is covered and what is not. By law they must disclose all the fine print. You'll need to wade through it but it would be worth the effort if it's a job you're interested in.

Dx 4/20/2008, IDC, Right, 4cm, Stage IIIA, Grade 2, 1/15 nodes, ER+/PR+, HER2- Dx 2/1/2013, IDC, Stage IV, metastasized to bone, mets, ER+/PR+, HER2- Hormonal Therapy 2/27/2013 Femara (letrozole) Hormonal Therapy 4/22/2013 Faslodex (fulvestrant) Targeted Therapy 2/25/2016 Ibrance (palbociclib) Chemotherapy 6/19/2017 Xeloda (capecitabine) Targeted Therapy 8/15/2018 Verzenio Chemotherapy 1/2/2019 Halaven (eribulin) Chemotherapy 12/30/2019 CMF
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Jan 23, 2020 01:12AM adymaria wrote:

Hi all,

Thank you all for your responses. I cant believe I started this thread nearly a year ago, but I still havent switched companies. I just got an offer letter/benefits summary this week. I have so many questions about the self-funded health plan but its impossible to get answers without telling my potential employer I have cancer. I will try to get the plan document, but in case that doesnt answer all my questions do you think it's a good idea to tell my potential employer about my cancer so I can freely ask questions about the plan? I've kept my diagnosis secret from everyone at work and kind of hate to share that info, but at the same time I want to make sure my procedure or my medication wont be denied if it's expensive (I've read a lot of horror stories) Have you shared your diagnosis before accepting a job offer?

Dx 5/15/2018, IDC, Right, 6cm+, Stage IV, metastasized to bone, Grade 3, ER+/PR+, HER2- Hormonal Therapy 6/5/2018 Zoladex (goserelin) Targeted Therapy 6/12/2018 Ibrance (palbociclib) Hormonal Therapy 6/30/2018 Femara (letrozole) Hormonal Therapy
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Apr 27, 2021 12:30PM sadwife wrote:

Adymaria, unless it is absolutely necessary, I wouldn't talk to my employer about cancer. You can probably say you have a concern about a major health issue. Most private employers nowadays are self-insured, so this is not a unique situation like someone pointed out. Another reason to not talk to the employer is that they probably won't know much about the nitty gritties of your situation. Lastly, if you do decide to talk to them, stick to the benefits coordinator in HR. And tell them what you are telling them is strictly confidential.

As a first step, I would try talking to the insurance plan directly about coverage - if you know exactly what plan you will be on, you may be able to talk to navigators there. Typically, the plan negotiates what is covered and what is not and not the employer. You can also ask the plan about all your concerns about employers capping what they will pay.

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Apr 27, 2021 01:40PM jhl wrote:


Can you share the state where you reside? Is it the state the new employer is in?

Dx 11/15/2019, IDC: Cribriform, Right, <1cm, Stage IA, Grade 2, 0/2 nodes, ER+/PR+, HER2-
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Apr 27, 2021 08:23PM alicebastable wrote:

I guess it depends on where you work, but I was very open with my workplace when I had cancer the first time (retired for the other ones). Everyone from the top down was super supportive and it never once came up at the next insurance sign-up time.

Ignore treatment info (below) which is a BCO glitch. Do not enter personal information on this site since they grossly mishandled a data breach. Surgery 7/11/2018 Lumpectomy; Lumpectomy (Left); Lymph node removal Surgery 8/8/2018 Radiation Therapy 10/29/2018 Whole breast: Breast, Lymph nodes
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Apr 27, 2021 09:40PM alwaysmec wrote:

I'm not certain about medical insurance, but about 15 years ago I worked for a pharmaceutical benefits management company. The self funded plans had a lot of access to the details of insurance as far as your treatment plan goes. I had one company who was quite small, but made tens of millions. They always knew exactly which drugs their employees were taking because they were the ones paying most of it out of pocket. I could imagine, other companies not being nice about paying for employee health expenses. I think a big problem with self funded also is that they had access to reports outlining what part of treatment cost so much and why, so they knew exactly which employees were costing them more. The employer I talked about above was great because they just ended up calling us all the time to say yes, go ahead and approve that treatment. But I don't think every employer would be like that.

Dx 4/2/2021, IDC, Left, 1cm, Stage IIA, Grade 2, ER-/PR-, HER2-
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Apr 29, 2021 12:14PM ashlyn525 wrote:

Who is the administrator for self funded plan? I am a health insurance agent. They have already offered you a position. It would be highly illegal for them to rescind your offer based on your health. Also with changes in healthcare. They cannot tell them exact medical issues but depending on the size of company it can be easy to figure out. Many extremely large companies have self funded plans. The stop loss just covers the employer if they have to pay out over a certain amount. I doubt you would ever see that. Hope this helps!

Surgery Cryotherapy (Left); Cryotherapy (Right); Lumpectomy (Left); Lumpectomy (Right); Lymph node removal (Left); Lymph node removal (Right); Mastectomy (Left); Mastectomy (Right); Prophylactic mastectomy (Left); Prophylactic mastectomy (Right); Reconstruction (Left): Aesthetic Flat Closure, Fat grafting, Nipple reconstruction, Nipple tattoo, Removal (Left), Tissue Expander; Reconstruction (Right): Aesthetic Flat Closure, Fat grafting, Nipple reconstruction, Nipple tattoo, Removal (Right), Tissue Expander

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