Coverage You Take Personally
Here’s a time to get nervous: You’ve got a health problem, and your group insurance is going to disappear. Maybe you were laid off or downsized. Or perhaps you decided to flee the corporate world and follow your dream to open that dress shop, become a ski instructor or lead tours to Nepal.
You’ve got to get a personal health insurance policy, but you are scared companies might turn you down with the dreaded phrase “preexisting condition.” To navigate the passage from the secure cocoon of group health through the winding river of an individual policy, you’ve got to remember two things: Get a “certificate of creditability” and remember the rule of 63.
The certificate is a statement from your former employer that you had health insurance. Armed with this document, you can approach any company that sells individual policies and the firm must sell you an individual policy. Your state of health doesn’t matter. It is your guaranteed right under the federal Health Insurance Portability and Accountability Act (HIPAA).
The HIPAA coverage is vital protection for anybody with a health condition that might jeopardize the chance to buy an individual policy.
The first step for people who leave a job where they have health insurance is to continue their coverage under the Consolidated Omnibus Budget and Reconciliation Act (COBRA). They can do this by paying the full worker’s and employer’s share of insurance, plus a 2% administrative allowance. COBRA is good for 18 months for a worker, and 36 months for an ex-spouse after a divorce.
A few months before the COBRA is due to run out, you should contact the insurer at your old firm and ask for your certificate of creditability so you can exercise your rights under the HIPAA. Asking early can help avoid bureaucratic problems. “I am encouraging my clients to ask for the certificate a couple of months ahead of time,” said Jacques Chambers, an insurance counselor with AIDS Project-Los Angeles.
Then start shopping around at insurance companies for your individual policy. When you call the insurer or the HMO, be sure you ask for the people who handle “HIPAA conversion.”
And make sure that no more than 63 days elapse between the end of your COBRA coverage and the start of your new insurance. If there is more than a 63-day break in coverage, you lose the guaranteed right to an individual policy, and the company can turn you down for medical reasons.
*
Question: I am a single, middle-aged independent contractor paying $169 a month for a Blue Cross PPO with a $2,250 deductible. Included in my benefits are prenatal, child care and pregnancy benefits I do not want or need. Yet I am forced to pay for them, indirectly of course. If I had a preexisting malady, that malady would have an exclusionary rider, would it not? Are there any policies offered, by quality providers, that do not force unwanted coverage on the insured?
Answer: “Maternity, well baby care and women’s health care are all standard benefits in any plan we have,” said a Blue Cross representative. The average member of a Blue Cross plan would be very upset “if we didn’t have those benefits,” he noted. “We try to offer as many things to as many people as possible.” Because maternity benefits are considered basic to virtually every health plan, you probably won’t be able to find a policy that excludes them.
*
Q: I have a friend, a woman who lives on a very small income. She turned 65, and her HMO has canceled her. She has no Social Security and has never been married. Where do you suggest she go to obtain hospital and medical insurance?
A: Someone who has not been in the Social Security system can buy into Medicare. The cost is $309 a month for Part A, which provides hospital coverage, and $43.80 monthly for Part B, which helps pay for doctor bills. Any 65-year-old who is a citizen or a legal U.S. resident for five years is eligible. Financial aid also is available for low-income people who cannot afford Medicare. She should contact her local welfare department to find out whether she is eligible for any of these programs: Qualified Medicare Beneficiaries, Specified Low Income Medicare Beneficiaries, Qualified Individuals, and Medi-Cal.
*
Q: I will be moving from California to New Jersey this month and don’t know what to do about insurance. As I will be giving up my job, I will not have any insurance until I find another one. Do you have any advice for me? I am single, 26 and have no children.
A: Under the COBRA law, if your former employer has operations in New Jersey and provides insurance there, it is obligated to offer you a chance to get that coverage. However, if the company doesn’t have any covered workers in New Jersey, you are on your own. Since you are young and single, and presumably in good health, you might get a good deal by purchasing a short-term individual policy. Get a high deductible; it keeps down the cost. Check with an insurance broker. You can keep the policy until you find a new job that, hopefully, offers health coverage.
*
Q: Why is the cost of insurance greater for Orange County residents as compared to other counties in the state? For example, Kaiser health care in Northern California is about $35 less per month. This practice seems discriminatory. Isn’t it time that health care costs be based on usage?
A: There are two different Permanente medical groups--the doctors who service Kaiser patients--in Northern and Southern California, with different fee schedules. And there are also variations in the cost of labor and operating an office in different parts of the state, says a Kaiser representative.
Federal COBRA law allows a divorced spouse of a worker with group health insurance to continue the coverage for as long as 36 months after the divorce. A reader wants to know:
*
Q: If during that three-year period I happen to remarry, would I still be entitled to continue my COBRA benefits?
A: Yes, you can continue the insurance from your ex-spouse’s company as long as you are not covered under another health plan. The key is your insurance status, not your marital state.
*
Q: Upon my return to work following a two-month leave due to a medical disability, my employer refused to restore me to my original job of inside sales. Instead, it placed me on the will call counter (same pay and benefits), saying it found it could do without me in inside sales. About one week later, an employee from another branch was transferred into my former job--in fact, he sits at my former desk.
The company’s position is that it placed me on a personal leave of absence . . . and it says that “there will be instances when positions cannot be held open due to business necessity.” I am claiming I was not on a personal leave of absence but, rather, on a qualified leave under the Family and Medical Leave Act.
Can they legally do this to me?
A: Federal and state laws provide guarantees of unpaid leave for workers who need time off because of a serious illness or to care for a family member with a serious illness. The Family and Medical Leave Act (FMLA) you mentioned covers firms with 50 or more workers within a 75-mile radius of the workplace and applies to workers who have been with the firm a year and worked 1,250 hours in the year before taking leave. The law says you are entitled to get the same job back, or a similar job when you return.
It sounds questionable that someone else was put in your job a week after you returned to work, says Doris Ng of Equal Rights Advocates, a public interest firm in San Francisco.
If the job is available, the first requirement of the law is to put you back in the job, she says.
Complaints can be filed with the U.S. Department of Labor or the California Department of Fair Employment and Housing. Equal Rights Advocates has an advice and counseling line, (800) 839-4372.
*
This column gets a new and expanded mission, starting next month. I will still be answering questions about health insurance, Medicare and Medi-Cal, and the panoply of benefits issues. But I will also take a closer look at other issues of interest to health care consumers: how to get the most for your medical dollar, and how to get the best services from your doctors, hospitals and insurers.
Send your questions, comments and suggestions to Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053. Or you can e-mail me at bob.rosenblatt@latimes.com.