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Question about lifetime caps/insurance

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I'm not sure exactly how this worked in the past. I am trying to think about how it might work future. Say a new healthcare bill was passed, to be effective Jan 1 2019. and a policy had a 1 million lifetime cap. Does that mean the amount towards the cap starts on Jan 1 2019, or would it also include the amount spent previously with this policy?

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I'm not sure exactly how this worked in the past. I am trying to think about how it might work future. Say a new healthcare bill was passed, to be effective Jan 1 2019. and a policy had a 1 million lifetime cap. Does that mean the amount towards the cap starts on Jan 1 2019, or would it also include the amount spent previously with this policy?

 

I'd guess it starts from the date of implementartion.  My friend had a healthcare with a particular lifetime cap when her twins were born premature.  Right about the time the surviving twin reached that cap, their employer changed health insurance and their care kept being provided under the terms of the new insurance policy.

Edited by vonfirmath
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I'm not sure exactly how this worked in the past. I am trying to think about how it might work future. Say a new healthcare bill was passed, to be effective Jan 1 2019. and a policy had a 1 million lifetime cap. Does that mean the amount towards the cap starts on Jan 1 2019, or would it also include the amount spent previously with this policy?

 

The insurance we had through 7/17/17 started listing amounts towards a lifetime maximum starting November 2016 (forum rules prevent me from commenting further on the politics of that). I double-checked old EoB's and nope, nothing was listed prior to the election.

 

The most recent EoB I got states:

 

"You've paid a total of $100,386.36 toward your Unlimited all medical benefits individual lifetime maximum."

 

So right now they're not placing a cap, but they know exactly how much youngest DD has used since whatever date they started keeping track. I know that $100k doesn't cover the full amount for 2016 because that total was $182k (most of that was her cochlear implant, which cost $125k just for the operation and device).

 

I don't know whether our new insurance will start keeping track nor whether the $100k already used only counts towards that policy or ANY policy she might have in the future with Cigna.

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The insurance we had through 7/17/17 started listing amounts towards a lifetime maximum starting November 2016 (forum rules prevent me from commenting further on the politics of that). I double-checked old EoB's and nope, nothing was listed prior to the election.

 

The most recent EoB I got states:

 

 

So right now they're not placing a cap, but they know exactly how much youngest DD has used since whatever date they started keeping track. I know that $100k doesn't cover the full amount for 2016 because that total was $182k (most of that was her cochlear implant, which cost $125k just for the operation and device).

 

I don't know whether our new insurance will start keeping track nor whether the $100k already used only counts towards that policy or ANY policy she might have in the future with Cigna.

 

Hmm, that seems a little stressful. As if they could just replace the 'unlimited ' with whatever number they've chosen.

I hate all of these unknowns. I feel like I need to start working on a Plan A, Plan B, etc just in case.. 

 

So potentially some people could all of a sudden have no more health coverage even though they have a policy?!

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So potentially some people could all of a sudden have no more health coverage even though they have a policy?!

 

And be virtually uninsurable.  

 

This is the way it used to be before the ACA.

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And be virtually uninsurable.

 

This is the way it used to be before the ACA.

Yes. Not even "virtually " but actually.

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 So potentially some people could all of a sudden have no more health coverage even though they have a policy?!

 

She's got Medicaid as secondary due to her disabilities so if the primary were to stop paying due to a lifetime cap, then it would be the taxpayers on the hook for her future bills.

 

But for those who recover from their illnesses after exhausting a lifetime cap, they'd be S.O.L.

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Yes. Not even "virtually " but actually.

 

I only said virtually because if you had a zillion dollars to spend, it was probably possible to buy a policy.

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She's got Medicaid as secondary due to her disabilities so if the primary were to stop paying due to a lifetime cap, then it would be the taxpayers on the hook for her future bills.

 

But for those who recover from their illnesses after exhausting a lifetime cap, they'd be S.O.L.

 

Also those who don't recover but continue living.

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Could the person who had already hit the lifetime cap get insurance from another policy? (If they were lucky enough to find another employer who offered a different insurance provider?)

 

Or if it was a child, and the parents had a choice of insurance plans though work, could the child be covered if the parent chose another one of the plans?

 

Ugh.

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Could the person who had already hit the lifetime cap get insurance from another policy? (If they were lucky enough to find another employer who offered a different insurance provider?)

 

Or if it was a child, and the parents had a choice of insurance plans though work, could the child be covered if the parent chose another one of the plans?

 

Ugh.

 

The thing is, insurance policies are not designed to benefit the insured, they're designed to benefit the insurance company.  On average, the insured will *always* lose.

Edited by EKS
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Could the person who had already hit the lifetime cap get insurance from another policy? (If they were lucky enough to find another employer who offered a different insurance provider?)

 

Or if it was a child, and the parents had a choice of insurance plans though work, could the child be covered if the parent chose another one of the plans?

 

Ugh.

Then you get into pre-existing conditions, which is one of the thing required to be covered under ACA, but that requirement may be taken away.

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Also those who don't recover but continue living.

 

But if they are disabled, they'd qualify for Medicaid like my daughter does. It's the people who get better so they don't qualify for Medicaid but still need normal healthcare treatment.

 

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This is a situation faced by an acquaintance of mine. One of her children had leukemia at the age of 3. She was covered under the father's insurance. He could not change employers because if he changed employers, she would have no insurance due to cancer being a pre-existing condition.

 

Then leukemia came back several years later. She was still covered under the same insurance, but was approaching the lifetime cap.

 

The leukemia came back again two years later, but this time we had the ACA, so the lifetime cap was lifted and she was able to get treatment again. Since insurers had to cover you despite pre-existing conditions, her father was able to change employers, which he had not been able to do before.

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But if they are disabled, they'd qualify for Medicaid like my daughter does. It's the people who get better so they don't qualify for Medicaid but still need normal healthcare treatment.

 

 

Not all people with disabilities qualify for Medicaid. It is based on the severity of the disability.

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Not all people with disabilities qualify for Medicaid. It is based on the severity of the disability.

 

 

and if the disability is mental health related lifetime caps run out quick on limited services and qualifying as "disabled" is quite difficult. 

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And not all states have Medicaid expansion where disabled children are covered.  Actually, last time I looked, the majority of states do not help with disabled children.  Families will purposely make sure they live in poverty so that their child can get medical care.  I've heard too many horror stories that make our country look very cruel and heartless.  

 

My 18 year old is probably close to maximum supposed allowances at this point.  He'll need lifelong care.  If we don't do it, someone will have to regardless of lifetime allowances.  It reminds me when the governor of MN started restricting the number of group homes allowed in the states.  It made no sense.  What were all those people who really need support supposed to do?  

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This is a situation faced by an acquaintance of mine. One of her children had leukemia at the age of 3. She was covered under the father's insurance. He could not change employers because if he changed employers, she would have no insurance due to cancer being a pre-existing condition.

 

Then leukemia came back several years later. She was still covered under the same insurance, but was approaching the lifetime cap.

 

The leukemia came back again two years later, but this time we had the ACA, so the lifetime cap was lifted and she was able to get treatment again. Since insurers had to cover you despite pre-existing conditions, her father was able to change employers, which he had not been able to do before.

 

This doesn't make sense.  Bill Clinton's presidency established health insurance portability, so as long as there was no gap in coverage of more than a certain number of days, a pre-existing condition did not exist.  That was well over 20 years ago.  Also most employer health plans at the time were written so that they covered pre-existing conditions, or they would after a certain number of days - possibly one year.  It's been a while since I worked for insurance companies (they hire nurses for claims stuff), but it was before the ACA & I'm pretty certain that I'm correct.

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Thankfully the current one crashed in the Senate: http://www.politico.com/story/2017/07/27/obamacare-repeal-republicans-status-241025

 

Yes, we remain concerned.

 

Our insurance no longer lists the total, but we've had years where if $1M was the limit, DH would be uninsured. This year could be one of those.

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And not all states have Medicaid expansion where disabled children are covered.  Actually, last time I looked, the majority of states do not help with disabled children.  

 

In 40 states plus DC those who qualify as disabled under SSI criteria are "categorically eligible" for Medicaid. The states that do not are a mix of "blue" and "red" states: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia. (Source is the SSA)

 

My state did expand Medicaid but that expansion does not affect my disabled child's eligibility since it's a different funding pot. It's why she is allowed to keep her Medicaid as secondary to employer-based coverage while income-eligible folks cannot.

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In 40 states plus DC those who qualify as disabled under SSI criteria are "categorically eligible" for Medicaid. The states that do not are a mix of "blue" and "red" states: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia. (Source is the SSA)

 

My state did expand Medicaid but that expansion does not affect my disabled child's eligibility since it's a different funding pot. It's why she is allowed to keep her Medicaid as secondary to employer-based coverage while income-eligible folks cannot.

 

Yes, but there are a lot of people who are disabled or living with lifelong conditions who don't qualify for SSI or who spend years getting on it.  Also, cutting back on/curtailing SSI is one of the goals of the present administration.  

 

My father has MS, of the relapsing remitting variety.  He worked until there was a massive layoff in his company when he was 60ish.  He spent nearly 2 years looking for work and even in a "worker retraining" program but his short term memory was not one where he could retrain and his age (and age discrimination) made it very hard to get considered for any jobs.  The only job he got hired for was part time and no benefits.  In the end, he took his early SS retirement at 62.  First, his unemployment benefits and then his paltry reduced SS amount (you get less if you opt to start at 62) were too much income to get Medicaid for adults. We are talking $1100 a month was too much income. He went uninsured from the time his employer benefits ran out until Medicare kicked in at 65.  

 

These were not uncommon gaps before Medicaid expansion.  

 

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In 40 states plus DC those who qualify as disabled under SSI criteria are "categorically eligible" for Medicaid. The states that do not are a mix of "blue" and "red" states: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia. (Source is the SSA)

 

My state did expand Medicaid but that expansion does not affect my disabled child's eligibility since it's a different funding pot. It's why she is allowed to keep her Medicaid as secondary to employer-based coverage while income-eligible folks cannot.

 

I have a child that is obviously disabled.  You spend 10 seconds with him and you know he's disabled.  When dh and I were thinking of moving to a different state to get out of the arctic blast zone, we checked out Tennessee, Illinois, and Texas.  All of those states did not have services available to him.  They had huge waiting lists that ds would have never been able to get place on.  Minnesota did have Medicaid services but it was county dependent upon how extensive they were.  We had to pay a parental fee based on income to access the services, but considering they did do a cost breakdown at the end to make sure you weren't paying more into the system than getting out of the system.  

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This doesn't make sense.  Bill Clinton's presidency established health insurance portability, so as long as there was no gap in coverage of more than a certain number of days, a pre-existing condition did not exist.  That was well over 20 years ago.  Also most employer health plans at the time were written so that they covered pre-existing conditions, or they would after a certain number of days - possibly one year.  It's been a while since I worked for insurance companies (they hire nurses for claims stuff), but it was before the ACA & I'm pretty certain that I'm correct.

 

Sometimes it depends on how long you have to work there before coverage begins. We're fortunate that we've always had coverage start on day one. Where my nephew works, it doesn't start until after 90 days. Due to ACA, pre-existing is covered there. But before ACA, when he started new jobs, it was an issue. In his industry, 90 days is the norm. It's still an issue that he has to deal with not having insurance for his family for 90 days.

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In 40 states plus DC those who qualify as disabled under SSI criteria are "categorically eligible" for Medicaid. The states that do not are a mix of "blue" and "red" states: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia. (Source is the SSA)

 

My state did expand Medicaid but that expansion does not affect my disabled child's eligibility since it's a different funding pot. It's why she is allowed to keep her Medicaid as secondary to employer-based coverage while income-eligible folks cannot.

 

Even when "categorically eligible", it doesn't automatically mean they get Medicaid. Some states have waiting lists for children that are eligible.

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This doesn't make sense.  Bill Clinton's presidency established health insurance portability, so as long as there was no gap in coverage of more than a certain number of days, a pre-existing condition did not exist.  That was well over 20 years ago.  Also most employer health plans at the time were written so that they covered pre-existing conditions, or they would after a certain number of days - possibly one year.  It's been a while since I worked for insurance companies (they hire nurses for claims stuff), but it was before the ACA & I'm pretty certain that I'm correct.

 

 

We bumped into a version of this.... Pre-existing conditions were covered only if there had been no gap in coverage. Lots of employers don't start insurance until after a trial period (90 days, 180 days). You had to be able to pay for COBRA during the interim gap and prove COBRA coverage....usually through some type of letter of denial/proffer of proof process there is a paperwork delay causing you to have to pay for another month or two of COBRA while the appeal happens.  For people who are single income households on a limited salary, it's hard if you were already kind of scraping by on budget constraints.

 

This is still an issue for a lot of families (when benefits start) because in dealing with chronic conditions, doctor visits, prescriptions and labs still need to happen...and COBRA is still crazy expensive. 

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I checked---our previous insurance company and our current one still log lifetime limits if I search under "total amounts paid" and select the appropriate time frame.  Let that sink in....the data is there and could be used against you depending on how a new law is crafted.

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I have a child that is obviously disabled.  You spend 10 seconds with him and you know he's disabled.  When dh and I were thinking of moving to a different state to get out of the arctic blast zone, we checked out Tennessee, Illinois, and Texas.  All of those states did not have services available to him.  They had huge waiting lists that ds would have never been able to get place on.  Minnesota did have Medicaid services but it was county dependent upon how extensive they were.  We had to pay a parental fee based on income to access the services, but considering they did do a cost breakdown at the end to make sure you weren't paying more into the system than getting out of the system.  

 

My daughter was put on the waiting list for the Medicaid waiver program for medically dependent children when she was three months old. We're still waiting. She's almost 9. We're in Texas.

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This is still an issue for a lot of families (when benefits start) because in dealing with chronic conditions, doctor visits, prescriptions and labs still need to happen...and COBRA is still crazy expensive. 

 

Tell me about it. We needed to pay for 1 month of COBRA due to when my DH's previous employer cut off benefits and when the new job's benefits kicked in. It's $1930/month. Not sure what Obamacare would've been for us but on the COBRA policy we had met the deductible and almost met the OOP max (only had $677 left) whereas with a new Obamacare plan we would've had to start all over again with the deductible. So I doubt the savings would've been worth it in our case.

 

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Sometimes it depends on how long you have to work there before coverage begins. We're fortunate that we've always had coverage start on day one. Where my nephew works, it doesn't start until after 90 days. Due to ACA, pre-existing is covered there. But before ACA, when he started new jobs, it was an issue. In his industry, 90 days is the norm. It's still an issue that he has to deal with not having insurance for his family for 90 days.

 

 

We bumped into a version of this.... Pre-existing conditions were covered only if there had been no gap in coverage. Lots of employers don't start insurance until after a trial period (90 days, 180 days). You had to be able to pay for COBRA during the interim gap and prove COBRA coverage....usually through some type of letter of denial/proffer of proof process there is a paperwork delay causing you to have to pay for another month or two of COBRA while the appeal happens.  For people who are single income households on a limited salary, it's hard if you were already kind of scraping by on budget constraints.

 

This is still an issue for a lot of families (when benefits start) because in dealing with chronic conditions, doctor visits, prescriptions and labs still need to happen...and COBRA is still crazy expensive. 

 

 

Yes, but that is why you were issued a Certificate of Credible Coverage when your policy lapsed, and that is why there were short term health policies available (that were cheap) and existed solely to prevent a gap in coverage. 

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But if they are disabled, they'd qualify for Medicaid like my daughter does. It's the people who get better so they don't qualify for Medicaid but still need normal healthcare treatment.

 

This is a huge and horrible gap. I know several people who fall into this hole. 

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My daughter was put on the waiting list for the Medicaid waiver program for medically dependent children when she was three months old. We're still waiting. She's almost 9. We're in Texas.

Beyond unacceptable! Just absolutely shameful that a developed nation allows this.

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Yes, but there are a lot of people who are disabled or living with lifelong conditions who don't qualify for SSI or who spend years getting on it.  Also, cutting back on/curtailing SSI is one of the goals of the present administration.  

 

My father has MS, of the relapsing remitting variety.  He worked until there was a massive layoff in his company when he was 60ish.  He spent nearly 2 years looking for work and even in a "worker retraining" program but his short term memory was not one where he could retrain and his age (and age discrimination) made it very hard to get considered for any jobs.  The only job he got hired for was part time and no benefits.  In the end, he took his early SS retirement at 62.  First, his unemployment benefits and then his paltry reduced SS amount (you get less if you opt to start at 62) were too much income to get Medicaid for adults. We are talking $1100 a month was too much income. He went uninsured from the time his employer benefits ran out until Medicare kicked in at 65.  

 

These were not uncommon gaps before Medicaid expansion.  

 

Very true. It is amazing to me how some people can get SSI so easily, and others who are in terrible shape and so obviously qualified can wait years to get it. Given the cost of healthcare, it is appalling at how low the income bar is set before "qualifying". Grrrr.....

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Yes, but that is why you were issued a Certificate of Credible Coverage when your policy lapsed, and that is why there were short term health policies available (that were cheap) and existed solely to prevent a gap in coverage. 

 

The Certificate of Credible Coverage only covers a short period of time. The gap  has to be less than 60 days. Cobra has always been expensive, not always sustainable for a family if they need it for 3 months. The nephew that I mentioned did do Cobra once, putting it on his credit card, as his dd was having major issues at the time, but most of the time, it's not an option. And in his job, it is normal to change jobs about every 18-24 months. Mostly because he works for contractors, but is not technically a contractor himself, so he still gets benefits.

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Another problem with COBRA is that it only applies to companies of a certain size. We got stuck having no choice but to go on an Obamacare plan briefly in 2014 because the previous employer was small enough to escape the requirement to offer COBRA coverage.

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My daughter was put on the waiting list for the Medicaid waiver program for medically dependent children when she was three months old. We're still waiting. She's almost 9. We're in Texas.

If it's any consolation, when they turn 18 in Texas, the rules seem to change. When we considered moving there, we thought if we could make it 2 years (ds was 16), we would be ok. We thought about moving to Illinois to be near family. Even with a very healthy salary, between the outrageous taxes, the extra housing costs, and the extra expenses that ds has, we would be close to living paycheck to paycheck. It really stunk to realize that.

 

 

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Another problem with COBRA is that it only applies to companies of a certain size. We got stuck having no choice but to go on an Obamacare plan briefly in 2014 because the previous employer was small enough to escape the requirement to offer COBRA coverage.

 

At least you had that option. You could have had nothing.

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If it's any consolation, when they turn 18 in Texas, the rules seem to change. When we considered moving there, we thought if we could make it 2 years (ds was 16), we would be ok. We thought about moving to Illinois to be near family. Even with a very healthy salary, between the outrageous taxes, the extra housing costs, and the extra expenses that ds has, we would be close to living paycheck to paycheck. It really stunk to realize that.

 

 

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I think that's in all states. It's because at 18, they are an adult. Different rules.

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At least you had that option. You could have had nothing.

 

Our option pre-Obamacare would've been to put the 4 of us in the family who are healthy on a privately purchased policy or maybe join a Healthshare Ministry and had our SN child be on Medicaid. But really all companies that have an employee who is not a partner/owner of the firm should be required to offer COBRA (ETA: if they offer employer-sponsored health insurance as this company did).

Edited by Crimson Wife

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Our option pre-Obamacare would've been to put the 4 of us in the family who are healthy on a privately purchased policy or maybe join a Healthshare Ministry and had our SN child be on Medicaid. But really all companies that have an employee who is not a partner/owner of the firm should be required to offer COBRA (ETA: if they offer employer-sponsored health insurance as this company did).

Not an option in my state. My sn child is on one of those fantastic wait lists.

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