Can you get EOC?

Apr 20, 2007

  1. Guest
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    I'm having an issue with one of the "dark color" carriers in CA. I want to see samples of the healthcare policies before I recommend them. The term I hear used is EOC (evidence of coverage).

    However the carriers simply point me to the web (even the agent's logon site) but all I find is 'fluff'... the pretty brochures they call a "summary of coverage" which don't always tell you what is NOT covered or go into detail. I feel as if I'm selling 'blind.' (I know the client has a 10-day look, but I'd like to review these policies (especailly the new ones) before I put my neck on the line and recommend them.

    Is this the same in all states?

    I met an assistant to my state assembly member yesterday at a chamber lunch and told her about this and she thought that it would be a good idea for carriers to either post complete policies on their site or have the DOI post pdf files on the state site. She is going to set up a meeting with her boss to discuss it.

    How does it work in other states? Can you (anyone) see the entire policy before purchase?

    Thanks,

    Al
     
    Guest, Apr 20, 2007
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  2. Dave020
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    Dave020 Super Moderator Moderator

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    I usually have Blue send me the pdf of EOC for whichever policy I need information on. There is simply too much paper involved in maintaining EOC on every plan I sell.

    Most carriers have plan similiarities that let you understand the group of plan benefits rather than dissecting each and every one (e.g., Blue Cross PPO Share plans all have same overall benefits, just the difference in deductible, OOPM and RX brand deductible).

    I recommend ordering e-mail from agent services the EOCs that you need to review, then learn the policies.

    Some interesting example not disclosed in the fluff we get to present:

    Only Blue CROSS CA has non-subcontracted mental health benefits in the IFP market. All other carriers use MHN or UBH and this is VERY important as a patient has to use the sub-carrier's network (or lack thereof) instead of the health carrier's network.

    Certain benefits are different for subscribers 0-18 than for adults. These are broken down in the EOC.

    Mental health parity benefits are not listed in the EOC, only non-severe benefits. But they list under mental health so it looks like there are all sorts of restrictions for treatment (30 days max, $175 a day and so on). Those are non-severe benefits and all parity benefits fall under hospital inpatient/outpatient same as surgery and such. This is not really even disclosed in the EOC.

    EOC is a great start to learn the "guts" of the plans. And it is knowing the guts that sets one apart from the competition.

    Just call agent support at whichever carrier you need and ask them to e-mail you the EOC for whichever plan(s) you want to study. I've never been told that I could not get one that way and it sure beats killing a forest with stuff that I would eventually throw away anyway.

    Dave
    www.davefluker.com
     
    Dave020, Apr 20, 2007
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  3. Dave020
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    Dave020 Super Moderator Moderator

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    One thing I meant to mention in that last post - did you know that BCC will pay mental health benefits (non-severe) for interns working under the supervision of a contracted provider, so long as the provider is supervising the treatment.

    This is VERY important and I can tell you that the other subs I mentioned above will NOT allow that. And their networks are a fraction of BCCs anyway.

    I write 95-97% Blue Cross CA or L&H for one simple reason, they are the innovator in California and all other carriers are simply immitators.

    Dave
    www.davefluker.com
     
    Dave020, Apr 20, 2007
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    I spoke with Blue Cross agent support. They do NOT have EOC for the new Lumenos plans because they are too new!! Gimme a break. I told her I would not sell it until I could read it. She could care less.

    I didn't ask her about email of PDF's of EOCs for older plans. I will call back and get them to send me the PDFs of the 3 or 4 plans I like to write.

    As opposed to Dave (whom I have the greatest respect for) I find Blue Shield in CA to be more consumer and agent friendly than Cross (In CA they compete and have no love for each other.)

    Al
     
    Guest, Apr 20, 2007
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  5. Dave020
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    Dave020 Super Moderator Moderator

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    Thanks Al, appreciate it.

    I won't hold my breath for the EOC on Lumenos any time soon, I dont think they document that way. Lumenos IFP plans work like this:

    -Preventative 100% straight up free to subscriber
    -All other services deductible first (which equals OOPM)
    -100% in network all other services after deductible, no copay no nothing

    If you download the plan summaries from the agent connect site, on page three of the brochure it spells it out what it covered and it is nice, includes all mental health (severe and non severe), Rx, chiro, everything but the kitchen sink. All covered in full after the deductible with no limitations.

    The only limitations on these Lumenos plans are:

    Skilled nursing 100 day max
    $380 per day ambulatory surgery for Non-par providers
    Lab & Xray require preauth
    Organ transplant travel expense limitations

    These limitations are also spelled out on page 3.

    Really there is no need for EOC, I think we are just used to seeing things spelled out in an EOC because of the various nuances to benefits under the older type plans. Lumenos is almost too simple in this respect and I have had to get my mind around the idea that it is not complex.

    Shield can be more friendly, but they have difficult underwriting (I have placed Shield declines with Cross as Level One) and tend to bleed a lot of money (see recent decision to abandon CAR (realtors) not long after abandoning PacAdvantage).

    Also, friendly is good until a client calls you to tell you his wife needs to go inpatient mental and you have to explain he can't use the great Blue Shield PPO network but instead has to use the sparse list of MHN providers instead. And yes, this has happened to me more than once, fortunately they were Blue CROSS clients and able to get into a local facility using the BCC PPO network.

    Dave
    www.davefluker.com
     
    Dave020, Apr 20, 2007
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    Yes, but a lot of agents I've spoken to think they are too expensive. I've been trying to find an analysis between the more expensive Lunenos plans with all the preventative services, vs. a cheaper HSA with none. It all depends on what a colon screening, mamo, pap, and shots cost these days.

    I asked some of my more experienced agent friends here if they had done a cost analysis but so far none have.

    From looking at the Lumenos plans they look to be a good deal for a younger person or family, but they are not priced very well for anyone over 50, IMO.

    That said, I think they wil have huge marketing appeal. People will feel like they are getting something for free, no realizing that the cost of all the preventative services are built into the rates.

    I like the 'concept' of Lumenos as people will not have an excuse to put off getting preventative care. And with the IHA plans (incentive health account) they "get paid" to get these procedures... and all of this may result in a healthier society.... which would be a good thing.

    So while I'm not the worlds biggest fan of BC, I give the good marks on bringing out Lumenos. I wonder how well they will sell.

    Al
     
    Guest, Apr 20, 2007
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  7. Dave020
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    Dave020 Super Moderator Moderator

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    Al, I think you need to recheck your pricing on these plans.

    Couple age 45 Area 3

    Lumenos HSA 3000 $382 (OOPM 3000)
    BSC 2400 Savings $375 (OOPM 3200) (No Maternity/Prev care copays)

    Lumenos HSA 5000 $228 (OOPM 5000)
    BCC 3500 HSA PPO $262 (OOPM 5000) (No Maternity/No Prev care)
    BSC 4000 Savings $491 (OOPM 4000) (Prev care copays)

    Looks to me that Lumenos provides a lot more and sometimes for less cost.

    Again, check your premiums apples to apples.

    Dave
    www.davefluker.com
     
    Dave020, Apr 20, 2007
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  8. Dave020
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    Dave020 Super Moderator Moderator

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    Couple Age 55 Area 3

    Lumenos HSA 2500 $604 (OOPM 2500)
    BSC 2400 Savings $828 (OOPM 3200) (No Materity/Prev Care Copays)

    Lumennos HSA 3000 $562 (OOPM 3000)
    BSC 2400 Savings $828 (OOPM 3200) (No Maternity/Prev Care Copays)

    Lumenos HSA 5000 $398 (OOPM 4000)
    BSC 4000 Savings $828 (OOPM 4000) (Prev Care Copays)
    BCC 3500 HSA $457 (OOPM 5000) (No Maternity/Prev Care Copays)

    Al, you really need to check your numbers, looks like Lumenos HSA plans in the older age groups destroy the other plans.

    How do you calculate them as more expensive??

    Dave
     
    Dave020, Apr 20, 2007
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  9. Dave020
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    Dave020 Super Moderator Moderator

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    Correction, BSC 4000 Savings PPO rate should be $636, not $828.

    Shield rates are quoted T2, as T1 represents 80% RAF and is unlikely on a couple over 35. T2 represents the standard rate.

    Dave
     
    Dave020, Apr 20, 2007
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    My rate chart shows the Blue Shield 2400 HSA is only sold for singles. The couple plan is 4800 which is $673 and the HSA 8000 is $532.


    We must be looking at different rates for couples for region 3. I'm looking at Feb 1. 2007. Perhaps ther has been a new one? The most expensive HSA for age 55 that I see is family plan 4800 which is $751.

    I didn't rate the Lumenos plans as I don't have time right now... and don't have the printed chart. . But I'll check it it this weekend.

    Thanks.
     
    Guest, Apr 20, 2007
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