Grandfathered plan... Time to change?

[SabineH]

My husband and I have had the same Anthem Blue cross PPO since 2003. We purchased this plan while we were in our mid 20's and have hardly used it until the last year or so. Our premium is only $290 a month for the both of us and our deductible is something like $4000. A max family out of pocket of $7500.
In the last year, I needed to get a diagnostic mammogram and ultrasound for a suspicious mass in my breast. I also went to see a specialist. My insurance denied paying my mammogram and the specialist. No big deal, as I ended up just having a benign cyst... but this made me wonder. What if there were something really seriously wrong with me? Would the insurance deny my claim? Why am I even paying $290 a month if they deny my claims?
I know the grandfathered plans don't offer the same consumer protection as the new plans.
If let's say, my spouse or I were diagnosed with cancer tomorrow, would be better off with a new plan?

 

[Franki52]

I have a grandfathered Golden Rule Plan and depending on each state will determine if a better option is available. I’m arizona we only have one ACA plan, Healthnet Ambetter and it’s costly with less doctor options. Be careful before dropping your plan and don’t be talked into a Christian based or cost sharing plan without all the specifics. I’m keeping my over priced high deductible plan in hopes things change soon and we have competition.

 

[Yagents]

Why was claim denied?
Was it discounted with network rates?
If so, then it was approved but subject to deductible, which is very low In your plan vs double that out on market. That price you are paying is CHEAP. The only reason you should change to an ACA plan is if you plan on having low income for next 2-3 years under $65k for household of 2. If so, then Aca tax credits may be enough to get your price down to same or lower than now. Mammogram diagnostic coding should have been covered. Preventative codimg mammogram may not have been with these old plans.

 

[SabineH]

Hi there, no the claim was DENIED... they paid for my ultrasound and my labwork but for some reason they didn't cover the mammogram. I had to call them twice, at first, they said it was a coding issue, then they came back and said diagnostic mammograms are only covered if I am admitted to the hospital? I ended up just paying cash for the mammogram...
Situations like that make me nervous. My husband has been having some prostate issues and we are a little worried about it. If it turns out to be a serious issue, i.e. cancer, what kind of tricks will the insurance play? Can they just drop us ? Can they deny to cover claims again?

 

[SabineH]

Hi there, no the claim was DENIED... they paid for my ultrasound and my labwork but for some reason they didn't cover the mammogram. I had to call them twice, at first, they said it was a coding issue, then they came back and said diagnostic mammograms are only covered if I am admitted to the hospital? I ended up just paying cash for the mammogram...
Situations like that make me nervous. My husband has been having some prostate issues and we are a little worried about it. If it turns out to be a serious issue, i.e. cancer, what kind of tricks will the insurance play? Can they just drop us ? Can they deny to cover claims again?

 

[tonyisme]

Amazing you're only paying 290 a month.
Think twice about dropping that

 

[DS4]

I'm an agent in California. Your Anthem grandfathered plan uses a different PPO network from the ObamaCare(ACA) PPO network. In my part of California, many primary care Drs and specialists will not take the new ObamaCare Network created on 1.1.14.
You would have a hard time finding physicians that don't take your current PPO id card!
Your $290/mo premium is cheap for a grandfathered plan. You must live in a rural area?
Regarding your denied claim, sounds like a billing/coding issue to me. Do you have an agent?
I would ride out your grandfathered plan as long as the premium is this low.

what kind of tricks will the insurance play? Can they just drop us ? Can they deny to cover claims again?

No tricks!
Can they drop you, "yes", only if they(Anthem) drops everyone else with the same plan.
Claims only get denied for non covered expenses.
Judging by your premium of $290/mo, I would say you have the PPO HSA 4100/8100, contract code T160??

 

[SabineH]

Hi DS4, Thanks so much for your feedback! My claim for the mammogram was definitely denied. I called Anthem BC twice. First they said it was a coding issue. Then they came back confirming it was denied claiming mammograms are only covered if I am actually admitted to the hospital? So far our insurance has never covered an office visit. In the past year we have gone to urgent care once, I went to a breast specialist for a second opinion (i'm fine btw- just had a benign mass)and my husband went to a dermatologist to have a suspicious mole checked out. The insurance never covered any of these office visits. Not even the Urgent care. And I mean, it is not that I just had to pay and it went towards my deductible. I mean, they denied coverage for these things. I am ok with paying for these random office visits though... because in total it was probably $500 out o my pocket... Considering I only pay $290 a month for health insurance for 2 people I can't complain. My husband is having prostate issues. I just want to be sure that if my husband has a serious problem and needs a biopsy or surgery, that they won't try and deny that too! I don't have an agent. I have had this PPO since 2002. We are not in a rural area. We are in suburban Ventura County.

 

[DS4]

Look at your Anthem id card. What is the plan name?? The name will be something like, PPO Share, PPO Basic, PPO HSA, Lumenos HSA, RightPlan PPO, SmartSense or Tonik???

Then they came back confirming it was denied claiming mammograms are only covered if I am actually admitted to the hospital? So far our insurance has never covered an office visit!

Because of this statement, I now believe you have one of the 2 Basic PPO plans. These plans are hospital/ surgery plans. Hardly any outpatient coverage. No coverage for Mammo's, office visits, x-rays, lab or Rx's.

 

[Dave020]

I'd be happy to go over your options with you if you want to give me a call.