Odd Question

[SME]

I have been reading the GR brochure and it states that a breast prosthesis is covered but not a replacement.
First- What is the difference?
Second- How are they getting around the federal law mandating masectomies and breast replacement be covered. Or does this only apply to group coverage.
Any ideas??

 

[Crabcake Johnny]

GR gets around everything playing the association card. I stopped offering them after finding out they are the only carrier in MD that doesn't comply with nearly a single mandate. Oh, and underwriting is terrible. Oh, and they erase your book of business by month 24. Cheap rates though.

 

[SME]

Thanks, it just makes me uncomfortable with the carrier. I've never sold much of it but am expanding into new states including MD. So I've been reading up on them learning the plans backward and forward. So far they make me a little nervous. Maybe it is just carry over from the group coverage I used to sell.

 

[somarco]

Federal laws (for the most part) have no effect on individually written plans. All carriers must comply with state laws.

 

[Crabcake Johnny]

State laws, yes - DOI rules, no. This is why GR issues riders in states where riders are forbibben, like CT. Until Copay Select was availble, all MD had was Copay 25 and 35, both with waiting periods on all adult wellness in clear violation of the MD mandates.

 

[SME]

How can they do this and get away with it? Doesn't the DOI have to approve all plans and rates?

 

[trvlnut]

Steph-
I came from group insurance too and I think these individual plans are terrible. I can't believe the exclusions and limitations. How does anyone know if they will be covered?

To answer your question, I think that if a lady has a mastectomy and needs a prothesis until plastic surgery is performed, then it's covered. I guess they won't pay for a prosthesic more than once.

ETA: I pulled out the GR brochure and it reads under Medical Expense Benefits page 11:
Artificial eyes, larnyx, breast prothesis, or basic artificial limbs (but not replacements).

I think the "not replacements" applies to the artificial limbs.

 

[Crabcake Johnny]

No - that's how companies like Mega Life get away with extremely limited plans. Yes, they have to file but the DOI has little control over what the plans offer. I met with 5 members of the MD DOI for 8 hours. Left up to them, certain Mega Plans would not be available but they have no control over it. When I quite Mega they had $300 a day R&B plans. You think the DOI's want those?

 

[SME]

That explains why Golden Rule never entered the NM market, and Mega has no presents either. EVERY plan has to be approved no exceptions. It might take forever to get a new plan approved but I never had experiences like this before.

 

[Crabcake Johnny]

The DOIs have really interpreted the association laws differently. Washington issued a cease and desist on Mega in 2004 because their plans were not compliant with the mandates, yet states like MD argue that they can't do anything about Mega because of their association protection. Then you have other states that won't allow individual plans to be sold if a joining an association is mandatory.