Can you get EOC?

[Dave020]

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.

I am using Feb 2007 the 100-page full rate guide. It is area 4 with Blue Shield, area 3 with Blue Cross - sorry for the confusion on that.

Also I am using Tier 2 rates which are the standard rate, Tier 1 is 80% RAF which is 20% below the standard rate and not very likely on a 55-year old. Since Tier 2 represents Shield's standard rate, it makes apples to apples when compared to Lumenos. If you use Tier 1, it is an unfair comparison.

Area 4 shows party of two age 55 rates Tier 2 as $634 and $828 respectively.

Dave

 

[Guest]

which is 20% below the standard rate and not very likely on a 55-year old. Since Tier 2 represents Shield's standard rate, it makes apples to apples when compared to Lumenos. If you use Tier 1, it is an unfair comparison.

Well I can only assume that Dave is one of the many of the populace who believe that everyone over 55 is physically 'washed up' and that they will never get Tier 1 rates. However, most of my over 55 clients get it... as did I (I have the BS Spectrum 4000 HSA) and I'm a few months short of 60... and I'm somewhat certain that I can kick Dave's ass any day of the week :-) <g> {just a joke folks... so don't get your knickers in a knot!} I work out with weights and run 2 miles a day (for over 30 years now!).... and there are tens of millions of people my age who do the same... do please don't group us all as being "over the hill." While we might see the top if it, we're not there yet!

How does Dave come the the conclusion that Shield's Tier-2 is their standard rate? TTBOMK we only get paid on Tier-1. To my way of thinking this would be their 'standard' rate.

I think that maybe the difference between Dave and myself is that he sees the carrier as the 'friend' of the client, and I see the carrier as an almost evil being that needs to be watched/monitored all the time because it is prone to doing what is in it's own best interest and not that of the policy holder. Dave has more experience than I do, but I know what I see on a day-to-day basis, and I hold the carriers in far more contempt than I do good graces. Then again, Dave may be right and that both Blue Cross and Shield are really pro-consumer. If so, he sees a different situation than I do... and I'm sure we will agree to disagree. And as always, YMMV.

Al

 

[Dave020]

I am 48, do daily 90 min workouts with both wieghts and bullworker (isos) and am an Air Force TSgt scoring 2nd best score in my unit PT fitness test out of 51 people, most 20 or more years my junior. Also use an albuterol inhaler for asthma and pravachol for very slightly evavated cholesteraol, which means I am uninsurable even with conistent bp 110/70 and BMI 24.0

Blue Shield came out with Tier One ratings about 3 years ago, and made it clear that this was a special rating for very healthy people. I talked to them about it several years ago and was told specifically that Shield Tier 1 is 80% of standard cost and Tier 2 represents the 100% standard cost. Feel free to call agent support and ask them. They told me to quote Tier 2 and then if we got tier 1, it was a nice price break.

I am certainly not suggesting that anyone over 50 can't get Tier 1, just that it is much more difficult. As I said above, I have placed Shield declines and T5s with Cross at Level One. I have had 60 year olds get super preferred with West Coast life before as well, so it is always up to the individual applicant.

My point was it is not a fair comparison to quote T1 Shield against Lumenos at 20% more by pricing index. T2 is the same rate so that should be used. Same with group, how fair would it be to quote one carrier at .90 RAF against another at 1.00 or 1.10? Of course the lower RAF carrier is gonna look good. BTW we do get paid on all five tiers, just lower commission rate as the tiers go up.

Here is an example of why I like Cross better - when they introduced non-maternity plans in CA, Shield and Kaiser filed and injuction and lawsuit to prevent the plans for being marketed. They lost their case and within a few weeks, Shield offered non-maternity plans as well.

I see the carrier as the control to the cost. The watchdog over the provider. Simple as that. In my years of selling and servicing health insurance, only Blue Cross has gone to bat for my clients time and time again. I have seen them send VPs to providers offices to explain contract violations that were working against my clients (one provider was sending balance billing to collections even before Cross finished the claim). I don't see the insurance company as the enemy, I see the provider as the enemy. Providers are notorious for balance billing, inflating charges and services provided, recommending unncessary and expensive tests and procedures and so on. Gotta make that mercedes payment, right? I had one client and his wife get balance billed for a lab test $1160 each. When the claim settled, NFR was $69 for the test. And yes, they send someone out to speak with the office regarding contract violations for balance billing. Again this one was sent to collections first, different provider different part of the state.

I also find Cross an innovator, plain and simple. Show me one plan in either Shield or HNets portfolios that was not in Cross portfolio first. Active Start=RightPlan, SimpleValue/SimpleChoice=RightPlan.

We can agree to disagree, and that is fine. All I know is that when I need a carrier to go to bat for my client, to pay the provider fast and timely, to give me a network of providers that covers all services, I can count on Blue Cross to provide that.

Dave

 

[J.R.]

I don't see the insurance company as the enemy, I see the provider as the enemy. Providers are notorious for balance billing, inflating charges and services provided, recommending unncessary and expensive tests and procedures and so on. Gotta make that mercedes payment, right? I had one client and his wife get balance billed for a lab test $1160 each. When the claim settled, NFR was $69 for the test. And yes, they send someone out to speak with the office regarding contract violations for balance billing. Again this one was sent to collections first, different provider different part of the state.

What is NFR and did you get my IM?

-J.R.

 

[Dave020]

NFR - Negotiated Fee Rate

I did get your IM.

Dave

 

[J.R.]

Thank you Mr. Burgundy, "Go San Diego!"

 

[Dave020]

"Stay Classy"

 

[Guest]

My point was it is not a fair comparison to quote T1 Shield against Lumenos at 20% more by pricing index. T2 is the same rate so that should be used.

So I was right... we are using different rating charts. I'm using the one that BS gives to clients in their large white folder with all the other 'stuff.' (I like the BS pre-sales material much better than the BC stuff... far more disclosure, etc.)

My BS rep said to quote Tier-1 seeing as that is what THEY quote (seeing as they give out the chart in the folder.) So I do (creates less confusion)... and my experience has been that clients either get it... or get declined! I think I've only had one or two rate-ups this year with BS. (Aetna is a different story!) I don't write that much with BC if I can avoid it for reasons below.

I don't see the customer OR agent service any better or worse between the two carriers. I find both do a pretty good job... and I've had both coverages over the years (currently with BS 4000 HSA since Dec.... previously with BC PPO 2500). My wife has BC Freedom One MA. As an agent both do a good job getting me answers, etc.

I tend to favor BS because they are more local and don't answer to Wellpoint stockholders, although I understand that is all changing. BS has a sales office half a mile from me, the gals in the office are always accomodating when I ask for materials, etc. People like to do business with those they know... and I'm no different. (And the BenefitMall people are across the street from BS and they REALLY go out of their way to help me out when I have group to quote... I love those people.)

It is interesting that Dave sees the carriers as the 'keeper of the culture' and 'proctector of the realm.' I've spent a career in healthcare on the IT (dealing with management) end of things for insurance companies, state agencies, and TPAs. (I met my wife at Blue Shield when EDS did all their data processing in 1976).

I won't go into detail with my opposition to Dave's opinion about the carriers, but if you really believe that the management of carriers have the best interest of consumers (your clients) at heart, I can only wish that in your next life you walk in the shoes that I've walked in these past 25 years.

And I have to differ with Dave about providers. My wife was a surgical RN for 25 years before being disabled so I had a lot of contact with docs, hospitals, surgi-centers, and all layers of provider MANAGEMENT. While you will all make up your own mind on this, in my experience I found far, far, far, far more crooked, deceptive, gaming, and basic fradulent people working for insurance carriers than ever came close in the provider community. Given the choice of having to trust a doctor or nurse or med. office manager vs. an insurance executive or underwriter with my life or my money or even my cat, I'll take the medical people any and every day over the insurance people.

That's been MY experience in and around the healthcare system since 1975 when I joined EDS (who did IT for many of the Blues across the USA).

So Dave, answer me this since you are the 'voice' of BC. Where are the EOCs for Lumenos? Do you think it is 'ethical' for BC to ask us to sell these policies 'blind.'? Have you seen these docs?

This was a good discussion. Thank you, Dave, et. al.

As always, (especially in THIS venue!!) YMMV !!!!!!!!!!!!!

Al

 

[Dave020]

So I was right... we are using different rating charts. I'm using the one that BS gives to clients in their large white folder with all the other 'stuff.' (I like the BS pre-sales material much better than the BC stuff... far more disclosure, etc.)


So Dave, answer me this since you are the 'voice' of BC. Where are the EOCs for Lumenos? Do you think it is 'ethical' for BC to ask us to sell these policies 'blind.'? Have you seen these docs?

This was a good discussion. Thank you, Dave, et. al.

As always, (especially in THIS venue!!) YMMV !!!!!!!!!!!!!

Al

I know the ones you are referring too, they only show Tier 1 rates. I don't like to use them because I prefer to quote the standard rate for every age. Tier 1 is the "nice price" but Tier 2 is the standard 1.00 RAF rate for those plans.

As to Lumenos, why complicate such a simple product. Is there really a need for an EOC on these? No nuances, the brochure spells it all out pretty clearly, at least to me (and I have talked this over with Lumenos as well, not just BCC).

Here is what the EOC would look like:

Prev Care 100% (nationally recognized - see the list)

Bridge (you pay the deductible before we cover anything else)

Traditional (we cover everything 100% in network, 70% out of network for all other services)

Limitations (here's a couple of things we limit and $5M lifetime)

That's it!

Remember these are Lumenos plans, not Blue Cross CA. Lumenos has had these kinds of plans in place for many years before Wellpoint bought them. No more need to spend 50 pages spelling out all sorts of things, you want chiro 7 days a week, pay your deductible and we'll cover it at either in or out of network benefit. Wanna have a baby, pay the deductible and we'll cover it. Drugs, pay the deductible and we'll cover it.
And so on.

I can understand agent confusion, these plans are too simple. Everyone is looking for the loophole that lets them exclude or limit benefits. Lumenos never did that in all the years they were private, and don't do it now.

If you aren't comfortable with Lumenos, then don't sell it.

I don't see myself as the "voice" of BC at all, I just know quality when I see it.

There will come a day, as you write more business, that a client is gonna call you and want to know why they can't use the carrier's network for certain services (i.e., mental health), and then you can have fun explaining that they don't have coverage for that from carrier X because carrier X subcontracts with subcarrier Y who has never bothered to negotiate a network nearly as large as carrier X's, which they can't use.

Do you disclose this on each sale that you make? Mister prospect, I want to make sure you are aware that all of the mental health benefits you or your family might need will not be provided by the health plan I am actually selling you, but by a small, third party company you never heard of that likely won't have a provider in your area and does not have a web site that will allow you to search for providers. And you can't use any of the providers from the carrier I am actually selling you because they don't provide this benefit.

Just seems to me that this kind of thing is an E&O claim just waiting to happen. And guess what, does anyone think that carrier X will come to your aid? Right. Carrier says, client should have read the disclosure and EOC. Client's lawyer says, did agent tell you about this? Client says, oh yes of course he/she did (NOT), guess who lawyer sues.

 

[Guest]

Remember these are Lumenos plans, not Blue Cross CA.

Has Lumenos been in CA before? I've been here 25 years and never heard of them. Why didn't BC brand them as BC plans... unless they were really well-known as Lumenos here in this state... and maybe I've been under a rock, but they are new to me!!

I can understand agent confusion, these plans are too simple. Everyone is looking for the loophole that lets them exclude or limit benefits. Lumenos never did that in all the years they were private, and don't do it now.

Yes, absolutely. I honestly can't think of a carrier that has a plan that does not have more things that it does NOT cover than things it does. So yes, I'm confused... and skeptical.

If you aren't comfortable with Lumenos, then don't sell it.

I think that's the entire point of my thread. I WANT to sell it but I don't want to simply take the word of BC (from its puff-piece brochure) that it's a good deal for the client. I want to make my own analysis... because I think that's what I get paid for to do. If you (all of you, not just David) want to trust BC, fine. But as President Regan said about dealing with the Russians "Trust, but verify."

I don't see myself as the "voice" of BC at all, I just know quality when I see it.

Well, I wasn't talking 'qualtiy' I was talking ethics, morality, and truthfullness. If you see BC as leaders in the industry in these areas, then we again have to agree to disagree.

And again, you put your trust in the carriers over the providers, and while I have a warmer feeling for providers, I don't totally trust them either (you have no idea how many bad medical decisions (and simple (but potentially devistating) mistakes) are made each day unless you are married to a nurse working in a clinical setting!) But as I stated in an earlier post, when it comes to honesty and ethics, I'll side with the medical folks over anyone directly employed (W2) by any insurance carrier.

Do you disclose this on each sale that you make? Mister prospect, I want to make sure you are aware that all of the mental health benefits you or your family might need will not be provided by the health plan I am actually selling you,

Absolutely. THIS IS WHY I READ THE EOC! I spell it out in chapter and verse, full orchestration, four-part harmony and use circles and arrows on the back of each policy (sorry, Arlo!) and tell my cleints that this system is broken, badly broken and that the best I can do for them is mitigate it.

I tell clients (and in my speeches) that many policies they can buy absolutely 'smoke pole' (to use an expression that was around here for a while) and that it is easier to throw money away on health insurance than on the roulette wheel (I live close to Tahoe so people here understand the reference.)

I got a call the other day from a woman. "I was referred to you by XXX. She said you will protect me from the carriers. Let me tell you about what Kaiser did to my husband.... ." I've created a reputation around here in the past six months as one (well maybe not the ONLY one) agent who does not like the system, does not defend the system, and sees his role as helping people protect themselves FROM the system.

I've been around the "back room" of insurance carriers as well as those same 'back rooms" in government agencies.... and the provider community. What I'm going to tell you next is the absolute truth.... for all three players. Call me jaded if you wish but I've been there and I go on record both public and private and say to any and all:

IT'S ALL ABOUT THE MONEY.

It's not about what is best for the insured, the patient, the individual doctor or nurse, or the community at large.

If you think it is, that's fine. But if so, I think you are simply being nieve.

Just seems to me that this kind of thing is an E&O claim just waiting to happen.

Not after a client has spoken to me. I tell them that the carrier will do everything they can to NOT pay the bill... and that the only friend they have in the system is ME... and I believe that to be true. YMMV.

And guess what, does anyone think that carrier X will come to your aid?

Everyone does... until I set them straight.

Right. Carrier says, client should have read the disclosure and EOC.

Yes, and the carrier is right. And I DO... which is why I'm bitchin' about not being able to easily get these things... or in case of Lumenos not get them at all!

Client's lawyer says, did agent tell you about this? Client says, oh yes of course he/she did (NOT), guess who lawyer sues.

Not me. I have a statement I have my clients sign that says that I've advised them to read their policy and that I've told them that no matter what they might think from any of our converstations that it is only the actuall policy that matters and that they know they have a 10-day free look. (And no, please don't ask me to send you a copy as it might be construed as giving out legal advice without a license.)

I think health insurance is a good thing.... a necessary thing. However when it comes to the carriers who sell it my motto has been and still is "Trust... but verify."

Read my website (below) and you will see who's side of the fence I'm standing on.

Al
www.InsuranceSolutions123.com