--> Have HMO through employer - all Rxs, lab work, and dr visits covered 100% --> Employer changes HMO plan to a self-pay and benefits change. No notice/letter/new plan summary, etc. sent to me. --> Rec new ID card from HMO at the end of the month --> Everything bounces back to me from that month, HMO pays $0, claims new plan in effect retroactive to the 1st --> One PITA company consistently calling me for payment (Rxs - $2k from 2003) Open or written? 4/6 years I have appealed the denial twice and just rec'd a form letter denying again. Sent a letter to Human Resources and heard nothing. Today the company called again, I refused to pay and she said they would continue to collect "their own way." I honestly do not believe I should be liable. I was not told the coverage changed and would not have gotten the meds if I knew they were no longer covered. There's nothing to garnish but I'm worried about my CR getting slammed. Open to advice...thanks
i had to do arbitration through the state dept of commerce (which regulates insurance) to get a med debt paid a few years back. check into who regulates insurance in your state and ask them for assistance.
Did HMO plan change "mid-year", as opposed to during the usual open enrollment period when you usually sign up? Signing up during open enrollment is usually accompanied by a payroll reduction contract to cover the HMO payments pre-tax. Regardless of what change the employer wants to make in the plan, you have a contract with the employer to deduct certain amounts pre-tax, to be paid for a particular HMO policy. Not doing so would appear to be a breach of this contract with your employer. What do they say?
In July (I think) we got a letter from the employer stating plans were going to change and if benefits changed we would receive a new plan summary. We never received anything other than the new cards in the last week of September. My prescriptions were covered 100% under a state mandate. Unfortunately, the plan they changed to was self-pay and state mandates are no longer applicable. From what I understand the employer did not have to tell me they switched to a self-pay. But, how the hell could I check in a timely fashion if they retro the benefits? I mean, I didn't even KNOW the plan had changed until the last week of Sept and by then it was too late and services were already rendered. Hubby was no longer employed at this point (left in May) and we were covered under COBRA. There was no change in benefits (from May-Sept) except that we had been paying $1000/month instead of a payroll deduction (until the new card fiasco.) Seems like I'm going to get stuck with this, huh? Thanks for all the help so far, I appreciate it!
How much money is involved? You might try a small claims case against your ex-employer for breach of contract and failure to pay under the agreed terms. "If they never notified you of new terms, and continued to take your COBRA payments, then the old terms are still in effect." What is it worth, and how bad do you want to burn bridges? (Does your husband need a recommendation to get a new job?)
Re: Re: Here's a medical question for you There's $1500 for the Rxs and another $1500 for a Dr bill (the Dr isn't bugging me much - yet.) Small claims max in RI (where I am) is $1500, I think. When we first called HR and explained the situation, we were told the HMO screwed up on printing the cards (that's why they were mailed late in the month) and sorry, there was nothing they cold do. I followed that up with a letter and got no response. This is where the state mandate comes in and everything gets murky. No, they didn't send a new benefit summary BUT no benefits, per se, changed. What changed was they went to a self-pay plan which in turn nulified the mandate. And, people have told me the employer had no obligation to tell me they switched to a self-pay. "If they never notified you of new terms, and continued to take your COBRA payments, then the old terms are still in effect." ^^^ is this still applicable? if just the way the plan was managed changed? I do not want anything negative on my reports - I'm over 700 now on all 3. There's no love lost between the employer and my husband. He's had a new job now for two years so that's not an issue. (These bills are from 9/03)
Re: Re: Here's a medical question for you First issue is to make sure the bill from the providers takes into account any contractual discounts between the provider and the HMO. Even though the employer may have been responsible for paying, if they processed the claims through an HMO, it was probably both to handle claims processing and to benefit from the HMO's contracted service rates with providers. Make sure the provider billed amounts are in accordance with the HMO terms. Sometimes if the HMO or company fails to handle the claim, they turn around and bill you at their full rate. I don't know what your company's obligations are under COBRA. I would presume you would be elligible at least for the same terms as their current employees, but also responsible for paying what the company would have paid. Did your company pay off the providers on the same terms as they would have for their current employees at that time, regardless of the issue of changing terms? Or did their change to self-insurance leave them the choice of whether to pay, in effect allowing them to arbitrarily reject any claims? Were other employees laid off at about the same time, and did the company shift insurance plans to limit COBRA costs for these ex-employees? Although the small claims limit is $1500, presumably each claim could be handled as a separate case.
Re: Re: Re: Here's a medical question for you I believe the bills are correct because the same Rxs were paid in full by the HMO twice previously (before Sept.) and the amount they are billing me for now is similar. We used to pay $200/month when he was working there. Once COBRA kicked in we paid $1000/mo. We had the same benefits, as far as I know, as other employees. We went to COBRA in May and the HMO paid this exact same bill 100% that same month so I know it's not a COBRA issue. When the company switched to self-pay in September, the HMO no longer has to honor state mandates. The company did not deny the claim, the HMO did. If the plan was not self-insured the bill would have been paid like previously. I think the employer just switched plans to save themselves money, not to help the ex-employees. If only they had told me they were switching to a self-pay then I would have known the scripts were not going to be covered. But...I'm told they don't have to since the core benefits didn't change. So who is responsible? Grrr And would I file the claim(s) against the company in MA or its headquarters - who he was hired by - in CO?
Re: Re: Re: Here's a medical question for you By self-insured, do you mean the company just pays, or the employee is responsible for prescriptions? If the company is paying, and the HMO is just handling the claims, then the HMO has no incentive to approve or deny. They may just act at the direction of the company. When my company self-insured, they would receive a list of claims, and HR would direct the insurance company to pay. Were you treated the same or differently from their then current employees? That may be what COBRA requires.
Re: Re: Re: Re: Here's a medical question for you Self-insured group health plans quite often are exempt from complying with State mandates because a self-funded plan isn't actually an "insurance plan" as defined in the law - although from the employee's perspective it certainly looks and feels like one. http://partners.financenter.com/hrblock/learn/guides/smbizempbenefits/sbself_ins.fcs I believe you are correct in how you interpret "self-pay." I don't know if this happened to anyone else. I assume the claims were not paid simply because since the company went self-pay, they did not have to honor the state mandate any longer. My point is I was not given notice that things were going to change.
