Self Funded Healthcare Plan

Not sure of that one. I just got a letter last week that Med Mutual will no longer service SC nor Georgia. I live in SC, after retiring from Ohio. No forewarning, just that effective in Jan, they will contract out the services to any Dr. or hospital at the lowest rate. I "still" pay my premiums to MM, which are going up $600 year next year, deductible going up $500, and out of pocket going up $900. Guess I'm lucky to have insurance, but gee.....no extra anything now! I, too, am worried bout the financial impact, being retired and on fixed income.

I suggest that you see human resources or whoever it is as soon as you can for more accurate information. A self-funded plan doesn't necessarily mean what you are describing. It might just mean for example: that they are paying for insurance for 80% of the costs but paying for 20% of the costs of the insurance themselves. In plans like these there are sometimes HSA's or health savings account features available as well. Please ask because hopefully you've been given the wrong information. Does your employer have more than 50 employees? There are all kinds of federal laws and state laws and I believe there are differences between which laws that they comply with based on the number of employees.

I am not an ERISA expert but I believe that your plan, unless it's exempted, is likely regulated by a federal law called ERISA (see the below link for description):

http://en.wikipedia.org/wiki/Self-funded_health_care

Self-funded plans are almost always administered by a "third party administrator" (TPA), often a well-known insurance company. You don't deal directly with the company for insurance. It is true that they may select a physician network that isn't to your liking - limited provider networks are one of the bigger dissatisfiers with modern insurance. OTOH there are now (finally) some basic standards for what constitutes minimal health insurance in the U.S. under the Affordable Care Act, so it could be much worse (and was until fairly recently). I've had coverage in the past under employer-funded plans and found it indistinguishable from the other kind (most of my colleagues didn't even know). In both cases the employer faces nearly identical cost trade-offs, whether the costs are transformed by an insurer into premiums the employer pays or the costs are paid (through the TPA) direrctly to health care providers.

I don't have full details yet but the company is fuly funding the health plan itself. We didn't have wonderful insurance to begin with but we had access to plenty of choices for drs. In the past I paid around $400/month for me and my partner and we had a $1600 deductible with 80% coverage and 20% co-insurance. With my illeostomy, fibromyalgia, arthritis, fatigue issues, and asthma I have a variety of specialists and the only one out of any of them that is in the new plan is my allergist (probably the most replacable of the bunch). Suzan will lose all her drs. I know how much ostomy supplies cost and have been terrified of loosing coverage since I got my illeostomy 10 years ago. I did some looking in the PCHS network and I have a choice of a a whopping 3 colo rectal surgeons in Columbus. Now in a city this size what are my odds that those are the best?? Now I don't have any needs for one now but only two years ago I unexpectedly developed an abcess that required surgical drainage. I have had MRSA twice in the last 6 months. I don't even know if my infectious disease dr is on the new plan. I am far from a simple patient.

Just checked my inefectious disease doc is not in the new plan either. I have 15 of those to choose from and only 9 rheumetologists to choose from. Oh and my company has approx 5000 employees and is based out of CA. All the CA employees are exempt and get to keep their HMO plans. Not bloody fair.

I wonder if the powers that be in your company have partners and/or children - plus themselves that need specialists like you do? How are they going to feel about scrambling to find new doctors to transfer their care to? It doesn't sound bad when the "other" person is forced to do it. It is hard enough finding a doctor that is competent and that you trust without having to change all of your doctors. I feel for you as I have several of the same health problems that you do.

Is there anyway you can bring up your concerns anonymously??? How can they have two different plans in the same company? I thought that plans couldn't discriminate between employees? I'm sure it is all perfectly legal, just seems fishy.....

(I didn't read all of CTB's link, sorry if it's explained there.)

One explanation may be that California has a lot of consumer friendly laws that are not in all states. That is how the California employees can be exempt from benefit rules in other states.

Jan

That is usually true with regard to state consumer protection laws, but please note that if it is an ERISA health plan, then to the extent state law conflicts with ERISA, the federal law (ERISA) will pre-empt any conflicting state law. For example in Connecticut we have an anti-subrogation statute which precludes insurance companies from intervening in personal injury lawsuits to recover the costs of medical bills they have paid. However, an ERISA qualifying plan preserves the right of the health plan to subrogate, meaning that when the personal injury plaintiff is insured by one of these health plans, the plan has its hand sticking out for repayment of the medical bills at the time of settlement. And sometimes it is an aggressive hand of the TPA.

When I explain this to clients, they are often shocked and it is news to them. "How could they????????" is the usual response. And I tell them they can because federal law says they can.

The only good piece of news for them is that most ERISA-qualifying plans will negotiate their subrogration claim. I usually argue to them that it's found money for them and they should knock down their subrogation claim by one third, since the money was realized without the benefit and cost of their own attorney and, therefore, they are being unjustly enriched by 100% recovery of the medical bills they paid. They usually play ball, but not always. I have wanted to file lawsuits against a few of these plans testing these and other theories I have, but in those cases did not have the client's authority to do so, because very little money was at stake.

Anyway this illustrates the constitutional law principle of preemption of state laws that conflict with federal laws. It should be noted that if the plan is NOT an ERISA qualifying plan, then the Connecticut anti-subrogation law comes back into play.

Is there only 1 choice of plans available to you? In a company the size you mention, there ar usually a choice of options for employees to choose from. Another plan might have higher premiums but better coverage? Is getting insurance thru your partner an option instead? Is there an option to pay more, if you go out of network in order to keep your doctors? If not, most plans have a provision to refer you out at in network prices if no doctors in network can meet your needs (although they will likely say the ones they have can indeed meet your needs).

A non self funded plan could tighten down the network and raise out of pocket costs, too, but a self funded, ERISA covered plan has ways of getting around some state mandates-not sure if that is coming into play here or not.

So sorry-whenever companies change insurance coverages it is always so stressful for those of us that have complex situations. Don't be afraid to speak did fly with someone at your HR to help you sort through what is most imprtfor you. Good luck.

After I have calmed down a bit I did send an email about my ostomy supplies to my benefits person. She is familiar with my freak outs this time of year . She said they will still be covered, but the supplier may change. I did find Edgepark on the list (Thank God!) but it has a couple of ** next to it that said there may be exclusions so I need to call them directly. Instead of using their website (which was coming up with weird results depending on how you searched) I found a number to call that has an automated system and it doesn't look as bad as it did at first. I do see my GP, GI and Rheumy doc on the list. Honestly those are the most important as my GP would likely continue to prescribe meds from me other docs if needed.

I am still worried about how much they are going to cover since it isn't really spelled out. Hopefully the Thursday webinar will give more details. Our out of pocket max is almost doubling and our deductible and premiums are all going up. Ugh! I hate this time of year.

I'm glad you contacted her. Things are sounding better as you have a few core doctors still available too you. I would be lost with out my Internist, GP, and GI. Also good regarding your supplies. I hope you find out things will be smoother for you partner as well. Please let us know this all ends up as I'm sure there are others here that will be faced with similar problems.

Apparently they have dropped anyone in the Ohio Health network which is a good part of the state. Ugh.

Don't even get me started on Health Insurance right now. I'm sorry your going thru this as well.