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What your health insurance company doesn’t want you to know

My wife is a Type 1 diabetic. She’s the type of person insurance companies go out of their way to deny coverage for, and while I suppose I can say I’m used to them not covering her without a fight, I’m not exactly good at fighting the system. What I’ve learned the hard way is that you need to make sure, every time you change health insurance, that you have at least 12 months’ worth of certificates of creditable coverage. And don’t expect them to tell you this.

You see, the more you don’t know, the more they can deny coverage and rake in profits. Health insurance isn’t about health, you see. It’s all about profits. In the last 18 months I’ve worked for three different companies, and due to being laid off suddenly–I literally found out one Wednesday afternoon that Friday was going to be my last day–I had a gap in employment last year.

My new job had a waiting period on insurance, so I ended up with a gap in insurance coverage, too. Further complicating matters was that my new employer had two insurance plans. One plan was cheaper, and you were eligible to start it immediately after the waiting period ended. I was eligible for the second plan, which purports to cover more, after I’d been on the job for some period of time (60 or 90 days). So when I started the new plan which, incidentally, costs $1,200 a month and has high copays, they asked for a certificate of creditable coverage. Never mind I’d changed plans within the same employer–I still had to go to the time and expense to get a certificate mailed to me, then mail it in twice, then fax it in after they lost it the second time.

Then, just when we thought everything was OK, they kept right on denying claims. Only we never got any phone calls or anything in the mail about this–we found out when doctors’ offices started calling us asking when they’d get paid. When we called the insurance company, they said they had record of calling us. Only they hadn’t. We had no voicemails from them, nor had either of us taken any calls from them either. Of course it was our word against theirs.

Finally the representative located the certificate of creditable coverage. “You only have a month’s coverage,” she said. That’s some serious rounding-down, but whatever. Finally my wife got the representative to admit they wanted a previous certificate of creditable coverage. I happened to have that, because I’d had to send it in when I started the job. So we repeated that drill, right down to them losing it twice. These guys seem to have a process.

Once again, we thought we were OK, until we started getting phone calls from doctors again, asking–you guessed it–when they would get paid. After about a week and a half worth of making daily phone calls to the insurance company, one of the representatives slipped up and said the magic words. “Between the two certificates you sent in, you still don’t have twelve months of previous coverage.”

“Oh, you mean we need a certificate of creditable coverage from the previous insurance? I don’t know if we can get that.”

The reaction from the representative made it sound like she’d slipped by telling my wife even that much. She called me, agitated. Of course I no longer had my insurance card from two previous employers, so I had no idea what the group number was or anything like that, but I did know the insurance was through Blue Cross Blue Shield of Alabama. I didn’t have a certificate of creditable coverage from them because for whatever reason, the insurance company from my previous employer never asked for it. Google to the rescue. I found several phone numbers for Blue Cross Blue Shield of Alabama. Surely if we called and told them they covered us up until June of 2012 and gave my social security number they would have record of it, right?

Why yes, and in fact, they were considerably friendlier and more forthcoming than our current insurance company, even though we were former customers.

I went through exactly the same problem in 2009, though I never got that insurance company to ever admit to anything. I ended up changing jobs to escape from them. But the situation with them was similar. I changed jobs in February due to my previous employer losing the contract I was working, and my previous employer had changed insurance providers the year before, so I had fewer than 12 months’ worth of previous coverage.

I had a similar problem in 2005. I worked in 2005 for a contracting company that didn’t provide insurance, and nobody I contacted was willing to cover my wife. One was nice enough to point out that Missouri has a high-risk health insurance pool, so we bought that for her. But the high-risk pool never mentioned anything about a certificate of creditable coverage at all, so they just sat there denying claims for six months and raking in money.

In all three cases, we were in the situation of paying more than a thousand dollars a month for insurance, but the insurance literally covering only prescriptions for generic drugs–they wouldn’t even cover vaccinations–so it was pretty much like not having insurance at all.

To keep from falling into that situation, every single time your insurance coverage changes, whether it’s from your employer changing providers or you changing jobs, get a certificate of creditable coverage from your previous provider, file it away, and when you change insurance companies, do five things:

1. Ask them where to send a certificate of creditable coverage

2. Get certificates showing at least 12 months’ worth of coverage, sending in multiple certificates if necessary to get 12 months. Short gaps in coverage seem to be OK, especially if you can provide more than 12 months’ worth of recent coverage.

3. Get a reference number. Write that reference number on the certificate(s), along with any other identifying information you’re comfortable divulging (such as your current member ID)

4. Send the certificate in with delivery confirmation. It costs extra, but this way it’s a lot harder to deny having received it. You might wish to fax it in as well.

5. Follow up a few days later. Don’t expect the insurance company to call you and let you know they received it. Call them and make them tell you they received it.

And good luck. Sadly, you’ll probably need it.

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4 thoughts on “What your health insurance company doesn’t want you to know”

    1. Note the last paragraph: I have had this problem since 2005, when Mr. Obama was a freshman senator from Illinois. The Affordable Care Act has nothing to do with this (and didn’t do much to fix it, as far as I can tell).

      Regarding business opportunity, I’m not sure how much money someone who’s been paying for insurance they can’t use and is paying out of pocket for everything has left. Unless they make six figures, they’re going to be bled pretty dry.

      It’s short-sighted too. In 2009, my employer refused to help me get my insurance straightened out. I left, went to another company, and when that contract came back up for bid, I wrote the contract proposal to go up against my old company, and won. They lost a multi-million dollar contract over a few thousand dollars. It was ruinous to me at the time, but mere penny-pinching to them, and it came back to bite them pretty hard.

  1. Dave,
    Will ACA help you? Hope so.
    I spent my working life without insurance. I couldn’t buy insurance and eat. Luckily, my children grew up without any medical problems.
    I have Medicare now but the first day in a hospital is $1084.00. Can’t afford Medicare deductibles on Social Security.
    It’s hell to be poor but most of the world’s population would like to be U.S. poor.
    “I’m too young for Medicare and too old for women to care.”
    Kinky Friedman

    1. It’s very likely the ACA will help, yes. At the very least, the most expensive ACA plan is less expensive than what I currently pay, even without any federal subsidies. I didn’t switch to ACA for fear of it getting cancelled and then being without insurance, so now I’m locked in until October or until I change jobs.

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