All Things in Moderation

Background

We bought the business my husband worked for the 23 years prior in 2001. We moved it from Huntington Beach to Riverside, CA, brought one employee with us and hired two more. I quickly became a payroll, tax, insurance, quick books, import/export, and photo shop expert of sorts. One of my trickiest jobs though was maneuvering through the maze of health insurance issues. We slogged along for about four years in this manner approaching retirement age. About six years ago we decided to move the business to our back yard and built a warehouse, transformed two bedrooms into offices, brought in three more phone lines with an elaborate phone and intercom system and set up a wired network for the computers etc. and voila we’ve been working from home since 2006. Our employees had drifted off one by one and we kept downsizing as necessary due to both our interest in slowing down and the business climate, so the move ended up being fortuitous. One of the expenses that always caused the most consternation, other than lease agreements of course, was the cost of health insurance.

Small Group Insurance

We originally planned to be semi-retired by this year and in many ways we’re close. When we built the warehouse and moved the business home, according to city ordinance, we are not allowed to have employees unless they live in the home. Obviously, before making this kind of commitment and the expense of building a warehouse, I needed to verify that with just the two of us we could maintain an employer provided health insurance plan. Luckily, any business with between two and twenty employees qualifies for small group insurance. Here in CA you’re required to submit tax returns and DE6 verification as proof, and sole proprietorship plus one employee qualifies. Otherwise, we’d be stuck searching the individual market, and at our age it would probably be priced exorbitantly or nearly impossible to qualify, even though we are quite healthy still. Honestly, we already feel we’re paying exorbitant prices so it’s difficult to imagine anything higher.

In addition to the yearly increases, based on some formula I’ll never be able to decipher, rates increase every five years on your birthday. In other words, when a person turns 60 their rate jumps up compared to someone who is 55. Since 2005 our rates increased substantially and by 2008 we were paying $1600/mo for the two of us for what is comparatively a modest plan with lots of cost sharing. I began looking around for a change on our renewal date of Nov. 1 and managed to switch from Health Net to Blue Shield and we saved about $3000 in 2009, but of course the real savings came with even more cost sharing. Last year I turned 60 (yippee), and so of course we faced another big increase, and by Nov. of 2010 we were looking at $1700 per month. The obvious thing was to begin looking around again. By this time I had taken over the job and no longer used an agent, so I’m pretty familiar with the ins and outs. I have learned that it’s much easier to make changes if you stay within the same company umbrella rather than change carriers.

A local access HMO 30 saved our bacon and we managed to lower our monthly cost to $1500 and keep our doctors group, local hospital and network of specialists that we’re somewhat familiar with. We received our new cards and put them in our wallets.

Yesterday

Every year in September my husband and I begin our yearly exams and let the doctors poke and prod us within reason. Neither of us has been to the doctor since we received our new insurance cards November of last year as we had a good year health wise. My appointment was yesterday morning and I showed up with bells on since I hadn’t been in the office since last year, and was chatting with the usual suspects (a couple of whom I’ve known for 30 years) and what not, when the gal at the desk called me up to speak with her. “I have good news and bad news”……………Oh no. “You’re covered but you need to go to Pomona to see your new doctor” and I quietly shrieked “You’re kidding me right?” Apparently, some wires were crossed last year and we were put into a local access group that’s about 40 miles away. So I flew home and called the insurance company and lo and behold our medical group doesn’t belong to a local access HMO and the nearest one is in Pomona, which apparently the card I’ve had in my wallet for the last 10 months clearly states.

You can switch health providers as long as they accept the insurance you have, but you can only switch health care plans once a year on your renewal date. So right now I have routine blood work and imaging referrals on hold until after Nov. 1, when we’ll switch to yet another plan. If anything happens to either of us in the meantime we get to go see a doctor we’ve never seen who’s 40 miles away. My husband told me yesterday, “No more horse back riding until after Nov. 1st for you young lady”.

Here’s the tricky part. In order to keep our premium in the $1600 range (OMG) we’re switching to an HMO 40 which, if you know anything at all about health insurance, just increased our cost sharing not incrementally but almost unaffordably. I’d say my horse back riding days are over. Another twist, as I had the one prescription I take without any renewals going forward, I went ahead and paid the cash customer fee to see my doctor. In the last 10 months we’ve paid $15,000 for health insurance with only a few prescription costs and I still had to spend $90 for a doctors appointment, sheesh.

I’m not really sure if people who have employer provided large group insurance understand the trials and tribulations or the cost of health insurance compared to the rest of us, so I’m curious what other experiences might be shared by our little group here.

Filed under: Uncategorized | Tagged: healt insurance, HMO, local access, small group | 14 Comments »