Some queries on how Protection America insurance will work in real life need

[bugmenot]

I am expecting a relative to visit me some time next year and came across this forum while trying to search for a visiter insurance plan for them. After going through the information available from forum as well as the website, I must say that the effort put in by Mr.Narender in replying to all the queries is really impressive. Protection America looks good for all purposes and it also has a good number of network of Hospitals, Doctors and labs associated with it.

I am relatively new to US and have not needed to go to any doctor till now, so not much clear about how the medical system and insurance work here. So I have some queries about how this protection America insurance will work in case of some medical need or emergency for visiter in real life situation.

1. Say if someone fall over in house and fractures some bone, you dial 911, ambulance will take to some hospital as per their assesment of medical need as you can not tell them where to go, it will be all their decision. If that hospital is not a part of that PPO network, will Protection America cover the expenses, if yes how much.

2. If the condition not serious enough to warrent 911 call, but you take the person yourself to ER. Will it make any difference if the Hospital to whose ER you go is a part of PPO Network of Protection America or not. The information on website says that for treatment received from a provider outside the PPO network, the plan pays 70% of eligible expenses up to US$5,000, then 100% up to the Policy Maximum. I underatnd this apply for outpatient visit to a doctor. Does this apply to ER visit and the subsequent expenses if admitted there, also.


3. What about presciption drug coverage and lab tests, I see that they give a Pharmacy Drug Card which allows members to purchase prescriptions at the lowest cost available. But, is that it. Or can you still get reimbursement of that presciption drug cost that you will pay and form it a part of single claim like say (doctor visit/ outpatient treatment within network + tests at partcipating lab + Presciption drug expenses) and you can get reimbursed after copayment and deductibles. I mean, do the presciption drug expenses and lab test expenses comes under outpatient treatment which is covered to 100% of policy maximum after coinsurance & deductables or not.

Thanks in advance.

[insubuy]

You have to first pay the deductible once before insurance company pays anything at all.
After that, if you go in the First Health PPO network, Protection America will pay 80% for first $5,000 in covered medidcal expenses, you pay remaining 20%. (Or 90/10 if you have purchased that rider at 5% extra premium.) After $5,000, insurance company will pay 100% up to the selected policy maximum.

If you go out of the PPO network, it will pay 70/30 for first $5,000 and 100% after that up to the policy maximum. This applies whether it is an emergency or not, outpatient or not, hospitalization or not.

1. That's not true.
Most of the hospitals are in the network anyway.
Still, you can tell them where to go given the choices of several hospitals.
And you don't have to wait until something really happens. You just look up the network in advance (right now) and remember the hospital names.

I had a real life scenario with one of the customers. On a Saturday morning, one person's father was walking down the stairs. As he was with holding baby in his hand, he could not see when the steps were ending, he fell down and broke his leg.

While Mr. was busy with ambulance people, Mrs. called our office and rep. picked up the phone. She asked us to look up the PPO network and described the situation. Rep transferred the call to me. (Actually, customer should have called the insurance company, but I was happy to help in all ways I can.)

I told her the names of few hospitals and they told the ambulance where to go. I was busy with this family whole Saturday morning and afternoon, even though ideally it is not part of my duties as a broker. And everything was taken care of properly. I asked them to post the experience on the web site, but they never did. Anyway.

In short, if the hospital is not part of the network, 70/30 for first $5,000 and 100% up to policy max after that.

2. Many people go to emergency room even when it is not really an emergency because it is weekend or appointments are not available easily. It costs lot of money in ER unnecessarily many times.

Therefore, every insurance company has made some rules regarding ER. In Protection America, the rule is that if you go an ER and if you are not subsequently admitted into the hospital, you are subject to extra $250 deductible per that visit.

Again, if the ER hospital is not part of the network, 70/30 for first $5,000 and 100% up to policy max after that.

3. Prescription drugs and lab tests are covered just like anything else. For labs, there is a PPO network.

However, for prescription drugs, there is no PPO network. You just use the Universal Rx card, get the Rx at the discounted price, pay the price and file for reimbursement with IMG, subject to deductible and coinsurance. In other words, prescription drugs are covered just like any other eligible medical expenes.


In short, going to PPO network is always recommended and beneficial to everyone. Just review the network for your area in advance and go there so that you don't have to search at the last moment.
Having said that, First Health PPO is such a large network that practically I have not heard from any one so far saying that they needed to go out of the network.

Please let me know if you have any other questions.

[bugmenot]

Thanks.

Thanks for the replying to my queries. I will definitely buy the insurance through you once the dates of visit are finalised.
Keeping a ready made list of all the hospitals that are in network is a really good suggestion to avoid last minute panic like one of your customers as you said.

I can not think of any other query right now. Will post again if will I have any

[Slavok]

Some questions before enrolling in Protection America plan

Hi, Narendra!

I am about to purchase Protection America plan for my relatives. We are thinking about the 90/10 plan with 0 deductible. But I do have a lot of questions about the plan.

1. Does the plan cover any preventive care (flu shots, children's immmunizations, annual check ups, etc.)
2. If the child is sick but has no fever, just cough, runny nose, sore throat or ear infection or stuff like that and we go to the doctor (one that's in your provider's directory of course :-)) - will that be covered?
3. Does the plan cover any dental stuff?
4. If we were to buy this plan for 6 month - do we have to pay the entire amount right away or can we get charged monthly?
5. What is the copay for doctor visits?
6. Are there any limitations or restrictions on how much is covered as far as doctor visits, hospital stays, and emergency room visits? For example: Doctor Visit cost 120 dolors but insurance only pays 60 dollars' per visits after I paid co-pay? Or if someone broke his arm and we go to emergency room which cost $300 but insurance only pays $100. I just want know if a there are any restrictions.

Thank you in advance for your help

[insubuy]

1. No

2. It will be covered, as long as it is a new medical condition as determined by the insurance company's claims department based on the doctor opinion, attending physician statement and medical records.

3. This is primarily a medical insurance.

Dental Injury: If you get into an accident and injure your sound natural teeth, it will be covered just like any other medical expense.
Sudden Acute Pain: Maximum $100.

For any other coverage, look at CAREINGTON dental plan available at

https://www.insubuy.com/individual-family-dental-plans/

It is $12/month for entire family and there is one time application fee of $20. It gets effective either first of this month or first of next month.

4. Buying and paying is one and same thing.
If you want to buy for 6 months, you must pay for 6 months right away.
On the other hand, if you want to pay for 1 month, you have to say that you want to buy for 1 month and then you renew it. As long as you renew the insurance 1 month or more, there is no renewal fee. If you renew for less than 1 month, there is a $5 renewal fee in addition to the premium. No matter how many times you renew the insurance, the deductible and coinsurance (80/20 or 90/10) are just once a year (annual).

5. There is no copay.
First you pay the deductible (which is $0 in your case) and they you pay the coinsurance for first $5,000 (90/10 in your case).

6. There are no limitations like that.
You first pay the deductible ($0 in your case). Then insurance company pays 90/10 (in your case) for first $5,000 and 100% after that up to policy maximum.
However, there is a special rule for emergency room. Look at item #2 in my previous reply.

Please feel free to post here or contact us if you have any more questions.

[Slavok]

Thank you for the fast reply, Narendra.

I do have some more questions.
1. If we buy this insurance say for 1 year and then during that year one of the insured gets stroke and then at the end of that one year we want to renew again - is that stroke going to be considered a pre-existing condition?

2. Also, what is the maximum total term that we can have this insurance (say if we get for 1 year, then renew for another one, and so on)?

3. What if the insured leaves the country (goes home for a couple of weeks) during the term? Will they still have the coverage after they return to the US? I do understand that it's not going to cover their health expenses at home country.

4. If we were to go with deductible $250 - is that an annual deductible per person or per family?

5. What does the renewal process involve? Do we need to fill out a new application? or is that just a matter of calling in and saying 'Yes, we want to renew'?

Thank you so much for your time.

[insubuy]

1. As long as it was covered in the first period and there is no gap in the coverage, it will be covered after you renew as well.

2. 3 years.

3. Incidental home country coverage is available. Read the brochure at https://www.insubuy.com/patriot-amer...e/brochure.jsp

4. Per person.

5. It is very simple.

You can either call us or visit https://www.insubuy.com/img/renewal/ to renew online. It only takes few minutes.

Please let me know if you have any other questions.

[bugmenot]

When to purchase

How many days in advance should/ can the health insurance be purchased for a visiter before the actual date of start of visit. The insurance is required only for duration of visit of course.

[insubuy]

Insurance can start as early as the next day or any future date you specify. Insurance is effective according to 12.01 AM Eastern time the day you specify.

And in order to cover during the travel time as well, keeping timzeone difference in mind between India and US, you should make it effective one day in advance.

e.g., if the person is traveling on Dec 15, you should make it effective Dec 14, and you should purchase it latest by Dec 13.

Of course, you can purchase it at any later time as well, if you wish.

[bugmenot]

Rephrasing my question

I am sorry, i think i did not make my question clear enough. I intend to buy insurance for my mother effective from 2-Feb-07 to 31-May-07. She will be reaching here on 3rd-Feb-07 and leaving on 30-May-07.

The question I was trying to ask was whether I should/can buy the insurance right now (fill the form, pay the money etc. for coverage for desired period) or say 1 month before visit start date or just a week before the visit start date or after she reaches here. I guess it could be purchased anytime, but what is the best advisable time or it does not matter at all.

Thanks in advance.

[insubuy]

1 week to 10 days in advance.