Question on Patriot America plan

[Rajesh650]

Hi, I had a few questions about the Patriot America plan.

1. I plan to purchase the plan for my parents (65, 63) for at least 4 months extending to maximum 6 months. I see that Protection America is billed as the best comprehensive coverage, however, if I anyway buy 4 months initially and then it can be renewed, then is there any downside to buy Patriot America? In fact it seems to have 90/10 coverage by default and is cheaper, so it seems to be better for me since renewability should not be an issue.

2. I am planning to buy 50,000 with 250 deductible. If I choose a 500 deductible I am saving around $180 in 6 months. Would you advise such a high deductible, specially if say on an average my parents will go to a doc once in those 6 months?

3. Is Chiropractor visit covered under this plan? Does it need physician approval?

4. Is Physical Therapy covered under this plan? Does it need physician approval?

5. Since it is affiliated with a PPO, do we need a "PCP" to be identified?

6. There are inexpensive "mall" doctors such as Quick Health, who have centers inside Longs or Walmart. They charge flat rate of $49 for doc visit and $29 for cholestrol testing and in fact do not accept insurance. Would these visits be reimbursable by this plan. I understand clearly that diabetes etc is not covered, but if we use these docs only for say general fever/cold/stomach upset etc., then would the plan cover this specially if they are not on the network? This way at least all small visits contributing to the deductible can be done by these doctors.

7. Any other suggestions for inexpensive doctor visit for small issues e.g. cough/cold/fever etc. similar to the above that you may be aware of (in the Bay Area)?

8. Is dentist visit related to a painful tooth ache (not related to accident) covered in this plan for natural teeth?

9. I see that this plan is affiliated with First Health PPO. I searched their provider directory for "Camino Medical" and "PAMF" and it does not show up, but caminomedical.org has listed First Heatlh PPO in their plans and PAMF also has it with a disclaimer that they are not its preferred vendor. So if I take my parents to Camino Medical in the Bay Area (who have not mentioned if they are preferred or not), would it count as In Network?

Thanks for your help!
Raj

[insubuy]

1. If you are buying for minimum 3 months initially, Patriot America is currently better choice.

2. There is no way to know in advance whether higher deductible would work out better or lower. If you never happen to go to Dr, higher deducitble is better. If you got to Dr even once or twice, lower deductible is better.

Having said that, $250 is the most common deductible. But you can choose from $0 to $2,500 deductibles.

3. No.

4. Yes, if referred by physician in writing.

5. No. PCP concept is only there in HMO, not in PPO.

6. If you go out of the network, after the deductible, insurance company pays 80% for first $5,000, you pay 20%. After $5,000, insurance company pays 100% up to the policy maximum.

7. ??

8. Covered up to $100, but subject to chosen deductible.

For better options, look at CAREINGTON dental plan at https://www.insubuy.com/individual-family-dental-plans/

It is $12/month per family and there is one time application fee of $20.

9. El Camino Hospital and El Camino Medical Group are definitely part of First Health PPO. For the medical group, you can't search by the group but you have to search by individual drs over there. Therefore, visits to any of those (Hospital or in network Drs in the Group) would be in network.

[Rajesh650]

Thanks for the prompt reply. A few more clarifications.

1. You mentioned dental pain is covered upto $100 after deductible. So, is that $100 flat coverage or as per the 90/10 coverage? e.g. with $250 deductible, if multiple dentist visits for the same issue cost $350, then would I still get $100 or only 90%?

2. If deductible is applied due to dental visit, is it also counted towards the rest of the policy?

3. If the first doctor visit is less than the deductible, is it correct that we should still file the claim as usual so that it is correctly accounted for in the deductible?

4. Are prescription medication for covered illnesses reimbursable in this plan? I am not referring to usage of the Universal Rx discount card, but rather if due to cough/cold or any other covered illness, if my parents need prescription medication, I wanted to confirm that the plan would cover it regardless of whether it was purchased using the discount card?

5. I read the brochure and it mentions that renewal rates may differ from the initial rate but there were no specific figures or percentages given. Can you please clarify what the renewal rates are?

6. On the claim form, section C-5 asks for all previous ailments etc and the attending physicians name and addresses. My parents have diabetes and bp, and have visited a few doctors over the past couple of years, so is it neccessary to gave every doctor's name/address or would just the family doctor's name/address do? when is this doctor actually contacted, and do we need their India phone number as well in the claim form?

7. For the "?" answer you gave, let me clarify: I wanted to know if you are aware of any low cost medical practitioners similar to the Quick Health services, who specifically cater to non-insured or travelers who have to pay from their own pocket for small medical expenses?

Thanks
Raj

[Rajesh650]

Oh and another thing.

I did a search for one of the physicians in the Camino Medical Group and they did show up as you said. However, physicians in the PAMF do not appear. Given that PAMF owns CMG, would going to a physician in PAMF be assumed to be in-network (PAMF is next door and CMG is almost 10 miles away for me).

Thanks!
Raj

[insubuy]

1 & 2.
There is $100 coverage, subject to deductible and coinsurance.

Lets assume you have taken $50,000 policy maximum with $250 deducitble. Lets take several scenarios:

Scenario 1:
You have not used the insurance at all. $100 coverage goes towards your $250 deductible and you still have $150 to pay towards future medical expenses.

Scenario 2:
You already have spent $600 in medical expnese. Insurance company will pay 90% up to total of $100 for dental.

Scenario 3:
You already have spent $7,000 in medical expense. Insurance company will pay 100% up to total of $100 for dental.

3.
That's right.

4.
Yes, they are covered just like any other eligible medical expenses. (Having Rx discount card is just an additional bonus to reduce the price of the drug both for you and the insurance company.)

5.
Renewal rates may differ for a couple of reasons:
* If the person goes into a higher age bracket at the time of renewal. Lets assume the person was 64 years old when purchasing, but is 65 years old when renewing. In that case, the person would be charged renewal premium according to age 65.
* If the entire insurance plan gets revised and the prices are different for everybody in the world. In that case, you may be charged different premium for renewing. However, this is really not a concern because the plan gets revised maximum once in a year and for the past 6 years, I have not seen the prices go up.

6.
The exact amount of information needed is decided on a case by case basis. After looking at the current medical records (generated during the treatment in the US), if the claims department determines that they require more information to make an accurate decision, they may ask further information.

7.
No.

[txh1b]

You mention in your post that you have not seen the visitor insurance price go up in the past 6 years. As you are an experienced insurance specialist, what is your thought on this?

Is it because the coverage is limited/fixed with exclusions for pre-existing conditions that the cost has remained stable? For example, for insurance provided by my employer (100% coverage, no deductible), my monthly cost has gone up from $45/month to close to $200 per month (100% coverage, 250 deductible) in the past 6 years also changing from PPO initially to EPO/HMO recently for the same coverage.

I understand that the employer might have changed their contribution but still, the prices have been going up for medical insurance and visitor insurance remains the same. Any thoughts appreciated.

[insubuy]

Oh and another thing.

I did a search for one of the physicians in the Camino Medical Group and they did show up as you said. However, physicians in the PAMF do not appear. Given that PAMF owns CMG, would going to a physician in PAMF be assumed to be in-network (PAMF is next door and CMG is almost 10 miles away for me).

Thanks!
Raj

I am not sure how exactly you are searching. Are you searching by entering PAMF? Are you searching by a doctor name? By an address?

If PAMF owns CMG, I would think PAMF is a superset of CMG. And therefore, going to PAMF may be considered the same as going to CMG. I would suggest you call them ask them whether they participate in First Health PPO or not to be sure.

[insubuy]

You mention in your post that you have not seen the visitor insurance price go up in the past 6 years. As you are an experienced insurance specialist, what is your thought on this?

Is it because the coverage is limited/fixed with exclusions for pre-existing conditions that the cost has remained stable? For example, for insurance provided by my employer (100% coverage, no deductible), my monthly cost has gone up from $45/month to close to $200 per month (100% coverage, 250 deductible) in the past 6 years also changing from PPO initially to EPO/HMO recently for the same coverage.

I understand that the employer might have changed their contribution but still, the prices have been going up for medical insurance and visitor insurance remains the same. Any thoughts appreciated.

This is my best estimation:
It is primarily due to the fact that it is short term insurance plan that does not cover pre-existing conditions, preventive checks up, immunizations, maternity etc. Those are the factors that drive the cost up.

Of course, I am a broker and don't own any of the insurance companies and therefore I don't have the complete premium data and claims data to make more precise comments than given above.

[Rajesh650]

Actually I was searching on the specific doctor's name as you recommended. I found a doctor in CMG and he was found as in-network on the provider directory. However, a few doctors I know in PAMF do not show up.

Even though PAMF owns CMG my understanding also was that they should be using the same network, however, PAMF site explicitly says that they take First Health but that they are not preferred vendors. I will call up and confirm.

Thanks for all your inputs.

Regards
raj

[insubuy]

Even though I can't comment on a specific facility or doctor, many times, if there are multiple doctors in the same clinic, only one or few of them are contracted with a given PPO network and when patients visits any of the doctors in that clinic, the clinic would send the claims through the doctor who is contracted with a particular PPO network. Of course, that may not happen everywhere all the time and that is why you need to confirm.

Also, for your information, you can always go to the doctors outside the network. There is no restriction that you have to go in the network only. If you go to the provider outside the network, instead of 90/10 coinsurance for first $5,000, it will be 80/20 coinsurance for first $5,000.

Many times, even if a particular doctor is not in the network, he may still bill the insurance company directly and not demand payment upfront. (That was the case with one of the Drs I used to go to when I used to stay in Virginia.)

Even if, the provider is not in the nework, and does not agree to bill the insurance company directly, still that is not a problem. You just take the bill from the provider, download a claim form from https://www.insubuy.com/clients/ and send it to the insurance company. After the papers reach the insruance company, rest of the processing is the same whether the doctor billed the insurance company directly or you mailed them the papers.

[insubuy]

Additional suggestion:

Please confirm with the clinic or doctor before the visit that they are still part of the network. In RARE cases, the PPO contract expired between the time the appointment was made and the actual appointment date.

[Rajesh650]

Hello Mr. Narendra,

Couple of more questions as I am about to book Patriot America for my parents.

1. They are starting Bombay at 4am 17-May-2008 (3:30pm PST 16-May-2008) and arriving same day here in SFO. I had a question on when to start their coverage: I read in earlier posts that you recommended starting one day early, however the brochure says coverage effective date is LATER of requested effective date or departure date from home country. In this case since home country is India that means coverage would only be effective 17th May, so is that the date I should put?

2. I also wanted to confirm how "departure from home country" is identified? e.g. one of the posts you mentioned how older parents can hurt their backs lifting luggage etc., so in case there is some injury to the back starting from Bombay itself; or say during a stop over in Seoul, would that be covered? Is boarding flight/check-in counter at Bombay airport be considered as effectively "departed from home country"?

3. Does Patriot America give international collect phone numbers for use in the unlikely event they need urgent hospitalzation?

Thanks!

[insubuy]

1.
The coverage starts according to the US Eastern time at 12.01 AM on the day you specify.

You need to put the departure date, effective date, arrival date etc. on May 16, 2008.
These systems and policies were made when so many people from India didn't come to USA. Therefore, they didn't realize that it takes more than a day to get here.

2. Any new medical conditions occuring outside the home country are covered. Therefore, if something new happens in Seoul, they are covered.
Any problem arising in home country is not covered.

3. Yes.