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  • WI - Qualifying Event for Insurance Change

    I hope I am posting this in the correct area, please correct me if I am wrong.

    My company is being bought out and my insurance provider is changing. The new insurance provider doesn't cover the hospital that my family goes to. We would like to change to my wife's insurance but according to her company this is not a qualifying event and we have to wait for open enrollment(end of 2006). Does anyone know if this is correct? Are there any Federal or Wisconsin laws that state otherwise?

    According to my wife's company we are not losing insurance or offered COBRA so it is not a qualifying event for them.

    My HR Dept. is dumbfounded and are trying to help, but they are so busy with merger details they haven't found any laws that state this is a qualifying event.

    Thanks in advance for your help.

  • #2
    They are correct. Your getting a new insurance carrier, even if the hospital you prefer to go to is not covered on the new plan, is not a qualifying event.
    The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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    • #3
      You would need to read the plan documents for the plan at your wife's company. Normally, losing insurance coverage altogether would be a qualifying event. I'm not familiar with any plan that would consider a different plan that the employee doesn't like to be a qualifying event.
      I am not able to respond to private messages. Thanks!

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      • #4
        If this is a Section 125 plan, I can pretty much guarantee that this is not a qualifying event. As Marketeer says, if you were losing coverage ALTOGETHER it would be, but just changing to a plan you don't like doesn't cut it. Section 125 plans are pretty rigid about what can and cannot be considered a qualifying event because of the pre-tax status.
        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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        • #5
          Thanks for the responses.

          The part that makes this ten times worse is that my Wife's company is the hospital that is not going to be covered by my new insurance provider. Now if we want to go to the hospital where my wife works we are going to have to pay out of network prices. We've tried talking to the HR dept of my wife's company and they haven't been very helpful. Anyone have any other thoughts or are we pretty much SOL?

          It just seems ridiculous that they couldn't make an exception when they are forcing one of their own employees to go to a competing hospital for care. There are a few people at my company that are in this same situation.

          Thanks again.

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          • #6
            Again, if this is a Section 125 plan, they do not have the option of making an exception. The law dictates what is and is not a permissable qualifying event, and this isn't.
            The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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            • #7
              Plus, they aren't forcing anything. If you choose to go to a hospital that is not "in-plan", that's your choice, you just have to pay for it.
              I don't respond to Private Messages unless the moderator specifically refers you to me for that purpose. Thank you.

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              • #8
                The part that makes this ten times worse is that my Wife's company is the hospital that is not going to be covered by my new insurance provider. Now if we want to go to the hospital where my wife works we are going to have to pay out of network prices The hospital where your wife works IS covered by your insurance - it's just not in their discounted perferred provider network, therefore if you seen services at that hospital, your shared cost is subject to meeting the annual deductible and most likely a lower co-insurance rate (i.e. 70/30 rather than 80/20 in network or something similar.)

                It just seems ridiculous that they couldn't make an exception when they are forcing one of their own employees to go to a competing hospital for care. The reason that some hospitals and medical providers are "in network" is because they have agreed to reduce their charges and fees and therefore the insuranced company can pass those savings along to the participants. For whatever reason, your wife's hospital is not in this discounted network, therefore there are no savings to pass along to the insureds if they use this hospital. It's not a question of making an exception - it's a question of sharing the reduced costs and with this hospital, there aren't any.

                The other posters are quite right that this does not qualify as a qualifying event.

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                • #9
                  Thanks for all the responses. I haven't heard back from my wife's HR dept if it is a Section 125 plan, but from the sounds of it, it most likely is.

                  I didn't even go into the other part of this saga, but my wife's hospital wouldn't negotiate with my new companys insurance provider to let us be considered in-network. So basically they are letting 400+ patients walk over to there competition and they don't care.

                  @Pattymd - When you don't have a lot of disposable income and your insurance rates are going up and you are going to have to pay over twice as much to continue going to the same hospital they pretty much are forcing us to change.

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                  • #10
                    I don't have much disposable income either. But I make choices, and some of those choices are based on my financial situation, just like you. "Forcing" implies "being made to". Legally, you aren't.
                    I don't respond to Private Messages unless the moderator specifically refers you to me for that purpose. Thank you.

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                    • #11
                      There are reasons why hospitals and phsicians choose not to be part of a specific network. Usually it has to do with the negotiated costs. Some networks dont pay as much as others and the dr/hospital just loses money.
                      No, it doesnt make sense at your level but this must make sense from a business perspective somewhere or they wouldnt be doing this.

                      Our hospital is part of our network but the local urgent care place isnt. That means that in an emergecy, our employees can not go to the cheaper urgent care place but must go to the more expensive ER at the hospital. That makes no sense to us, since its more costly for the insurer and us.

                      However, the urgent care place says our plan's negotiated coverage is lower than many others and if they started accepting it not only would they not cover their expenses, they wouldnt have the staff to treat all the potential patients.

                      Its perfectly legal.
                      I find that the harder I work, the more luck I seem to have.
                      Thomas Jefferson

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                      • #12
                        Morgana, did you happen to notice that this thread is almost two years old?
                        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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                        • #13
                          Nope, I sure didnt. Sorry. I usually look at that.
                          I find that the harder I work, the more luck I seem to have.
                          Thomas Jefferson

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