Florida Health Insurance

This is a Miami Dade Blue case study clipped from several different clients that had different questions about the plan.  Rather than include this in our Miami Dade Blue health plan section this is unique to our Florida Health Insurance Case Study Section.

Question:  My primary care physician is not on your list of In-Network providers. If I read the documents correctly, I will still be able to use this physician; however, the amount I have to pay may be higher due to how the “balance due” is calculated. Is this essentially correct?

Also, I have once yearly blood work done by this same physician – will this be covered or will I have to pay the “balance due” that is over the $50.00 per visit payment amount?

Miami Dade Blue Answer

You are very welcome, if your primary care physician is not in-network then you are correct in that, you would still be able to use them but you would be subject to the outlined out of network benefits.  Which I believe you have an understanding on but let me elaborate just to be sure; BCBSF would still pay the $50 towards the “contracted rate” for whatever medical services are being rendered and you would pay the balance up to the provider’s charges not the contracted or allowed amount.

So, for instance in the example noted below a doctor visit would be similar to this scenario.  If you were to go to an urgent care center or a doctor who is out of network then you would be subject to the same out of network benefits.  BCBSF would pay $50 towards the contracted or allowed amount of $112 and you would not pay the $62 as if you were in network, but rather the difference of the balance up to the provider’s total charges of $154 which would be $104.00.  Had the provider been in network then you would only be responsible to pay $62 – the difference between Blue Cross Blue Shield of Florida’s $50 payment and the contracted amount.

Ideally you want to stay in network, let me know your PCP’s name and I will contact the office to verify if they will be joining the network since there are many still enrolling since the plan is so new.  In the examples below Miami Dade Blue is used to determine the average copay at a Miami Dade physician.

I hope that was a good illustration and answered your question but let me know if you want to further discuss.  With regards to the blood work, if it’s performed by that same out of network physician then the same idea would apply.  However, if you were to go to Quest Diagnostics then you wouldn’t pay anything as per the contract Blue Cross Blue Shield of Florida has established with Quest as is illustrated below.  Below is the Miami Dade Blue Lab Example

Question: What’s the difference between Cover Florida and Miami Dade Blue?

Miami Dade Blue is significantly different than Cover Florida in that Cover Florida is a guaranteed issued policy and requires that the applicant be without insurance for a period of 6 consecutive months preceeding the application process.  Also, since it is a guaranteed issued policy and must approve all applicants the premium is significantly higher than with Miami Dade Blue plan, since MDB is not a guaranteed issued policy and can issue riders, exclude conditions, or decline an applicant in adherence with their underwriting guidelines.

And finally, Cover Florida is a limited benefit plan – Miami Dade Blue offers a 5 million lifetime maximum benefit (meaning BCBS will pay up to 5 million per individual’s lifetime on the policy), Cover Florida offers $25,000 calendar year benefit maximum per individual and a TOTAL Lifetime Maximum benefit of $50,000.  Although I have attached the Cover Florida Plan I and Plan II benefit details I included below a snapshot of the financial features in which reiterates these benefit maximums.

Miami Dade Blue Individual and Miami Dade Blue Group Health Insurance Comparison

I’ve gone ahead and attached just the benefit details for the individual plan and the group plan with my notes.  I looked it over again and only found that the Per Benefit Period and Lifetime Maximum Benefits with the Miami Dade Blue health plan Group and Individual plan are different with respect to the mental health benefits.  Other than that, I cannot find any other differences.  The reason group rates are more expensive is because it assumes more liability, in that, a group policy must be issued to all individual regardless of their risk class and assumes coverage for all pre-existing conditions including maternity.  Whereas with an individual Miami Dade Blue Plan you are underwritten individually and may have riders issued on your policy or be rated up or declined even depending on your health risk class.

So if you are all insurable, and if you let me know what medications and/or conditions any of you or your family members have I will be more than happy to advise what the underwriting guidelines stipulate respectively.

As far as being comparable to what you currently have I don’t know, nor am I sure if you were asking about that – but if you’d like to tell me the name of your plan and number code I can tell you how it measures up and the differences.  I’m sure there are differences if we are comparing either one of these Miami Dade Blue plans with your plan now, but I’ll be happy to go over them with you.

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