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Some things I've learned about medical insurance this year

Panina

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However, the doctor(s) still need to accept Medicare patients.
My mom has traditional Medicare and there has never been a doctor she has gone to that didn’t accept it. She has been to the best doctors. What I like about it is she can choose the doctor versus having to choose one in a network. She does buy a supplemental plan to cover the 20%.

Now what I have learned about medical insurance this year......it is so unfair. My other half had a bad long deep cut in his leg that happened from a freak accident and had to go to the emergency room for stitches and staples.

He already pays a very high premium for the affordable health care plan. His deductible is so high and he is on the silver plan, between deductible and co payments so far he received bills of almost $5000 that he has to pay.

All I know is I pay full cost on an insurance plan that my deceased husband use to be on. I get the luxury of staying on it as long as I pay full cost of what the company pays, and it is a luxury. In eleven years my premium has only gone up $60 and I only would have to pay $500 if the accident happened to me plus I am able to see any doctor I want and he cannot.

Meanwhile my current other half’s insurance costs 3x of what mine costs plus all these deductibles and co payments. And he still has a few more thousand toward the deductible if additional bills come in.

To add injury to insult, he is retired military and eligible for Tricare and the system failed there too. With all the forms and calls to apply for his pension no one told him he had to apply for Tricare before his retirement date. Being the paperwork went back and forth many times because the helpline kept sending wrong forms, wrong info, missing forms, delays occurred. Now months after his retirement date they are so behind with processing and told him until he is approved for his pension he cannot go on Tricare. Thus all these medical bills wouldn’t have happened if he was on Tricare like he was supposed to be. Ugh.
 

Luanne

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My mom has traditional Medicare and there has never been a doctor she has gone to that didn’t accept it. She has been to the best doctors. What I like about it is she can choose the doctor versus having to choose one in a network. She does buy a supplemental plan to cover the 20%.
When we moved to Santa Fe we needed to find new doctors. Since dh was on Medicare we wanted to find doctors that would accept it. My sil's doctor would not. Turns out he retired a couple of years after we moved here, so maybe he just wasn't accepting new patients at all. We did find an internal medicine doctor who was accepting new patients, and new Medicare patients.

When my dd wanted to find an OB/GYN we got some recommendations. When we went in for her appointment I asked if the doctor was taking Medicare patients. Nope. Then I asked if someone was a current patient and reached Medicare age would they still be a patient. Yes. So I went in for my first exam two months before my 65th birthday. I became a patient and was able to continue to see this doctor.

So, while we are not restricted by a network, we are still restricted to doctors who accept Medicare patients.
 

WinniWoman

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My mom has traditional Medicare and there has never been a doctor she has gone to that didn’t accept it. She has been to the best doctors. What I like about it is she can choose the doctor versus having to choose one in a network. She does buy a supplemental plan to cover the 20%.

Now what I have learned about medical insurance this year......it is so unfair. My other half had a bad long deep cut in his leg that happened from a freak accident and had to go to the emergency room for stitches and staples.

He already pays a very high premium for the affordable health care plan. His deductible is so high and he is on the silver plan, between deductible and co payments so far he received bills of almost $5000 that he has to pay.

All I know is I pay full cost on an insurance plan that my deceased husband use to be on. I get the luxury of staying on it as long as I pay full cost of what the company pays, and it is a luxury. In eleven years my premium has only gone up $60 and I only would have to pay $500 if the accident happened to me plus I am able to see any doctor I want and he cannot.

Meanwhile my current other half’s insurance costs 3x of what mine costs plus all these deductibles and co payments. And he still has a few more thousand toward the deductible if additional bills come in.

To add injury to insult, he is retired military and eligible for Tricare and the system failed there too. With all the forms and calls to apply for his pension no one told him he had to apply for Tricare before his retirement date. Being the paperwork went back and forth many times because the helpline kept sending wrong forms, wrong info, missing forms, delays occurred. Now months after his retirement date they are so behind with processing and told him until he is approved for his pension he cannot go on Tricare. Thus all these medical bills wouldn’t have happened if he was on Tricare like he was supposed to be. Ugh.


It is so disgusting how veterans especially- and heck- all people- are treated in the health care system here.
 

bogey21

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Traditional Medicare + Supplement + Part D for prescriptions provides the most flexibility but it is a lot more expensive. Counting the deduction from my Social Security for Part B I spend around $5,000 a year for the combo. When you add it all up a $0 premium Medicare Advantage Plan looks pretty good despite its shortcomings...

George
 

isisdave

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George, on MA you still have to pay the Part B premium ($1608 this year). The remainder is $3400 or $283 a month. You should be able to find a Medigap plan G or N, and a low-cost Part D drug plan, for less than that. I'm 70 and I'll be paying $135 for N next year (AARP's UHC deal) and $14 for WellCare Wellness Rx (PDP)

One thing to note: some companies charge depending on your current age (so it goes up every year); some on your age at enrollment (should go up with inflation but less than age-rated); and some (including the AARP plan) are community-rated, which means not age-dependent. So use the plan comparison tool at medicare.gov to find the candidates. You still have to go an look up prices for each of them, which is a pain, but worth it for a couple thousand a year.
 

VacationForever

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Traditional Medicare + Supplement + Part D for prescriptions provides the most flexibility but it is a lot more expensive. Counting the deduction from my Social Security for Part B I spend around $5,000 a year for the combo. When you add it all up a $0 premium Medicare Advantage Plan looks pretty good despite its shortcomings...

George
Everyone has to pay the $144.60 to Medicare, whether you want to be on traditional Medicare, Medigap or Advantage plan. In your case, you are also paying IRMAA penalties and so would anyone having higher income. In addition, not all Advantage plans are free. The Aetna Medicare Advantage Select PPO here costs $73 per month.
 

JudyH

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I am now thinking when I turn 65, I will buy a supplement plan so that I don't need to worry about whether a hospital or doctor is part of a Medicare Advantage PPO or not. My husband's Medicare Advantage Select PPO plan (no referral needed) allows him to see doctors everywhere in the US as long as they are part of PPO's doctors and hospital network which exists in all 50 states. It also covers urgent care/emergency care outside of the US.

But if you are taken someplace in a true emergency or are unconscious, you have no way of knowing if a treating doctor is a part of that network. Most of us are at risk for that situation regardless of the level of our insurance plan.
 

bogey21

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Everyone has to pay the $144.60 to Medicare, whether you want to be on traditional Medicare, Medigap or Advantage plan. In your case, you are also paying IRMAA penalties and so would anyone having higher income. In addition, not all Advantage plans are free. The Aetna Medicare Advantage Select PPO here costs $73 per month.
What you are saying is true but my bottom line is that I have chosen to spend about $5,000 per year for coverage I want versus a $0 premium Advantage plan that is available to me...

George
 

WinniWoman

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George, on MA you still have to pay the Part B premium ($1608 this year). The remainder is $3400 or $283 a month. You should be able to find a Medigap plan G or N, and a low-cost Part D drug plan, for less than that. I'm 70 and I'll be paying $135 for N next year (AARP's UHC deal) and $14 for WellCare Wellness Rx (PDP)

One thing to note: some companies charge depending on your current age (so it goes up every year); some on your age at enrollment (should go up with inflation but less than age-rated); and some (including the AARP plan) are community-rated, which means not age-dependent. So use the plan comparison tool at medicare.gov to find the candidates. You still have to go an look up prices for each of them, which is a pain, but worth it for a couple thousand a year.

My husband will be on Medicare for the first time starting 1/1. His Plan F- community rated (NY)- is $230 per month and we chose the cheapest Part D plan- Wellcare- for $14 per month since it covers his blood pressure medicine. We couldn't make heads nor tails fo the drug plans anyway.

When we move out of state which will hopefully be shortly after 1/1 we are hoping for a cheaper premium for the Medigap plan.
 
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geekette

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But if you are taken someplace in a true emergency or are unconscious, you have no way of knowing if a treating doctor is a part of that network. Most of us are at risk for that situation regardless of the level of our insurance plan.
even if you do end up at "a covered hospital", ins co can still deny payment, saying it wasn't medically necessary. This is the new trend. You can't just have chest pains, you have to know you are actually having a heart attack. loony.
 

rapmarks

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even if you do end up at "a covered hospital", ins co can still deny payment, saying it wasn't medically necessary. This is the new trend. You can't just have chest pains, you have to know you are actually having a heart attack. loony.
This happened to us three times but it was way back in the seventies. My three year old son with 106 fever not medically necessary , and a couple other incidents.
But, you can go to an in network hospital, see an in network physician , but if he orders an X-ray, mri, or cat scan that is read by an out of network radiologist, that won’t be covered.
 

VacationForever

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I guess it is the advantage of being in a true HMO system like Kaiser. You go to Kaiser ER or urgent care. All doctors work for Kaiser. The downside of a HMO system like that you cannot go to an outside specialist, unless you want to pay for it, when you have an incompetent specialist.
 

Luanne

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I guess it is the advantage of being in a true HMO system like Kaiser. You go to Kaiser ER or urgent care. All doctors work for Kaiser. The downside of a HMO system like that you cannot go to an outside specialist, unless you want to pay for it, when you have an incompetent specialist.
What do you do if you are traveling and need medical care and there is no Kaiser around?
 

VacationForever

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What do you do if you are traveling and need medical care and there is no Kaiser around?
Don't travel. LOL. Seriously when we were with Kaiser, my husband caught norovirus and most likely on the flight over to Las Vegas. My husband went in an ambulance and they took him to the nearest hospital. He was in a very serious condition and they did alot of tests on him, EKG etc etc. The hospital accepted the Kaiser card and we did not receive any bills from them on our return. We did receive letters from Kaiser indicating how much they paid for the treatment.
 

Timeshare Von

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I disagree. Take the time to make your own rational decision. Then act. I have ignored the advice of Cardiologists three times with no negative ramifications. First, 30 years ago I was told I needed a pacemaker. I refused. Second, 7 or 8 years ago Cardiologist wanted to put me on Multaq, a drug I considered dangerous as I was on a blood thinner. I refused. And Third, about 3 years ago I was advised to have an ablation (where they deaden part of the heart) for my A-fib. After study, I refused. I'm still here. 84½ young and doing fine. My cynical opinion is that some (maybe much) of the advice given patients is to gin up income for Doctors and Hospitals...

George

I too have had a similar situation (so far) George!

My heart condition landed me with a specialist who wanted to install an ICD as well. I have refused that due to more unintended consequences than the risk factor of the actual condition at my age. Not to mention as a cancer survivor, the chances of cancer coming back and being the cause of death down the road is higher than the HCM I have.

I too have a guarded outlook on medical advice and motive. I also feel some medical professionals just want to be the hero, performing heroic procedures . . . and in some cases, experimental based on theory (i.e., never been done before) type stuff. I know for a fact that was the case with my father back in the 1970's!

Two medical stories . . . He survived this radical "first time on a human adult" surgery.

Only to have them try more heroic procedures two years later, that he died from.
 

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A bright side tip: for those that are having kids or have daughters/granddaughters of that stage in their life, some health plans (mostly high deductible plans) have a pregnancy program where you call their nurse to check in every few weeks, and they write you a check for being a good patient. I called during second trimester and they sent me a check for $200; I think If I called during first it would’ve been around $400.
 

Quiet Pine

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My husband will be on Medicare for the first time starting 1/1. His Plan F- community rated (NY)- is $230 per month and we chose the cheapest Part D plan- Wellcare- for $14 per month

"Medigap Plan F and Plan C can't be sold to newly eligible Medicare beneficiaries after January 1, 2020." Seems that he just squeezed in. I also have Wellcare Part D for $13.10 a month. Deductible is $435, and I spend way less than $100 a year on medication. It's insurance so I don't mind. I pay house & car insurance and don't complain when the house doesn't burn down & the car isn't totaled.
 

WinniWoman

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"Medigap Plan F and Plan C can't be sold to newly eligible Medicare beneficiaries after January 1, 2020." Seems that he just squeezed in. I also have Wellcare Part D for $13.10 a month. Deductible is $435, and I spend way less than $100 a year on medication. It's insurance so I don't mind. I pay house & car insurance and don't complain when the house doesn't burn down & the car isn't totaled.

as long as a person is Medicare eligible in 2019, they can still get plan F or C for 2020.
 

CalGalTraveler

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We have visited the ER in Vegas and Texas and Kaiser directed us to local ER. No problems. Took our Kaiser card and no bill other than copays. It's when you dont need ER or urgent care when Kaiser issues arise.

Also if there are Kaisers in the area it can get confusing. We had a snafu in non-Kaiser Hawaii ER visit but it was all paid for in the end.
 

Talent312

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As long as a person is Medicare eligible in 2019, they can still get plan F or C for 2020.

I just started my initial enrollment period (IEP), but wont turn 65 until March.
Thus, no Plan F for me. So, I'll go with Plan G instead (which ain't to shabby).
DW has Plan F... But at least we'll both have the same WellCare drug plan. :thumbup:
 

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Thanks to all who replied. Good news - we're not alone in our frustration. Bad news - we're not alone in our frustration - and situations.

Here's an update (to original post) to the cardiologist bill (considered out-of-network). It was actually $970. They did call back on Monday and after we talked for a bit, she offered - since I would be self-pay - I could pay half ($485) to clear it. I had already hit my high deductible and told her that because they wouldn't change the coding to emergency that we had to self-pay (without it going against deductible) in order for them to get paid - and that wasn't fair. She said (again) their office uses Medicare and Medicaid guidelines so that's why they had to code it as an office visit. 'So, you're telling me that Medicare is requiring you to lie in order to code it 'properly' because I never set foot in the office?' (I said it nicely). I also told her I didn't envy her her job as she had to deal with people like me (patients who didn't agree with their coding), the office policies and Medicare and Medicaid guidelines. She was very nice and all (and she sounded like she agreed with me - but she couldn't say that much). She then offered to give me an additional discount of 40% off if I paid it in one lump sum (rather than setting up the $485 in payments). She said that took it down to $291. I told her I needed to discuss this with my husband and call her back. After my husband said 'a few things' (including filing bankruptcy) we felt it in our best interest of using our time to 'just pay it and get it over with'. I talked to the gal today. I'm going to call her again on Monday to pay it (wanted to make sure I had it in our HSA account).

Unfortunately, this is the second bill like this - and it was sorta handled the same way. This was another out-of-network doctor that had been assigned during the emergency room visit. That bill got knocked down from $525 to $212 and some change. Same kind of circumstance. That happened early on and we felt it wasn't worth the time to fight it any longer than we had - so we paid it (and it didn't go against deductible). So we've paid the deductible AND the $212 and will also pay the $291. An extra $503 out-of-pocket for out-of-network doctors who had been assigned in an emergency situation and who then would not code it as an emergency.

This lesson is most crucial. Be persistent and get some sort of discount especially if you are 'self-pay' (including if you're paying toward your deductible after the bill has been knocked down by insurance). I really never 'asked' them for a discount. I just kept stating my case ('change the coding') AND that it is unfair to make my husband work additional hours in order to pay this bill because their office is unwilling to code the bill so that the insurance would pay. I still don't get this.

In the end - the Doctor's office would probably have gotten the $485 (maybe more) if they had changed the coding to 'emergency' and submitted it that way and gotten paid by insurance (since I had hit my deductible). The woman I talked to said that if she did that, the guidelines would consider that 'fraud' (???). Their own rules messed them up. And their rules are making us pay an additional $291 out of pocket. But I guess it's better than $970. And there's the rub right there. 'Happy' to pay $291 instead of $970. Grrrrrrr

Final lesson? Maybe, if I'm out of town, I won't give them insurance info and see what happens. Hope I never have to test this theory.
 

Passepartout

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This is exactly why when we buy travel insurance, we ONLY buy PRIMARY coverage. That way if you have a claim, it doesn't have to be submitted to your 'regular' insurance first.
 

Brett

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Thanks to all who replied. Good news - we're not alone in our frustration. Bad news - we're not alone in our frustration - and situations.

Here's an update (to original post) to the cardiologist bill (considered out-of-network). It was actually $970. They did call back on Monday and after we talked for a bit, she offered - since I would be self-pay - I could pay half ($485) to clear it. I had already hit my high deductible and told her that because they wouldn't change the coding to emergency that we had to self-pay (without it going against deductible) in order for them to get paid - and that wasn't fair. She said (again) their office uses Medicare and Medicaid guidelines so that's why they had to code it as an office visit. 'So, you're telling me that Medicare is requiring you to lie in order to code it 'properly' because I never set foot in the office?' (I said it nicely). I also told her I didn't envy her her job as she had to deal with people like me (patients who didn't agree with their coding), the office policies and Medicare and Medicaid guidelines. She was very nice and all (and she sounded like she agreed with me - but she couldn't say that much). She then offered to give me an additional discount of 40% off if I paid it in one lump sum (rather than setting up the $485 in payments). She said that took it down to $291. I told her I needed to discuss this with my husband and call her back. After my husband said 'a few things' (including filing bankruptcy) we felt it in our best interest of using our time to 'just pay it and get it over with'. I talked to the gal today. I'm going to call her again on Monday to pay it (wanted to make sure I had it in our HSA account).

Unfortunately, this is the second bill like this - and it was sorta handled the same way. This was another out-of-network doctor that had been assigned during the emergency room visit. That bill got knocked down from $525 to $212 and some change. Same kind of circumstance. That happened early on and we felt it wasn't worth the time to fight it any longer than we had - so we paid it (and it didn't go against deductible). So we've paid the deductible AND the $212 and will also pay the $291. An extra $503 out-of-pocket for out-of-network doctors who had been assigned in an emergency situation and who then would not code it as an emergency.

This lesson is most crucial. Be persistent and get some sort of discount especially if you are 'self-pay' (including if you're paying toward your deductible after the bill has been knocked down by insurance). I really never 'asked' them for a discount. I just kept stating my case ('change the coding') AND that it is unfair to make my husband work additional hours in order to pay this bill because their office is unwilling to code the bill so that the insurance would pay. I still don't get this.

In the end - the Doctor's office would probably have gotten the $485 (maybe more) if they had changed the coding to 'emergency' and submitted it that way and gotten paid by insurance (since I had hit my deductible). The woman I talked to said that if she did that, the guidelines would consider that 'fraud' (???). Their own rules messed them up. And their rules are making us pay an additional $291 out of pocket. But I guess it's better than $970. And there's the rub right there. 'Happy' to pay $291 instead of $970. Grrrrrrr

Final lesson? Maybe, if I'm out of town, I won't give them insurance info and see what happens. Hope I never have to test this theory.

yes, threaten them with bankruptcy. You may label non-network doctor medical billing a 'bait and switch" or "racket" ..... others call it "legal fraud"

https://www.nytimes.com/2019/12/07/...l?action=click&module=Opinion&pgtype=Homepage
 
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WinniWoman

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