Good morning.
We have big challenges but we’re not going to focus on those in this post. Instead we’re going to focus on smaller, more solvable challenges in this series of posts.
Do you need to know if your deductible applies to a preventative visit?
Are you getting a ton of mail about Medicare Advantage plans?
What does redetermination mean for Medicaid?
Or any of the 1,001 other confusing things about health insurance that we have to deal with every day no matter what happens in Washington.
Let’s be a helping community for each other. Put your questions and situations in comments. We’ll try to solve them and I’ll recap a few at the end of the week.
Thursday
I was speaking with a friend yesterday who just turned 27, and was leaving her family’s insurance for the first time. Now, she and her family have no idea what they’re doing – apparently they started on the exchanges, but balked when they saw the prices. She didn’t even realize she should be getting a subsidy (I am very certain she would qualify for a subsidy). So she went off-exchange, where she was quoted a much lower price (for a bronze equivalent or something, I’m sure), but when she mentioned she had been sick the month before, they raised the quote by $30, and she thought that condition wouldn’t be covered for the first year.
So my question is – I thought preexisting conditions were no longer a thing at all, even off exchange. Am I wrong? Or did she maybe misunderstand what was going on? Or were they just taking advantage of someone who has no clue how any of this works?
gkoutnik
OK – are there really any differences among Medicaid Advantage policies? As someone who has had employer insurance all his adult life, and has never ‘shopped’ for health insurance, what should I be looking for?
MattF
Yeah, I get a lot of Medicare Advantage mail, along with AARP mail, retirement community mail, hearing aid mail, investment advice mail, et cetera. Also, in my case, my employer offers a retiree health benefit– basically a secondary insurance policy + drug benefit. There’s a complication if you go to a physician who doesn’t accept Medicare– you have to figure out what the Medicare coverage would have been and then submit a claim to the secondary insurer. I think that the secondary insurance is a pretty good deal– I’ve gone to a few pre-retirement meetings and asked questions– but, actually, I have no idea. I think an MA plan would be a plausible alternative, but, again, I actually have no idea, and I’m wary about giving up a retirement benefit
Armadillo
US citizen who lives overseas. I currently pay for my own insurance (myself and kids), which does not cover the US. What is the best way for me to get US health care coverage for my family? We will likely remain overseas, but sometimes come back to visit relatives or to see medical specialists because our country of residence does not provide those services.
Armadillo
And also thank you very much for all that you have done.
Peej01
I’m not 65 yet, but I’m thinking that I should get a Medicare supplemental insurance plan when I go on Medicare. Can you explain the costs/benefits of those policies?
AliceBlue
Dumb question probably, but here goes: I’ll be 65 next July. Will I be automatically enrolled in Medicare or is there an application form? Also Peej01’s question @ #6.
Barbara
@MattF: @Peej01: @AliceBlue:
For starters, go to Medicare.gov. There is a handbook that you probably already received but its on-line alternative can be easier to navigate. There is also a health plan comparison tool that allows you to plug in your exact drugs in order to personalize the comparison. It is my experience that most Medicare beneficiaries ask a threshold question of whether their doctor is in the network. For that, you might need to just ask your doctor. The comparison tool allows you to order results by premium, maximum out of pocket, etc.
MA versus Med. Supp. or some other kind of wrap around: The general perception is that if your employer is paying for an option, it usually ends up being a better deal, but you should do your homework. And no, I wouldn’t waive anything.
One thing to remember: for Medicare Supp, you are not underwritten when you are first eligible so if you think you want Supp, the best time to try it is when you are first eligible, because if you first enroll later, you will end up paying more. Also, some options are set to grandfather (although I am not sure of dates), so you if you wait you might not be able to buy them later. You can always enroll (during the next enrollment cycle) in Medicare Advantage if it seems like the best option. Many people like MA because it rolls everything together. It tends to be less expensive if you don’t have any employment related subsidies, but that varies dramatically by plan and by geography.
Medicare.gov also has a Med. Supp. premium and out of pocket cost estimator, but for actual pricing you need to contact a broker or insurance company.
Alice, the handbook should tell you exactly how to enroll, and the website has a whole section on applying for Medicare. Part A is easier, but Part B has premiums so you have to figure out how to pay for it. If you wait to enroll in Part B, your premium will go up over time.
rikyrah
Once again..
THANK YOU SO MUCH MAYHEW FOR ALL THAT YOU DO.
You can’t imagine how much information and fears you help quell on a daily basis :)
You rock!!
MomSense
My friend just canceled her physical, after waiting months for a doctor accepting patients, because she was told she had a $30 copay. She cannot swing the copay right now for all sorts of shitty reasons.
I thought physicals were covered by the ACA and not subject to copays or deductibles.
HELP. She’s a heavy smoker and needs to be seen.
BroD
My perplexity has to do with the fact that my wife is retiring from the university system. She’s carried me and my daughter on her health care plan for decades (I could have but I retired earlier) I’m not sure what impact her retirement will have on our options. I guess we’d better get clarification, huh?
Thanks for dislodging this (pretty significant issue) from the back of my mind!
Yarrow
@MomSense: She needs to tell the doctor’s office she’s booking the appointment as her annual physical. That is covered without a co-pay. One per year. She could have visited her doctor previously this year and have a balance and the $30 is a balance from that and not a co-pay. Or, the doctor could be doing some testing that isn’t covered under the annual physical and she has to pay for that, but they probably wouldn’t tell her that up front. It could be as simple as her calling back and making sure she’s booked under annual physical.
Yarrow
My question is: What happens to older parents who reach Medicare age but still have kids under 26. How are those kids “covered under their parents’ insurance?” I don’t think they can go on Medicare, can they? Does that dump them into the Exchange (or off-Exchange) market sooner?
Barbara
@Yarrow: Medicare is by individual eligibility criteria and dependents are definitely not covered by association. Looking at some various resources, your options are the exchanges, COBRA continuation under the employer’s plan, or, depending on income status, possibly Medicaid, or just individual coverage off the exchanges.
Barbara
@MomSense: A gentle rejoinder: How much does your friend spend on cigarettes during the course of a week? It’s situations like this that make me angry that cigarettes are even legal. She needs help because she smokes and because she smokes she has even less money available to get help.
MomSense
@Yarrow:
I think they are coding it such that they can charge a fee. Bastards. She had to wait months to find a doctor accepting new patients.
MomSense
@Barbara:
Yup. I am still so beyond disgusted that the manufacture of death was enabled for so long. It is such a terrible habit to break. The suffering is unbelievable.
Adria McDowell
What exactly does “catastrophic cap” mean? Recently, we received letters from our insurance saying, for example, that for our daughter, she has reached $1,345 out of a $3,000 catastrophic cap. Is this a yearly catastrophic cap, or lifetime? We are on TriCare (my husband is retired).
stibbert
Hi David,
Awhile back (when you were Richard), you had a friend FP about end-stage home hospice care.
Can you post a link to that thread?
I recall the post & comments were full of good info & kindness, I’d like to read it again, it would be a help to me.
Barbara
@Adria McDowell: FYI: https://www.tricare.mil/Costs/CatCap?sc_database=web
Everyone should bookmark the consumer explanation websites for their benefit plans.
Adria McDowell
@Barbara: Oh wow, thank you! (Now I feel stupid, because I probably could have found that. We are pretty spoiled having TriCare- we have very few complaints. I wish that were so for everyone).
I know TriCare does things a little differently, so I figured I would ask the experts here. I have no excuse for not knowing this stuff. ?
Another Scott
Not exactly health insurance, but maybe you have an opinion you can share.
J and I are in our mid-late ’50s. Her mother was able to get a Long Term Care policy at the last possible minute and it was a financial life-saver and was the only way we were able to care for them in our home (in-home health aids) for so long. Her sister’s employer had a benefit where they would pay a substantial amount ($5k?) toward a policy, so waiting wasn’t too painful as far as the premium goes.
We know the policies are initially cheaper when bought earlier, but we’d like to wait if we can.
Is there some good rule of thumb about when the appropriate time is to buy such a policy? Any resources to help figure out the cost/benefit for various scenarios?
(Her mother lived to 90, her father 88. My dad is still around at 82; my mom didn’t quite make it to 80.)
Thanks for all you do here.
Cheers,
Scott.
raven
@Yarrow: The have to be listed as “wellness” exams here.
MrSnrub
My wife had thyroid cancer (easily treated, in remission).
Part of the treatment required 2 injections which cost $1700.
Her endocrinologist office submitted the claim as medical and we would have been stuck with most of the cost.
My wife’s hospital job is in insurance so she told the endocrinologist to check the prescription benefit and we were able to get it for $100
So: why does the endocrinologist, who does this all day, every day, submit for the wrong coverage, or not submit for all coverages?
If it had been me, I wouldn’t have known and would have faced that $1700 payment as my only option.
Barbara
@Another Scott: Here is a fairly good article on the issue: https://www.nytimes.com/2015/12/19/your-money/long-term-care-insurance-can-baffle-with-complex-policies-and-costs.html
Which basically advises you to consult a fee based financial planner. Here are some considerations that might not be obvious.
1. Most insurance companies will give you a little break if both spouses become insured.
2. Even if one spouse never needs the benefit, odds are the other will. One way to think about this is, what happens if you need to spend a lot on one spouse while the other is still healthy? What will that spouse have to live on once the cushion is gone?
3. However, there is an income component to all of this: if you have enough savings, self-insurance works, and means you will save your money if you don’t need it. On the other side, if you have modest savings, you are probably better off saving your money to build up retirement income, because chances are you would end up spending down your assets even if you do have long term insurance, which typically has a significant deductible plus out of pocket expenses (none is a 100% benefit). So if you would be availing yourself of Medicaid anyway, there is no reason to waste your money on ltc.
4. LTC premiums are going way up. Waiting might not be the best route. My view is that if you think you need it, you should buy it while it is cheap for you. If you don’t know whether you should buy it, then wait.
Adria McDowell
Here’s another one: my mother went on the exchanges and looked into getting insurance. I think she only looked once, and said the monthly cost was too high. I don’t remember exactly how much it would have been, but my parents decided to just pay the penalty (despite my mom having serious health problems due to afib and undiagnosed thyroid issues- we recently learned she has hyperthyroidism). Here are the details:
A) my dad is retired (union pension, uses the VA for his health care). He is in his 70s, and has claimed that Medicare hasn’t helped one bit. I have my doubts.
B) my brother lives at home with them, and helps out with the bills, but files taxes separately.
C) she is unable to work due to lightheadedness and being out of breath due to the hyperthyroidism.
D) they live in Florida.
Would my brother’s income count towards the overall household income, and would that put my mom out of reach for a subsidy? I have a feeling she looked at only one plan and gave up, so I’d like to look for her, since I have more patience for that.
Barbara
@MrSnrub: Varies totally by insurance plan. Endo probably gets paid more for the drug if it is reimbursed through the medical benefit. The drug benefit is much more highly managed in most plans.
sacrablue
I’ve been on Tricare/Champus since 1977. I’m now in the process of switching to Tricare For Life because I start on Medicare in September. Registering online for Medicare A and B took about 5 minutes. Now I don’t know whether to find a new primary care doctor or sign up for Tricare Plus. Driving 60 miles to see a specialist at a military facility is not appealing to me. The one I need to see now is only accepting active duty appointments. I want to know how to find a decent doctor that will accept Tricare for Life instead of Medicare Advantage (Kaiser won’t).
Barbara
@Adria McDowell: Not if they aren’t claiming him as a dependent and he isn’t claiming them as dependents, which no one should be able to do unless they are providing more than half of the dependent’s income. Your dad’s pension income would likely count.
ETA: Tell your dad that the way Medicare is protecting him is that whenever he gets any service or item outside the VA, he can’t be balance billed beyond what the Medicare fee schedule pays. It’s invisible to most people but it is one of the most powerful consumer protections of being covered by Medicare.
raven
@Barbara: We bought LTC 10 years ago. Rates still go up but we’re hoping it pays off since we have no kids.
MomSense
@Adria McDowell:
Sometimes people look at the cost of the premium without looking at the subsidies and think it is too expensive. Can you run their income on health sherpa or healthcare.gov and see what you find?
Adria McDowell
@Barbara: That’s what I thought. My brother is 37, so yeah, no one is claiming him. What probably happened is she added my brother’s income into it, and that put her way out of reach for a subsidy. My dad’s pension is good, but it’s not THAT good, so she would probably qualify. I think their Florida residence making things that much harder, too (no Medicare expansion- fuck you, Rick Scott).
Thank you, David and Barbara, for your help and expertise.
NJDave
Are in-patient mental health benefits ever covered, without a fight? After my daughter’s suicide attempt, a residential treatment center was recommended, which we then used. Our insurance company says that it isn’t the “least restrictive environment” and therefore won’t pay. We’re appealing and expect that we’ll have to sue to get any payment at all. I recall seeing that “mental health parity” was still being defined, some 7 years after implementation. Any idea if this is an achievable reality?
Barbara
@Adria McDowell: Credit where credit is due: Rick Scott tried hard to get Medicaid expansion in Florida, but the Florida legislature would not go along. So in this case, Scott isn’t the villain.
Adria McDowell
@sacrablue: You could try calling the TriCare contractor for your region. They might be able to help you decide and find a new primary care provider. I’ve dealt with the North and South regions, and their customer service is excellent.
raven
Here’s what they list as wellness:
Adria McDowell
@MomSense: yeah I probably can get that info. It’s what I’ll probably do.
Adria McDowell
@Barbara: I’m still gonna give him a “fuck him” for his company’s Medicare/Medicaid fraud shenanigans in the 90s, though. ?
Kraux Pas
When we do get to the bigger challenges, can we organize a “call your Congressfolk” campaign around that? Perhaps a FP post enumerating the biggest known gaps in the post-ACA health care system, some brainstorming about ideas, and encouragement for elected D officials to seize the initiative since the failure of Republican repeal efforts?
Kraux Pas
@Barbara:
Considering that many, many voters are primarily considering the top of the ticket,can we say Rick Scott’s coattails are the villains?
ThresherK
Good news: We just got our ACA approval letter.
Bad news: On Point has an hour covering Trump’s Tweet-directive regarding transpeople and serving in the military, and NPR found Andrew Sullivan to interview.
Barbara
@raven: Yes, as one broker said to me, the way to think about LTC insurance is as insurance for one spouse’s income after the other spouse requires significant LTC expenditures. Which means that if you are single, you are less likely to need it at all.
Mary in ohio
@Barbara I work at a Doctor’s office the answer you get as to who is in network is as good as the person answering the phone. Instead call your Doctor’s office and ask for their tax ID. The insurance company can run the number through their system and let you know for sure based on that number whether they are in network.
Barbara
@NJDave: Parity was well-intentioned but kind of ill-thought out. The problem is that mental health services are structured differently. There is no “residential treatment” for most non-mental health conditions, and most people don’t see a doctor on a weekly basis for physical ailments, or only for a short period until they are healed. So it’s trying to fit a square peg in a round hole and it leaves everyone in a perpetual state of confusion. I don’t know what the answer is for you but I am really sorry that you are struggling in your effort to get your daughter help she obviously needs.
Scout211
@sacrablue:
We found that if a doctor accepts Medicare, they accept TriCare-for-life. I think it is required by Medicare because it is a qualified supplement.
It was way easier to find a doctor that accepts Medicare/Tricare than Tricare.
sacrablue
@Adria McDowell: I haven’t had much help from them in the past for anything that goes outside of TriCare. Adding the Medicare portion to this causes the problem because TriCare for Life becomes a substitute for a Medicare Advantage plan. I have to find a doctor that accepts Medicare and will bill TriCare for supplemental care and Part D. I want to know how to find a good doctor. Most people I know use Kaiser or their doctor is too far from me. I found a Kaiser doctor that I liked, but Kaiser won’t accept TriCare for Life. They only want to sell me their own plan, so that I have to pay their co-pays and their pharmacy expenses.
Another Scott
@Barbara: Thanks for the pointer.
On your #3:
Unless I’m misinterpreting, the bolded part isn’t quite right. J’s mother’s policy was $200/day benefit for a maximum of 3 years. There was no “deductible”. We simply had to roll the dice on when we wanted to tell them when we wanted it to start and we could use the money on anything (but you’re right that it didn’t fully cover all of her expenses). There probably was a waiting period – I don’t recall that detail.
You’re right that Medicare and spending down assets does figure heavily into it. We consulted an elder-care/family planning lawyer about that as soon as they moved in with us after they sold their home. She did end up eventually going on Medicaid and spending her last 18 months or so in a nursing home (started as private-pay, then transitioned to Medicaid (lots of the “better” places around here won’t take someone unless they private-pay for some period of time first)) – it got to the point that we would have needed two full-time in-home aids to care for her Parkinson’s and it was just too much. :-(
We don’t know what we would have done without the nest-egg from the gains on their home, and the LTC insurance. Even then, Medicaid was still essential. People live too long and care is too expensive. :-( I don’t know what other people without our good fortune do.
Thanks again.
Cheers,
Scott.
The Moar You Know
@NJDave: The answers to your actual questions are:
1. No. They always fight everything WRT mental health.
2. Again, no. Mental health simply does not have parity. And should. The biggest problem is that most mental health practitioners aren’t doctors, and don’t get that AMA boost.
I watched the insurers decimate my mother’s counseling practice starting in the early 1990s. The military (Tricare/CHAMPUS) were the first ones to stop covering visits. It finally got so bad in the 2000s that she surrendered her license and gave up practicing. Most psychologist/therapists/counselors have at this point. There is no money. If she’d gotten the MD and gone into psychiatry that story would have ended much differently…but that was not doable for a single mom in the late 1970s.
tl;dr: it’s a fucking mess. Good luck. Hope your daughter is doing better.
Scout211
@Scout211:
Re: Tricare-for-life
Be sure to get your new military ID card when you turn 65. The information on your card reflects your new insurance plan change from Tricare to Tricare-for-life.
Scout211
@sacrablue:
Tricare-for-life is not Medicare Advantage. It is a supplement to regular Medicare. And really, it is awesome!
No other supplement plan has part D drug benefit as part of the supplement. And all of our regular medications are FREE. You have to use mail order and accept generics, but no premiums and no copay–this has saved us so much money.
sacrablue
@Scout211: I don’t know why, but most of my friends that are happy with their doctors, use Kaiser. I wasted an hour of my life last week on the phone with Kaiser only to find out that they don’t accept TriCare for Life. I can stay at the military clinic I use now through TriCare Plus but I would lose the use of the co-located VA departments (radiology, physical therapy, women’s health, etc). Driving 60 miles for a ten minute appointment to get an injection in my hand makes me crazy. I’ve had 40 years of being a “dependent” and I can’t take it anymore. I have to have my sponsor accompany me to get I new ID card. Give me a break, I’m 65 years old. I can fuckin do it myself.
sacrablue
@Scout211: I’m on TriCare Prime and I happily use the mail order pharmacy for my prescriptions. I’m just annoyed because I just had to renew my ID in June and now it expires at the end of August. It is a royal pain to get my husband to take time off from work to go to pass and ID with me.
Scout211
@sacrablue:
Sorry about your dilemma. We both love our doctor and love Medicare/Tricare-for-life. But yeah, Kaiser is a Medicare Advantage plan and Tricare-for-life is a supplement. We were able to keep using our civilian doctors once we switched to Medicare and have been very happy with our entire healthcare. My husband has had some expensive procedures and treatments for various chronic conditions and we pay so little for premiums and healthcare that we have stopped sharing the info with friends. They are shocked and envious.
With Medicare, you actually don’t require a primary care doctor as a gatekeeper. You can use any Medicare provider for services. Of course, we all need one but it is not like an HMO with every referral controlled by the gatekeeper.
Ask around about primary doctors. Don’t ask if they take Tricare. Most don’t. But IIRC, they have to take Tricare-for-life if they take Medicare.
And yes, having your sponsor there for the ID appt is silly. But I guess there could be fraud if divorces occur and dependents are still enrolled.
Good luck. We really feel lucky to have no supplement premiums and no drug benefit premiums. And we have had good medical care.
I hope you can find a good solution.
sacrablue
@Scout211: Thanks for your understanding. I still have a month to figure it out.
Scout211
@sacrablue:
At least you can make appointments now. And there are lots of places you can go that aren’t on post that may be closer to where you live and work. We walked in and were done in 10 minutes with an appointment at an Army Depot but went to a Travis AFB one time (with appt) and were there for an hour.
Barbara
@Another Scott: Waiting period is right, not deductible. But also, most policies pay a percentage of expenses, not 100%. The point is simply that even with LTC, you will have out of pocket expenses that can be sufficiently large to spend down your assets. The point of LTC is to protect your assets. If you don’t have a lot of assets to protect, there is no point in buying it.
Adria McDowell
@The Moar You Know:
Really? For in-patient services?
TriCare covers my mental health provider, so I’m really shocked to hear this.
Adria McDowell
@Scout211:
The Moar You Know
@Adria McDowell: Pretty sure outpatient. I am not sure, however. She did a lot of DV and substance abuse work, I know that much. Not a business where you talk to your kids about a lot of details, as it turns out for several good reasons.
Adria McDowell
@The Moar You Know: Hmmm. I use outpatient mental health services with a clinical social worker (behavioral and cognitive therapy), and all I pay is co-pay. I even get 8 visits without referral. Perhaps the situation is better now than when your mom was practicing. It’s a shame, since lots of service members/veterans need mental health services. I’m sure we could use your mom’s talents/expertise.
Monala
Over the last 7 years, my family has been covered (or uncovered) in a number of ways, including employer insurance with both small local insurers and large national plans, SCHIP, and the exchanges. And under every plan that had a deductible, there was a certain amount of benefits you could access before the deductible kicked in, such as 3 office visits, 2 scrips and 1 lab. Are we alone in this? I keep reading about people who never use their insurance because they can’t afford the deductible, and I wonder why there aren’t any pre-deductible benefits they can access.
Barbara
@Monala: Depends on the state, the employer plan, and whether benefit is now considered preventive (which are supposed to be pre-deductible).
Cheryl Rofer
Something to note: I needed to go back to Healthcare.gov, and instead of the login, I got a “Please wait” screen
This is going to be a problem for people who are working from a library computer, for example.
Adria McDowell (formerly LurkerExtraordinaire)
@sacrablue: I found some info for you. According to the Wright Patterson AFB ID card section website, if the sponsor fills out DD Form 1172-2, or gives the dependent a power of attorney, the sponsor does not have to be present:
http://www.wpafb.af.mil/Welcome/Fact-Sheets/Display/Article/917300/88-abw-id-cards-and-installation-passes/
Hope this helps a little bit!
The Moar You Know
@Adria McDowell: It would have to be better, as it couldn’t get any worse. And yeah, I’ve interviewed some scary guys recently (my company hires vets only with rare exceptions, like myself). The need is out there.
She was VERY good at it. Hilariously enough, she’s now a C-level executive for one of CA’s largest insurers and makes more money in a month than she did in any year she practiced. Not bad for a woman of 70+ years! So that won’t happen.
sacrablue
@Adria McDowell (formerly LurkerExtraordinaire): Yes, I am checking to see if my closest pass and ID will accept the form (notarized). I spent 7 exciting years at Wright-Pat. Then we moved to California.
Cheryl Rofer
@Cheryl Rofer: About a half-hour wait.
Yarrow
@MomSense: Late to the thread, but your friend should call back and tell them it’s for an Annual Physical, or, as raven said, a Wellness exam. She can even ask them what the coding should be for her one free visit per year. If she can’t do it, someone else could do that sort of legwork of finding out the right wording for her.
Calling back over and over again for an appointment to open up due to cancellation works too. Often someone can be seen sooner with some persistence.
Susan K of the tech support
Who is the owner of the definitive database that everyone else in this industry uses to contact a person for age-related matters, based on your birth year? I was born in 59. 9 is next to 0 on keyboard, and someone, somewhere had a typo (Birth year 1950) that’s resulted in a deluge of nine-years-early mailings ranging from AARP (started getting invites at 40, smh), retirement stuff, and now, medicare medicare medicare.
Who owns that Master Database and how can I get that damn typo fixed?
Julia Grey
HAHAHA. Good luck with that.
Scout211
@Susan K of the tech support:
Late to this but have you contacted social security admin to see if they have it wrong in their database? I would would think that Medicare gets that information from the social security admin. IDK but I would think you could probably start there. You may need to bring a copy of your birth certificate to a SS office to correct it.