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Meaning of life

"The meaning of life is to find your gift. The purpose of life is to give it away." ~ Pablo Picasso

Sunday, October 14, 2012

Insurance Woes and Understanding Coverage

The last few months have been pure HELL! So much is going on and I'm exhausted, depressed and maybe even a little bitchy! (Alright...A LOT BITCHY...SO THERE!) My blood pressure has been a roller coaster. I had this cyst on my cheek that has come and gone for years and the doctor at MD Anderson just throws antibiotics (Bactrim) at it which tears up my stomach. It finally blew up last week and my face looks horrid. I've been trying to grow out my hair to donate it to Locks of Love but I CAN'T STAND THE LONG HAIR...adding to my misery. I now have a new health insurance plan and frankly with all my research I'm still a little worried about. I had to drop my private health insurance when the premiums reached over $800 a month and I'm still paying MD Anderson for last year's medical bills! Oh...and there might be a little stress involved here.

During this time I had a roof leak and I was told it was not covered on my homeowners insurance, but the damage to the interior is, subject to my deductible. So I paid the full cost of the roof repair while they have issued a payment for interior damage that is about $1,400 shy of the estimates and nobody will return emails or phone calls from the insurance company! I could affect repairs with the money given if I do the paint myself, but that's not why I have insurance and I'm not really well enough to do all that. AND if you remember last time I climbed a latter I fell and spent over 6 weeks in bed recovering from a pulled groin muscle and had to use a walker for several weeks after, but then that was with a chainsaw not a paint brush. Dare I??? Hum...The whole thing just sucks!

After realizing I might be a bit under insured, I called my homeowners insurance to increase parts of my coverage. I was told, "You have an open claim. We cannot make changes to your policy with an open claim. Would you like to close that claim out?" Ah...NO! Not until somebody calls me back to discuss the inadequate payment that was made for those damages!!! The rep told me she would forward the message to the adjuster and his supervisor so someone would call me back...TWO MONTHS...NADA!

Now let's talk Health Insurance! I know many of you have had trouble attaining or maintaining your health coverage and there are so many options out there if you are well, but it's harder at the moment if you end up with a preexisting condition. I don't want to get too detailed here because there are so many variables that affect your choices and availabilities. You need to do plenty of research before you decide to drop or modify your coverage.

You might have coverage from your employer or continue to pay your own privately. Perhaps you are disabled or over 65 and on Medicare. With Medicare comes many choices. If you are healthy you can get a supplemental plan (at an added cost to you) to cover things Medicare doesn't pay for. I had this setup for my mother after General Motors canceled health benefits to all retired salaried employees. It worked out well with the exception of having to enroll her in Medicare Part D (prescription drug coverage) which left her to payout thousands of dollars after hitting the infamous "donut hole" after her first order of scripts.

Some only have the option of staying solely on "traditional" Medicare or choosing a Medicare "Advantage" plan (Part C.) Some of these plans throw in the Medicare Part D drug coverage while you must continue to pay your Part B. This can get very complicated and expensive if you are a cancer patient taking a lot of medications, but remember some medications might be covered under your Part  B. For a better understanding of Medicare Part D from the American Cancer Society click (HERE)

One thing you cannot do is have a supplemental plan with the Advantage plan, that's only reserved for tradition Medicare. Advantage plans try to keep you "in network" allowing lower co-pays for using doctors or hospitals that accept this plan. These plans also put a cap on your yearly out of pocket whereas with traditional Medicare you are subject to a 20% co-pay on almost all services. Have your eyes glazed over yet from trying to comprehend this little bit of information? There are a few different Advantage HMO. PPO, POS, and Regional plans offered making it even more confusing and if you get an agent involve to try and help you, they will most likely guide you towards a company they get a referral fee from.

Just hit up AARP and they will fit you into a United Health Group plan that might lead you to believe you are fully covered. But that wasn't the case when in 2008 Lisa Kelly walked into MD Anderson in Houston (my understanding is, they are "out of network" or don't accept this plan at all) for treatment of leukemia and she was told she was grossly under insured and they asked for $45,000 up front to care for her. Full Story HERE

READ and understand everything about any changes to your policies as they seem to change yearly and you only have a short window of opportunity to exchange plans or go back to traditional Medicare. There are many companies out there offering these plans and they all seemed to be different yet still labeled "Medicare Advantage." Also make sure your doctor's and hospitals accept your plan BEFORE signing up for it. Providers can leave the network even if you still carry the plan, so stay on top of that and review everything each October when you have the chance to change plans.

What seems to make this even more complicated is that even the providers don't seem to know the differences. I went to a new doctor last week, one I waited months to see and researched extensively. He quit and walked out days before my appointment leaving me with a new, new doctor I know nothing about (that's a whole other story! AND NO, it wasn't my fault...I had nothing to do with it!!!)

I was charged $40 for the office visit and since this was the very first time using my new insurance I didn't think much of it. Then I read I was entitled to one free yearly "wellness visit." So I called the insurance company to ask exactly what that was, mostly because the doctor wanted to see me again for a full physical since I was a new patient. In conversation I learned that a standard office visit is subject to a $10 co-pay if the provider is "in network." Since they were in network, I realized the doctor's office overcharged me by $30.

At this point I have to give major credit to my health insurance rep on the phone who has promised to call the doctor's office and straighten it all out and inform them my next visit should be classified as my yearly wellness visit and there should be no charge. We'll see how it goes. Pardon me if I think it won't be as simple as all that.

Dealing with insurance companies (or people for that matter) has never been more difficult due to how complicated the policies are. I think they should limit ALL available plans to THREE: Bronze, for young and healthy, Silver for people with some reoccurring problems, and Gold of the disabled, over 65, or severely ill. Make it that simple! I think it's criminal to make this so complicated!!!

Peace B

***THIS IS NOT A RECOMMENDATION OF ANY KIND! I AM NOT AN EXPERT AND SOME OF THE INFORMATION REPORTED HERE I STILL DON'T FULLY UNDERSTAND AS I FURTHER IMMERSE MYSELF INTO THIS NEW WORLD. PLEASE UNDERSTAND YOUR OWN POLICIES! I CANNOT EXPRESS THIS ENOUGH! THIS IS ONLY A CONDENSED VERSION OF WHAT I HAVE LEARNED SO FAR AND IT'S MAD COMPLICATED!

6 comments:

Maureen said...

Hey Brian!
I'm sorry you are going thru this insurance nightmare...not what you need.

BUT...I'm glad to see you posting.

Oh and go to Food Network and see if you can find the Iron Chef episode that was Battle YAK!!!

{{{hugs}}}

Leah said...

Brian, I am so sorry you hace to fight Homeowner AND personal insurance, especially when you don't feel well!! However, if anyone can boil it down to understandable chunks, it is you!!!
I'm out pn long-term disability and Soc Security. When you figure it out, I'd love a crash course. It is challenging when you're healthy, but having to make sense sick..."Forgetaboutit". I am sending love and sincere wishes for you to feel better! And, even if you're feeling BITCHY and want to vent, you're among frends who love and care about you. We REALLY WORRY when you don't post.

Dr. Swill said...

Maureen,

YAK??? Seriously they had YAK? Where were we at??? I would have gladly been the taste tester!!

Hope you are well!
B

Dr. Swill said...

Leah,

Thank you. I added a link to the story from the American Cancer Society explaining Medicare Part D better. Check the end of the paragraph with the link: "For a better understanding of Medicare Part D from the American Cancer Society click (HERE)"

This still seems to be an ever learning process and I stress over making the wrong move. I chose the best option for me, but I had to give a lot up in return. The change to new insurance has screwed up my medications, partly because of the new doctor or rather his ill trained staff. And yet I can't blame then totally because even I am have a hard time understanding it.

My best advice: once you find a plan that works for you. READ and understand the policy so you can use it to the fullest.

If you are on SS the best move is to stay one Regular Medicare and pay for the best supplemental "GAP" package you can afford. I did not have that option as it was too late for me. This MIGHT change in 2014 if the preexisting condition clause is dropped from health insurance plans.

If a GAP policy is not an option, you can stay on standard Medicare with a Part D plan (remember SOME chemo meds might fall under your Part B and thus you avoid those meds pushing into the dreaded "donut hole." BUT with standard Medicare you will be subjected to a 20% co-pay which could be devastating in the event you require a lot of services and hospital stays in a year.

I chose (for now) a Medicare "Advantage" plan that includes Part D drug coverage (some do not.) There are a lot of drawbacks with this. You are subjected to using "in network" doctors if you want to keep your out of pocket expenses down. The upside is that my plan caps my yearly expenses and there are 14 states that offer services in network with my plan. I am allowed to go out of network IF a provider will accept my plan, however the out of pocket cap is more than doubled.

Plan benefits vary by insurance companies so this makes it more difficult to chose and every year providers are added and can drop out of networks so it's a gamble. Your doctor might be in network this year and out the next. You MUST review your plans every year and can change plans during open enrollment October 15 - December 7.

That's about all I know at this point (IF I understand it correctly) and everything changes in January and might ever get really hairy depending on the presidential outcome.

Be well...email me for more info if you like.

B
This should have been a blog post! lol

Anonymous said...

I'M SO SICK OF IT ALL. THANKS FOR SHARING THE ABOVE. JUST WAIT TILL OBAMACARE SETS IN. I DON'T WANT TO THINK ABOUT IT.

GRANNY

Anonymous said...

HONEY, YOU CAN BITCH ALL YOU WANT. WANT UNTIL YOU GET IN YOUR 70S AND THERE'S NO ONE THERE TO HELP YOU . GRAMPS IS 83 AND DOING EVERYTHING. HE LOOKS AWFUL AND I FEEL GUILTY. HE'S KILLING HIMSELF. HE ALSO HAD CANCER A FEW YEARS BACK.

GRANNY

Words To Live By:

"The best way to find yourself is to lose yourself in the service to others." -Mahatma Gandhi