Getting HOSED by my health plan - anyone else?

[StephN]

Hello everyone -

Well, after riding along pretty well since going on disability and rolling my old health plan into a "med-advantage" plan, I am getting knicked but good.

Last year they nearly doubled my premiums, but not much else changed. This year the premiums went down by $50/month, but a bunch of "coinsurance" kicked in with lowered covered percentages on things like scans, where I have to make up the difference.

Scans so far is the BIG one for me. They are only covered now at 80%. Does not matter what kind of scan it is, what it is for or who orders it. Does not matter if the scan is for monitoring cancer or not. I have to pay 20% of the BILLED amount to the center where I have the scan.

If I was in treatment for active mets and having more frequent scans, I would go broke! How are the others out there dealing with this?

This seems to be the insurance company's answer to the comprehensive health bill of 2 years ago. I have complained, but am told I have the option of looking for another coverage during the open enrollment later in the year.

[hutchibk]

They said when passing the health bill that they wanted to do away with Advantage plans... I am guessing that this is what Advantage plans have been forced into in order to make them inherently unpopular.

Can you opt back into regular Medicare w/ a supplement? Medicare premiums are slated to go up, too, and my premiums on my supplement went up by 50% last summer due to the health bill... it's not perfect by any means, I hate Medicare for many reasons (what they pay my oncs is outrageous, treatments that they refuse to pay my oncs for is outrageous, etc), but I have mine set up so that I'm not responsible for the 20%. However I do have to pay $400 a month for Medicare, Supplement and Part D premiums.

[StephN]

Brenda -
You mentioned Medicare with a supplement - this is what I have.

My Med-advantage plan IS my supplement with prescription coverage as well.

It is a Blue Cross affiliate called Regence. This is a major plan in our region.

[Jackie07]

I just started using Medicare (Advantage Plan provided by the Insurance company affiliated with the hospital/clinic) in January. I joked with my oncologist that I was going to visit him 'every day' since there's no co-payment [used to be $40?] for office visits.

Another thing I liked is the much cheaper co-payment for Tamoxifen. (Because of Part-D?) I did get something in the mail the other day stating that I owe the hospital several hundred dollors (Had some lab works and an MRI). It's a non-profit, so I just set up another monthly draft plan with them. I think there are three drafts of $50 each now... (I'd had it set up one time at $25 each month - as long as they get that monthly payment, nobody bothers me with collection phone calls... When I was paying for a much bigger bill 20 years ago [We didn't realize the special contract for the brain surgery/rehabilitation had expired, so we ended up owing several thousand dollars for the follow-up MRI and office visit], the hospital actually wrote off about half of the amount after I had been paying regularly for a couple of years.)

[pibikay]

I am wondering how your insurance plans work.Here in India you have to insure for a amount chosen by you and pay premium for that.All medical bills upto the amount chosen by you are reimbursed.But there are lot of excptios.In 2010 when Hema's treatment started her insurance ended ti and with only part of third herecptin being passed
In 2011 she is on Tykerb and Xeloda which are termed out patient treatmens.I have sent a claim for the first two months and I am keeping my fingers crossed as in reply to my query on their help site they said "claim under process"

[hutchibk]

Interesting... my supplement is just a standard Medi-gap supplement designed to pay the 20% that Medicare doesn't pay, and that is it's only purpose. If Medicare covers it, then my supplement kicks in and pays the remaining 20% no questions.

I avoided the Advantage plans because my insurance agent told me they capped out at something like $1,000,000. I figured if I lived long enough, and went through enough treatment/scans/etc that I would bust through that cap in no time.

Word is and some evidence has shown that those on disability and those with chronic conditions are not at all satisfied with the managed care aspect of Advantage.

I think if you shop a little, you can find a traditional Medi-gap supplement and dis-enroll from Advantage, rolling back into traditional Medicare w/ Medigap supplement. You would also need to get a Part D supplement as well. Depending on what all of the extra benefits your Advantage offers, you would probably lose some of those... and you probably have to wait for the traditional November open enrollment period.

[sarah]

Oh Stephanie,
so sorry you're having insurance problems, worrying about paying for your health really sucks. Hopefully Brenda's advice will help you.
Do you have someone who can check the different possibilities out for you so that you don't have to deal with this yourself? A son or daughter or best friend or husband?
I remember in the US the first time I was diagnosed with cancer and I called my great insurance company (we were working and could afford excellent insurance), I got off the phone in tears because of course there were so many loopholes. My husband told me that was the last call I was making to the insurance people, paying would be his concern, not mine. worrying about money when your health is at stake makes me sick. I definitely couldn't handle the money and my health.
I do think Stephanie that there may be someone at the US social services that could advice you as well - your hospital will have a social service person who can help also. The hospital social services helped me with my mother's medicare (in NY) when she had a problem. Unfortunately you have to know where to turn for help. Also sometimes the hospitals have a service to help those who can't pay or are elderly and not working, so do ask for their help. St. John's Hospital in LA has an association with a group called "Healthy Living" that is a pay as you can outfit where the tests are done at St John's but through this non-profit association but if you don't know about it, you don't know where to turn. My husband suggests (in America) always going to a St. hospital, they seem to more compassionate!!! Not sure he's right but...
I feel so lucky living and being treated here in France where health is valued over profit and the more serious the disease, the better the coverage. Cancer is covered 100%, a cold 60%!!
Good luck and stay focused on your health and have someone else check into the solutions for insurance and payment. Maybe ask the people at breastcancer.org also since they are a much bigger group.
Hope the tests are good.
hugs and love
sarah

[Barbara H.]

Hi Stephanie,
I am doing well and happen to enjoy my job, but your exasperation with health insurance is one reason I am not in a hurry to retire. In spite of this, I have had issues with receiving Tykerb; dealing with mail order pharmacies is a pain when they only send you a month's supply.

I hope that you solve this issue soon.

Best,
Barbara H.

[Mary L]

I have medicare and AARP for my secondary ins. So far everything has been covered. This will be tested in April when I have to have all my scans done. It is scary as we have to do the tests and if we can't afford it and it is not covered, what do we do???

[StephN]

Mary -
Be sure and check the booklet you were sent with the 2011 coverage. Basically I had to get the 2010 book and go item by item to compare with 2011 to see which coverages changed.

One positive that I took advantage of is the change from $200 every 24 months for vision hardware to $200 every 12 months. This is about the only benefit on the plus side that I see.

[hutchibk]

Here's some info on Medigap plans available in WA state... medigap is state specific.

http://www.docstoc.com/docs/6583472/...-Medigap-Plans

Also, when I was shopping for mine I used Medigap360.com, and they found the perfect fit for me. http://www.medigap360.com/medicare-s.../medigap360-2/

[StephN]

Thanks Brenda -
I know I have to revisit my supplement plan, but some of the choices are NOT accepted by the U of W and their affiliates.

For instance, the plan the city retirees mostly use is NOT accepted by my group. I know because a friend who wanted a second opinion on a cancer diagnosis could not go there as that plan is not accepted.

So, there are several considerations.

Sarah -
you have good ideas, but my hubby has a local HMO and I don't want to go there. He is supportive, but I will need to do the research.

[sarah]

Hello Stephanie,
Sorry to hear you have to do your own research, that's tough but I know from the Cancer Support Group (for English speakers) that I help start here, often the husbands, boyfriends (men) who are the caregivers can't cope and don't want to accept that you have a deadly disease. We have tried hard to reach out to them and a few times it helped but generally not and in some cases the husband left or left during the tough part. I'm lucky I know in that my husband was fully involved the first time around, this time because it's in French and his French is horrible I'm more on my own but he cooks, etc. and of course there are some very involved male caregivers in our group but I've been told by one of our psychologist members that men don't know how to deal with things they can't fix and they don't like to reach out and ask for help. Hey, they don't even like to ask for directions!!! lol!
Hopefully the info that Brenda (Brenda hope you're doing well) gave you works for you.
I would have thought that the Northwest had good support in place.
I know things are getting tough over there, my sister-in-law is a teacher at a Catholic school (yes a teacher! those damnable greedy people who have run the country into debt!!!! at least that's what they're trying to convince everyone) and she is paying more and more of a co-payment each year although her salary isn't going up. I don't think retire at 65, don't think she can. Lucky she's healthy so far - don't think she can afford not to be! lol! and she's in San Francisco! California is pretty good for making insurance companies pay for regular check -ups and important preventive tests - when the insurance companies complained of the cost and threatened to leave California, California told them to go ahead and leave and they'd set up their own program!!! The insurance companies stayed of course.
Was Breastcancer.org any help? Someone should set up a forum for helping people with these issues because it is complicated and worrying. Maybe next time a public option will be voted in and then we'll see if things become more affordable and fair but with all the money given to corrupt Congress, I doubt it. Most working people I know there pay between $12,000 - $25,000, some paid by their companies which seems a lot. My sister-in-law's share is $6,000.
Makes me proud that my dad, the doctor gave so much free help to his patients who couldn't afford to pay or pay much. I wish he was alive for me to tell him.
hugs and love
sarah

[Joan M]

Steph,

I'm dreading the switch to Medicare, but I think that Brenda and Mary have the combo down just about as good as it can get under these circumstances. That is, take a plain-vanilla medicare plan (no advantage plan), and then a supplemental, secondary plan.

I plan on enrolling in AARP as my secondary. I have a friend who turned 65 in December, and I "warned" him against advantage plans (he's healthy). He took AARP as his supplement.

Joan

[Jackie07]

Brenda,

I just called a toll-free number from one of the links you listed. The lady on the phone told me that the supplement plan does not cover what Medicare doesn't cover (except the 20% gap)

Are you able to see your oncologist with Medicare Supplemental Plan? None of my doctors (even my family doctor)accepts Medicare, that's why (just remembered) I have to buy the Medicare Advantage Plan. I know Medicare won't cover my brain tumor...

[hutchibk]

Exactly what I said above. Medigap ONLY covers the 20% that Medicare doesn't pay, but only if it's a Medicare covered charge. And you need a Prescription Part D plan too. Just be very aware that the new health law intends to eliminate Medicare Advantage in the next few years.

Medicare covers all my brain tumors/treatments so far. You might need to shop for other doctors in the Austin area. However, I don't blame doctors for not taking Medicare... it paid my Med Onc less for an office visit than I charged women to color their hair. It denied full payment to my Rads Onc (by at least 1/3rd) for my first IMRT brain rads treatment, stating that he gave me too many fractions in their opinion.

Eventually, it might be impossible to find docs to take Medicare because of the reimbursement rates and eventual rationing... and I really can't blame them when that happens. Then I will be totally screwed. Signing on to Medicare was a huge mistake that I made, but turns out there are NO good choices left anymore.

[sarah]

I agree that doctors may opt out of medicare, some even opt out of preferred payment insurance companies and HMOs because of the paperwork and restrictions. I think on a hopeful side that they will be replaced (it's already happening) by immigrant doctors for whom the salary seems adequate. If they are Chinese or some other nationalities, they may not be as warm and fuzzy but they will still be good doctors. Let's hope the medical insurance that doctors pay doesn't get too high (it's high already), that would be a negative also.
health and happiness
sarah

[hutchibk]

Medicare doesn't come close to "paying an adequate salary" if those are the only patients a doctors sees... they can't run their businesses and pay staff/nurses and themselves adequately on such low reimbursement. I require warm and fuzzy, and am lucky to have it, I suppose.

[Jackie07]

I searched my e-mail files and found a message from Medicare. The questionnaire I was supposed to fill out did include an option for 'other. Because there wasn't enough 'visual ques', I had thought Medicare did not cover my brain tumor and breast cancer. [Coupled with the fact that none of my oncologists (surgical, medical, radiation) were listed as providers of Medicare.]

Reading the book [Medicare & You] again, I found that the two plans - Medicare + supplemental plan and the Medicare Advantage plan are just like the other medical insurance choices: either a Non-HMO or a HMO/PPO.

The Medicare Advantage plan is pretty much the Medicare version of HMO/PPO. I'm sticking to my HMO because it's a huge medical facility and it has saved my life several times. The insurance concern was never an issue here. The neurosurgeon who had seen me 15 days before the surgery in June, 1990 had even told me [before my insurance issue was resolved -> a special contract was eventually made] to go to the emergency room if I began to experience certain symptoms.

He happened to be a 'warm and fuzzy' doctor of Chinese descent...

[hutchibk]

I have had warm and fuzzy from several different nationalities.