Healthcare/Insurance cost rant

CC Ohhh how I feel your pain. The games 'they' play with our lives and our medical care are ridiculous!! I currently have Bluecross/blueshield. In 2025 my retiree health insurance provider is switching to Etna insurance company. I have no idea what that will mean for my coverage of Rinvoq, my current out of state doctors, or anything else. Insurance is a scary ride for us all and it shouldn't be!!! It sounds like you are doing the right things in contacting your benefits administrator. Just don't let them rest...they tend to be...squeaky wheel gets the grease...type. MY insurance pretty much tells my doctors what kind of care they will be allowed to give. Just not right!! Our country goes out of its way to nose into other nations business...why can't they just help our own people get good ole fashioned medical care from our doctors?!! SO frustrating. Just hang in there and try your best not to get stressed...easy for me to SAY. LOL Best of luck to you and know that it will work out.

For those of you on regular Medicare with a medigap and a drug plan -- how do biologic infusions (like remicade, entyvio etc) get paid? Am I correct that they go entirely under Part B and then the medigap policy picks up whatever medicare doesn't pay? Does Part B cover 80% and then medigap pays the other 20%? Do you have to get pre-authorization from Medicare? Does Medigap have any say in what they cover and what they won't cover?

I am thinking about ditching my employer insurance completely and going on Medicare. I was going to wait until I started getting SS before signing up for medicare, but with all of my docs, labs, hospital potentially being out of network, I am weighing all my options.

I did check with my co-pay assistance and they will cover the $11,000 I will need to pay for my November infusion if insurance and health group don't reach an agreement. So then insurance will have to pick up the rest of the cost for Nov and all of Dec.

My PA expires in December right after the 12/5 infusion and I will need to get a new one for the Jan 2 infusion. I have my doubts that I will get a PA approved for an out of network provider.

I know that I will be paying more for Plan B plus the supplements than I pay for employer insurance, but if my docs etc are out of network, that is a separate out of pocket max than what my prescriptions will be -- they will be in network and subject to a different out of pocket. I will be spending a lot for meds that I didn't before.

This is all so complicated and annoying.

RE Straydog's remarks above: The American Association of Retired Persons co-operates nationally in U.S. with AFL/CIO retirees. Somehow I got on their newsletter e-mailing list a while back, and see that they oppose Medicare Advantage Plans due to recorded incidents of private manager graft + cost-cutting by denial of needed care in many cases! They advise all retirees to opt for original Medicare. I did that back when I retired because I already knew the problems associated with Advantage Plan Rx formularies and their preference for generics. They are oblivious to IBDers' "heterogeneity of response to Rx meds", which our sub-specialist gastros have recognized for years now. / Old Hat (40+ yrs with left-sided UC; in remission taking Colazal)

Medicare does not require prior approval. I remember I was so worried before my first infusion because the dr office told me they didn’t need prior approval but I was scared Medicare wouldn’t pay for it. I’ve never had a problem. There’s been a few blood tests they wouldn’t pay for but the labs will always inform you first and then you can refuse the tests if they’re too expensive. If the lab or dr doesn’t inform you Medicare won’t pay then you are not liable. I’m also on plan f thank god. I think plan g is very similar except there might a little more expense? Plan F supplement completely picks up the 20% Medicare doesn’t pay. Seriously it’s the least hassle free insurance I’ve ever had. My husband and I have the same supplemental - blue shield/blue cross and now pay a combined $471 a month. Better than what we paid private insurance by a mile. The Medicare payment is deducted from our monthly check. I don’t even know how much it is. 😀

I have been researching Plan G policies and there is a big difference in premiums. Having a difficult time in finding the actual policies to I can see why the price is different when they all have to cover the same things. Do some Plan G policies offer extra stuff?

Clo -- do you have an Advantage plan or regular medicare? I have heard of problems like that with Advantage plans, but not regular Medicare. With my current insurance problems all of the UHC Advantage plans are also no longer in network with my provider. Regular Medicare and medigap plans are still in network though.

If this is because of an Advantage plan, since it's now open enrollment, can you switch?

I have original Medicare. My health insurance that I was able to keep as part of the retirement benefits package acts like a supplemental and covers alot of the balance left over.

My issues is that there are doctors out there refusing original Medicare. It's scary.
Good luck making your decisions. Double check everything multiple times.

Clo

Basically I agree with Straydog, but the problem of MDs opting out of Medicare participation can be cyclical, if not geographical. Ten yrs back I had a female gyn for consecutive years who suddenly decided to quit Medicare. Then I had a terrible ordeal trying to connect with a participant, 'til I finally found one female who was staying with Medicare and also immediately helped me with a serious brewing condition. Around that time the most experienced doctors seemed to be men who had already quit Medicare farther back! From 2015 onward younger females have entered specialty practices, in my urban area, who accept Medicare, though it's still hard to get/keep participants who practice internal medicine. (Remember Songlady's posts about finally seeing the NP "to get a foot in the office door"?) Doctors not only relocate more than they did formerly, but also change their insurance affiliations for various reasons, including reimbursement rates. I had a male MD relative in general practice in CA for decades who decided to retire at age 65 because he got fed up with the heavy load of insurance "paperwork". / Old Hat (40+ yrs with left-sided UC; in remission taking Colazal)

I'm in the Dallas area. So far.... My regular Obgyn stopped seeing Medicare patients... (I'm using my urogynocologist for now) my Infusion clinic, my knee surgeon, and one of my PCPs...in the last year. So I may just be hitting a "gray" area that no one else will experience.

Research everything and double check yourself. Check with your doctors, check the physicians around you that you may be interested in using....

And just because you may really like your current doctor...that does not mean you won't find someone just as knowledgeable or someone that you may just "click" with.

Clo

My provider group and my employer insurance still have not reached an agreement. They are both being asses. Health insurance says to find a different provider. Provider says to get different insurance (not something that can be done unless you want to pay more to get non-employer insurance). I read in the local news that that this affects 35,000 patients at my provider. To big city people that might not sound like a lot, but for this area that is HUGE!

As of 11/1, all of my docs are out of network. I spent most of the day Thursday going back & forth with my GI office to get them to fill out a form to apply for Continuity of Care with my employer insurance to stay in-network for 60 days for my infusions. It was a simple form, but doc's office had issues. Took them about 4-5 times until they had it filled out correctly. First time they didn't even have the doc's name on it. Then they didn't mention the infusions. Then they listed the infusions as twice a year with my last one in March (that's doctor info not my infusions). I got approval from UHC but it didn't specifically say it was for infusions, but my benefits admin checked and it covers both the doc and infusions thankfully. I guess the words "catastrophic complications" that my doctor used on the application explaining why the continuous treatments are necessary made UHC move quickly.

I had to get that CoC because that out of pocket max for out of network, may not cover the full amount billed and I still would be on the hook for thousands of dollars. Anyway, I am now covered for the rest of the year.

Today I applied for Medicare A & B. I asked for coverage to start on 12/1. Hopefully that will speed up the process so I can get the number I need to get a medigap policy. I meet with an advisor next Saturday to go over options, pick the plans for G & D and get them all ready so that as soon as I have the medicare number he can fill it in and send them off. Agent thinks I will have a number in 2-3 weeks (it will take longer to get the card).

Even though I am covered for the rest of the year with employer insurance now I wanted an overlap in case anything gets delayed. Similarly, I am signing up for employer insurance for 2025 during our open enrollment (deadline is 11/8) and then I will cancel that once everything with Medicare and medigap is set up.

I guess I am officially old now since I applied for Medicare lol

To get to see a specialist around here it can be 2-3 months. It will probably be double that soon if those 35,000 people affected by the insurance battle all have to move to the only other provider in the area.

A lot of people here from Canada seem to like their healthcare ... most other countries like theirs too. It only seems like it's us Americans who are always complaining. If only politicians would stop with politics and actually do something to fix things I think it would be amazing. We have the benefit of seeing the good and bad of all health care systems around the world.

Thanks, Susie. I will check out Boomer Benefits.

I can't imagine paying cash for medical care. They must give them much better prices .. or they are super rich.