Health Insurance. *&%$#!

[Wonderdog]

Greetings,

I'm a single guy with no dependents, no mortgage and I recently turned 55. I'ved saved 1.8 and have a pension worth 400K as a lump sum.

Not quite FatFIRE, but it would keep me comfortable.

And yet I cannot retire.

I have a rare pre-existing condition for which I receive periodic treatment at the Mayo Clinic. The Health Exchange plans available where I live are both HMOs, with no option to go outside of network. My employer is no help.

Has anyone been in a similar situation and solved this problem?

Thanks,
John

 

[cathy63]

Can you relocate to a place where there's a health plan that includes the Mayo Clinic? I guess the obvious choice would be Rochester MN, but maybe there's a Mayo outpost in some other area that could provide your treatments?

 

[Dtail]

There is a Mayo clinic outpost in Florida, plus the ACA plans in FLA have many PPO options in general.

 

[Rianne]

Is there anyway Mayo can coordinate treatment with St. Louis hospital? St. Louis has a few pretty excellent options, Barnes, St. Lukes, Kindred. My DB has a rare disease and Mayo coordinates his treatment with hospital in Chicago. Drs. actually communicate with each other b/c this is so rare.

 

[Spock]

I haven't needed to research it personally, but I understood pre-existing conditions was no longer a factor "post-ACA". I would start with Mayo to find out what plans they accept or are in-network for and then find out what those policies cost.

 

[MRG]

What is your projected income? Many hospitals will greatly discount treatments for those of lower incomes. Might look into methods of managing your income and what assistance programs the Mayo might have.

Also are there other options for treatment at places in the HMO networks?

 

[Bir48die]

I haven't needed to research it personally, but I understood pre-existing conditions was no longer a factor "post-ACA". I would start with Mayo to find out what plans they accept or are in-network for and then find out what those policies cost.

OP's issue is not pre-existing condition limitation. It's using the exchanges and they would not cover the Mayo out of network claims.

My response would be to pay for private insurance as I do which yes is expensive but could cover your condition.

 

[Aerides]

My response would be to pay for private insurance as I do which yes is expensive but could cover your condition.

Where do you buy private insurance outside of the ACA with comprehensive coverage without network limits?

I mean I understand forgoing ACA subsidies and such, but even if I ignore those, I still might have limits on what the insurance in my region considers an acceptable provider.

I'm lucky, in FL, if I want to go with a high metal plan, I can get the Cleveland Clinic via BCBS. But I can't get them on a silver or bronze plan. And afaik, there is no difference going in or out of the exchanges. Some areas of the country have only one or two HI providers for the entire state so if they say "no Mayo" then you'd have to budget for out-of-network costs, or find another state with coverage and move. (AZ/Scottsdale area has a big Mayo hospital and it's really nice).

 

[audreyh1]

OP's issue is not pre-existing condition limitation. It's using the exchanges and they would not cover the Mayo out of network claims.

My response would be to pay for private insurance as I do which yes is expensive but could cover your condition.

What private insurance? Generally doesn’t exist beyond what’s offered with ACA compliant plans and these are very close to what is offered via exchanges. It’s rare you will get access to a wider network by buying insurance directly. I do but insurance directly, but I don’t get access to a wider network. It’s simply not available to individuals.

 

[Senator]

I have a rare pre-existing condition for which I receive periodic treatment at the Mayo Clinic. The Health Exchange plans available where I live are both HMOs, with no option to go outside of network. My employer is no help.

Pre-existing conditions are covered. Does your current health-plan providers not treat that condition? An in-network hospital is probably statistically the same as the Mayo.

While the Mayo is good, I am not sure they have better results than other high-quality hospitals. My friend, who is now dead, blames the Mayo for killing him.

 

[Sojourner]

What private insurance? Generally doesn’t exist beyond what’s offered with ACA compliant plans and these are very close to what is offered via exchanges.

+1

I know from personal experience there are essentially two types of insurance available in the individual market. ACA-compliant plans (through the exchange or directly from insurers) and short-term plans with enormous deductibles and low coverage limits. I looked around extensively a few years ago and could not find any other viable options.

I agree with the various suggestions for OP to consider relocating to a state that allows for Mayo Clinic (or equivalent) treatments to be covered under an ACA plan.

 

[pb4uski]

.... I agree with the various suggestions for OP to consider relocating to a state that allows for Mayo Clinic (or equivalent) treatments to be covered under an ACA plan.

It may not require moving to a different state, plans vary by zip code.... the OP needs a plan where the Mayo Clinic could be used by the OP... preferably as an in-network provider.

 

[Sarah S]

If relocating isn’t desirable / possible have you explored the idea of shared care with your Mayo doctor that Rianne mentioned? It obviously depends on the specifics of your disease but if you do not need expensive treatments or surgeries that only Mayo can do ( or that you only want there) it could work. Local specialists could monitor you and order blood and imaging and perhaps you could visit your Mayo doctor and pay cash a couple of times a year. You said you saved 1.8. If it is 1.8 million you should be able to manage that well enough. This won’t work if too much needs to happen only at Mayo.

I understand completely. I have a somewhat unusual disease and I won’t leave Massachusetts because my doctor here is one of the top specialists in the world and I am ACA dependent

 

[audreyh1]

Pre-existing conditions are covered. Does your current health-plan providers not treat that condition? An in-network hospital is probably statistically the same as the Mayo.

While the Mayo is good, I am not sure they have better results than other high-quality hospitals. My friend, who is now dead, blames the Mayo for killing him.

I think Senator makes a good point. Is Mayo Clinic really your only option?

 

[Animorph]

For an early couple of ACA years I was able to find ACA-compliant health insurance that was not offered through the state marketplace. I had to go to each possible insurer's website and see if they offered something different. Same as marketplace coverage, but different networks, PPO, or HSA compliant. The last two or three years I haven't seen this anymore in our area, but maybe other states still have some additional options if you check.

Otherwise I'd check with Mayo and see if they would recommend a provider that is on one of the ACA-available networks that could give you the same treatments.

My PCP is not on my ACA plan. We have an agreement for costs similar to insurance negotiated rates. With a high-deductible plan I'm paying 100% anyway. If the Mayo treatments are not too expensive you could opt to just pay for them yourself. But check with Mayo so you don't get ridiculous list prices.

We've changed ACA insurers every year except 2019. Mostly because of insurers dropping out. We've always had some of our preferred providers not covered. So you may go through the same thing next year!

 

[Bir48die]

What private insurance? Generally doesn’t exist beyond what’s offered with ACA compliant plans and these are very close to what is offered via exchanges. It’s rare you will get access to a wider network by buying insurance directly. I do but insurance directly, but I don’t get access to a wider network. It’s simply not available to individuals.

Like those of us that pay for BCBS or Kaiser that aren’t subsidized? I’m confused

 

[MichaelB]

Like those of us that pay for BCBS or Kaiser that aren’t subsidized? I’m confused

We can only enroll in those policies that are available in our zip codes. Many BCBS PPO policies, for example, are available in some areas but not many others. This is the issue the OP is facing.

 

[orchid55]

Yes, in my area of suburban Atlanta the only policies available on or off exchange are HMO policies with no out-of-network coverage. It is impossible to buy a PPO.

 

[audreyh1]

Like those of us that pay for BCBS or Kaiser that aren’t subsidized? I’m confused

I buy insurance directly from the insurer BCBS directly, not subsidized. My only option is an HMO. I don’t have access to all medical facilities - the network is somewhat limited.

 

[Wonderdog]

Thanks everyone. I appreciate your replies.

I have a congenital heart defect. My Mayo surgeon (now retired), pioneered the technique to "repair" my defective heart valve. The local surgeon to whom I was initially referred, and who worked at the Nationally Recognized Best Hospital in St. Louis, told me that he had only previously performed this operation 2 times (versus the 450 times my surgeon had).

I put "repair" in quotes because with congenital heart defect surgery, there's no such thing as a cure. I return to the Mayo Clinic every other year for a checkup because I know that I will eventually need a re-operation.

I *could* forgo the Mayo Clinic and receive care locally, but I'd be putting myself in inexperienced hands, especially surgically. As a friend told me once, you never want your doctor to look at your condition and say "that's interesting, I've never seen that before". You want a doctor who has seen patients like you a thousand times.

I investigated plans outside of the ACA and found that all of them come with pre-existing conditions clauses, which is a no-go for me.

Previously, I had only considered moving to Illinois because I could maintain relationships with family and friends. I hadn't considered it seriously because, with ACA plans changing every year, moving to get coverage might be for naught the following year. For example, in Missouri, in 2018, Anthem Blue Cross pulled out of the counties in and around St. Louis and Kansas City - where the best hospitals and most expensive doctors are located. In order to get Anthem Blue Cross (and it looks like they only offer an HMO), you have to live outside of the two biggest cities in the state.

Currently, it looks like BCBS of MN has a plan that includes the Mayo Clinic in network. Now that I think about it, I'd be surprised if the ACA plans in the Rochester area *don't* cover the Mayo Clinic. Since my eventual reoperation will be an elective procedure (versus an emergency), I suppose I could move to Rochester just before needing it. Recovery would be difficult without family nearby, but I imagine that problem could be solved. I hadn't thought of this option before talking to you all, so thank you. This conversation has helped me see some things I hadn't considered before.

 

[pb4uski]

It pains me to type this, but with the way plans change, wherever you move to for good health insurance, you might be better off to rent than to buy.

 

[LARS]

Health Insurance. *&%$#!

Not to throw cold water on you, but even if you find a solution today, there is no guarantee it will carry thru until you hit 65 and are Medicare eligible.

So if the access to Mayo is critical I think you really have to think thru continued access to steady insurance that provides that access.

 

[Rianne]

Slightly off topic, but not really. Diagnosis, a new documentary on Netflix about New York Times medical journalist, first episode. A young woman had painful lasting bouts over 9 years and could not get a DX. Long story short, through world wide internet connections with her symptoms basically, thrown out there for everyone to see. A doctor in Italy read the article with symptoms. The Italian DR's solved her extremely rare condition through genetic testing at no cost. Just saw this last night. She went to Italy and had all these tests done, at no cost, from DR's in Turin, Italy.

I don't mean to sound "flip" but not only should you move to better healthcare at affordable costs, you may consider moving overseas.

 

[Chuckanut]

I don't mean to sound "flip" but not only should you move to better healthcare at affordable costs, you may consider moving overseas.

Your not flip at all. I am using Voltaren on my knee. I paid about $22 OTC for a large tube of it in Poland and brought the unused portion home. In the USA I would need a script and it would cost at least double that for a tube about 1/4 the size.

Now, why in the world can the Italians, Poles, etc. get this product so easily and cheaply and we in the USA have to pay so much and see a doctor for the Rx (talk about running up costs!) I am all for safety in medicine, first do no harm, etc. but are all these other countries throwing caution to the wind when it comes to this product? I think not. If I am wrong, please let knew why.

 

[Mr._Graybeard]

Interesting story on the Milwaukee Journal Sentinel website today. A Wisconsin employer, Ashley Furniture, pays employees and their dependents to get their surgery done in Mexico. The surgeon in the story is a Mayo graduate. https://www.jsonline.com/story/news/solutions/2019/08/23/milwaukee-orthopedist-meets-patient-cancun-knee-surgery/2071238001/