What's the future of the ACA?

[marko]

Slightly off topic but last week I went to the pharmacy to get a months supply of Simvastatin. Granted it is a generic and common drug.

I was three days early for my supply and BCBS couldn't cover it for another three days.

I told the pharmacist that I was leaving for Florida the next day and couldn't wait. He suggested I call BCBS and battle it out. Then...the guy standing in line next to me said "Why don't you ask how much it is if you pay out of pocket?"

I learned two things:
1) At least in Mass, it is against the law for a pharmacist to offer the retail price unless you ask. That is why the pharmacist told me to call BCBS! If I asked he must tell me but he couldn't suggest that I pay out of pocket. Who benefits from a law like that?

2) My prescription cost (no insurance) was $6.95! WHAT? I was going to spend a half hour on hold with BCBS for seven bucks? I was always under the impression that even with a common generic like Simvastatin it was in the $50 range for a month's supply. Seven bucks?

[joeea]

Quote:

Originally Posted by marko My prescription cost (no insurance) was $6.95! WHAT? I was going to spend a half hour on hold with BCBS for seven bucks? I was always under the impression that even with a common generic like Simvastatin it was in the $50 range for a month's supply. Seven bucks?

Most drug plans have a web site where you can check the cost of a medication, and determine if it is covered or not.

I don't have BCBS, but I always check first.

Quote:

At least in Mass, it is against the law for a pharmacist to offer the retail price unless you ask. That is why the pharmacist told me to call BCBS! If I asked he must tell me but he couldn't suggest that I pay out of pocket. Who benefits from a law like that?

I believe this is an insurance contract issue (between the insurer and pharmacy) and not a law. And it's not limited to Massachusetts.

See: https://www.nytimes.com/2018/02/24/u...g-clauses.html

[REWahoo]

Quote:

Originally Posted by joeea I believe this is an insurance contract issue (between the insurer and pharmacy) and not a law. And it's not limited to Massachusetts. See: https://www.nytimes.com/2018/02/24/u...g-clauses.html

New Federal law in October should have invalidated such contract terms:

Quote:

Insurers will no longer be able to bar pharmacists from telling consumers when paying cash would be cheaper than using insurance for their prescriptions, as a result of bipartisan legislation signed Wednesday ...

https://www.aarp.org/health/drugs-su...armacists.html

[24601NoMore]

Quote:

Originally Posted by explanade They spend more on marketing than R&D and they’re hiking prices on drugs developed decades ago. They’re not even pretending that the hikes are to recoup R&D or for future R&D. They’re practically saying “because we can.” The other villains are the pharmacy benefit managers taking their own cuts.

Recent example of "because we can"..

I was prescribed a topical NSAID cream for some mysterious leg pains I've been having. Was told that because it was a "compound" drug that only specialty pharmacies could fill. Called CVS and was told they couldn't because it was a $3,000 (?!!) cream.

Got the cream (Pennsaid) and saw on my HC Portal that the Pharmacy charged over $5,000 (!!!) for ONE TUBE OF CREAM.

I can't fathom why one little container of topical cream would be $5K, even IF the drug company was "pretending" to recoup their R&D costs. Nope..they charge $3 -$5,000 per tube "because they can" by all appearances..

Oddly enough, the HC company covered the cost without even batting an eyelash. Yet, they made me jump through all sorts of hoops to cover a ~$1K MRI for the same issue..go figure.

[jimbee]

Quote:

Originally Posted by marko Slightly off topic but last week I went to the pharmacy to get a months supply of Simvastatin. Granted it is a generic and common drug. I was three days early for my supply and BCBS couldn't cover it for another three days. I told the pharmacist that I was leaving for Florida the next day and couldn't wait. He suggested I call BCBS and battle it out. Then...the guy standing in line next to me said "Why don't you ask how much it is if you pay out of pocket?" I learned two things: 1) At least in Mass, it is against the law for a pharmacist to offer the retail price unless you ask. That is why the pharmacist told me to call BCBS! If I asked he must tell me but he couldn't suggest that I pay out of pocket. Who benefits from a law like that? 2) My prescription cost (no insurance) was $6.95! WHAT? I was going to spend a half hour on hold with BCBS for seven bucks? I was always under the impression that even with a common generic like Simvastatin it was in the $50 range for a month's supply. Seven bucks?

I haven't used my medical insurance to buy prescription medication for years. It is always more expensive than goodrx.com or wellrx.com.

[fh2000]

Quote:

Originally Posted by RetireSoon Recent example of "because we can".. I was prescribed a topical NSAID cream for some mysterious leg pains I've been having. Was told that because it was a "compound" drug that only specialty pharmacies could fill. Called CVS and was told they couldn't because it was a $3,000 (?!!) cream. Got the cream (Pennsaid) and saw on my HC Portal that the Pharmacy charged over $5,000 (!!!) for ONE TUBE OF CREAM. I can't fathom why one little container of topical cream would be $5K, even IF the drug company was "pretending" to recoup their R&D costs. Nope..they charge $3 -$5,000 per tube "because they can" by all appearances.. Oddly enough, the HC company covered the cost without even batting an eyelash. Yet, they made me jump through all sorts of hoops to cover a ~$1K MRI for the same issue..go figure.

Is $5,000 the negotiated amount from your insurance company, or there is a lower amount that you do not see from your Portal?

[gstillson]

Quote:

Originally Posted by RetireSoon I can't fathom why one little container of topical cream would be $5K, even IF the drug company was "pretending" to recoup their R&D costs. Nope..they charge $3 -$5,000 per tube "because they can" by all appearances.. Oddly enough, the HC company covered the cost without even batting an eyelash. Yet, they made me jump through all sorts of hoops to cover a ~$1K MRI for the same issue..go figure.

How long did the MRI take? I had one done and it took all of 20 minutes.

$1000 for 20 minutes is also a pretty good scam, especially considering how old the MRI technology is now.

[24601NoMore]

Quote:

Originally Posted by fh2000 Is $5,000 the negotiated amount from your insurance company, or there is a lower amount that you do not see from your Portal?

It was >$5K ($5,200-something IIRC) paid.

ETA - just checked the Portal. Paid > $5,300 (!). Crazy. If I had known, I would have never gotten the RX filled.

[Mulligan]

The reality of the situation is such that the underlying problem of the issue is not being addressed. And nothing near term will suggest otherwise that it will be. So in reality its a game of every man and woman for him/herself. Find a cost shifting angle to move the financial burden to someone else, or at least away from having to pay for others. Depending on ones needs that can be HSAs, short term insurance that is renewable, healthcare ministries, income management for ACA, PT employment that has health insurance, etc...I have found the best suitable plan for me. Longtime GF will be moving in with me and in a year I will cost shift onto Fortune 500 company using their domestic partner plan. After cafeteria plan tax reduction, I will pay $150 a month for a robust network, $200 annual deduction, with dental and vision all included in the $150 premium...I will ride this for 10 years right into Medicare, I hope!

[scrabbler1]

Quote:

Originally Posted by pb4uski Sounds like NY insurers used the repeal of the mandate to take you for a ride. This link of a study by Kaiser Family Foundation suggests that most insurer adjustments for repeal of the mandate were modest... on average 6% and ranging from 0% to 14%. https://www.kff.org/report-section/h...iums-appendix/

I can see why New York is at the top end of the 0-14% range. Not allowing age rating will increase the rates for younger people while lowering them for older ones. These rightly or wrongly inflated rates for younger people will more easily drive them out of the insurance market once the mandate has been repealed. And remember that more than half of the state's population lives in the downstate NYC-LI metro area where the rates are already higher than in the rest of the state.

I remember from my actuarial days when I was estimating the percentage of uninsured motorists. The higher-cost urban areas always had higher rates of uninsured drivers than the lower-cost suburban and rural areas. I see no difference between that and how those uninsured people are distributed in the HI market.

No, I'm not being taken for a ride as you suggest.

[gstillson]

Find a sugar momma. Best idea yet actually.

[youbet]

Quote:

Originally Posted by explanade Had a bad experience with trying to get second opinions for my father who was on an Advantage plan. .

My DW was able to get all the second opinions she wanted using her Advantage plan. And she also had access to any of the cancer centers she wished (as long as they accepted Medicare assignment). Your dad made a mistake when he selected his Advantage plan as many do. They assume all the plans are close to the same and they aren't. You need to understand the important differences.

I assume you got the second opinions regardless of insurance coverage. They usually aren't expensive as long as the required diagnostic test results are already available and can be carried to the second opinion doc.

[explanade]

Quote:

Originally Posted by youbet My DW was able to get all the second opinions she wanted using her Advantage plan. And she also had access to any of the cancer centers she wished (as long as they accepted Medicare assignment). Your dad made a mistake when he selected his Advantage plan as many do. They assume all the plans are close to the same and they aren't. You need to understand the important differences. I assume you got the second opinions regardless of insurance coverage. They usually aren't expensive as long as the required diagnostic test results are already available and can be carried to the second opinion doc.

It was Kaiser, which was one of the highest rated Advantage plans.

But if we wanted to go to UCSF, we’d have to pay for ambulance and hospitalization out of pocket.

They refused to release Medicare funds and the clerk at their claims office said they never do.

We took imaging to another doctor who had a complete different opinion, which we presented to the Kaiser doctors who all said nothing can be done.

We weren’t conv8nced that was a medical opinion as much as a financial one.

[youbet]

Quote:

Originally Posted by explanade It was Kaiser, which was one of the highest rated Advantage plans.

That confirms that the "rating" doesn't account for the network or type (HMO vs PPO) of plan.

Quote:

We took imaging to another doctor who had a complete different opinion, which we presented to the Kaiser doctors who all said nothing can be done.

There ya go. Although I wouldn't have gotten involved in an HMO style Advantage plan to begin with, given that your dad did, this was the way to go. How did the second opinion information factor into or change the course of treatment your dad was receiving?

In DW's case, her Advantage PPO plan covered second opinions to the same extent that traditional Medicare would have and the second opinions supported the original diagnosis and treatment recommendation so nothing changed. But we both felt better for having another independent source of analysis and opinion.

As was mentioned earlier in the thread, it does seem like progress towards universal coverage in the USA will likely involve some restrictions in flexibility such as those in Advantage HMO plans or the national plans of countries like Canada or the UK. We probably all need to practice living and dealing with those restrictions, although I don't look forward to them.

[Lisa99]

On a slightly different but related topic the ACA "cliff" of $60k has caused us to keep our withdrawals artificially low which isn't a bad thing.

So instead of withdrawing a little more than 5% per year until SS kicks in, we're below 4%.

[ivinsfan]

Quote:

Originally Posted by youbet My DW was able to get all the second opinions she wanted using her Advantage plan. And she also had access to any of the cancer centers she wished (as long as they accepted Medicare assignment). Your dad made a mistake when he selected his Advantage plan as many do. They assume all the plans are close to the same and they aren't. You need to understand the important differences. I assume you got the second opinions regardless of insurance coverage. They usually aren't expensive as long as the required diagnostic test results are already available and can be carried to the second opinion doc.

All advantage plans are different and that's the problem...just because you were able to buy this plan in your home area, doesn't mean the poster's Dad had that option. It's not as simple as blithely saying "He picked the wrong plan"

[youbet]

Quote:

Originally Posted by ivinsfan All advantage plans are different and that's the problem...just because you were able to buy this plan in your home area, doesn't mean the poster's Dad had that option. It's not as simple as blithely saying "He picked the wrong plan"

Sorry, nothing "blithe" about it. If he wanted flexibility in providers and network, then choosing an HMO-style Advantage plan was indeed the wrong choice. If only HMO-style Advantage plans were being offered in his area and he wanted wide network and provider flexibility, IMHO he should have then gone with traditional Medicare + supplement. He did have options and he picked one that was in-congruent with his coverage desires. Happens all the time.

The reason I keep beating the drum on the subject of Advantage plans not all being the same is for just this reason. Some folks keep discussing them as if they are all the same and they aren't. You need to know what you want and then compare that against the features of the various types of Advantage plans available to you and against traditional Medicare + supplement.

In our household, DW went Advantage and I went traditional Medicare +supplement. So far, we're both satisfied with our choices almost 7 years in. Although, I haven't needed any extensive coverage to test my situation whereas DW, unfortunately, has used hers a lot.

[ivinsfan]

Quote:

Originally Posted by youbet Sorry, nothing "blithe" about it. If he wanted flexibility in providers and network, then choosing an HMO-style Advantage plan was indeed the wrong choice. If only HMO-style Advantage plans were being offered in his area and he wanted wide network and provider flexibility, IMHO he should have then gone with traditional Medicare + supplement. He did have options and he picked one that was in-congruent with his coverage desires. Happens all the time. The reason I keep beating the drum on the subject of Advantage plans not all being the same is for just this reason. Some folks keep discussing them as if they are all the same and they aren't. You need to know what you want and then compare that against the features of the various types of Advantage plans available to you and against traditional Medicare + supplement. In our household, DW went Advantage and I went traditional Medicare +supplement. So far, we're both satisfied with our choices almost 7 years in. Although, I haven't needed any extensive coverage to test my situation whereas DW, unfortunately, has used hers a lot.

You know it's unfortunate that Medicare coverage has gotten to this point...in fact Advantage plans can change their coverage and perhaps the plan you pick now will morph into an entirely different plan 5 years from now. Medicare recipients don't have the same freedom of movement between plans and coverage that others do, it would be nice to see that change.

[youbet]

Quote:

Originally Posted by ivinsfan All advantage plans are different and that's the problem...just because you were able to buy this plan in your home area, doesn't mean the poster's Dad had that option. It's not as simple as blithely saying "He picked the wrong plan"

Help me, will ya? You say that I said "He picked the wrong plan" with quotes indicating not a paraphrase but the exact words I used. In going back to my posts, I don't see that. Can you point me to it please?

[youbet]

Quote:

Originally Posted by ivinsfan .in fact Advantage plans can change their coverage and perhaps the plan you pick now will morph into an entirely different plan 5 years from now. Medicare recipients don't have the same freedom of movement between plans and coverage that others do, it would be nice to see that change.

This is my main concern with DW's Advantage plan, that it will change. My research so far has indicated that if it changes to the extent that it "morph(ed) into an entirely different plan," that would be a "qualifying event" and she would have guaranteed access to change to traditional Medicare and purchase a supplement without underwriting. I haven't completely figured out to what extent they could make small changes without triggering a "qualifying event." But, thankfully, so far, so good. Provider accessibility, coverage, cost and customer service have all been very good. In fact, compared to Medicare, customer service is outstanding. Get this........ she calls with a question and someone promptly answers the phone and either knows the answer or calls her back in a reasonable amount of time. I've never had that kind of experience with traditional Medicare.