Have you had a hospital stay or expensive health care with health insurance?

[ivinsfan]

SecondCor I guess the OP should have PM'd you that's a great list and pretty much says it all.

 

[ivinsfan]

The ACA was billed as a boon to the uninsured. We see that many of those on ACA today are young retirees or full time RVers or yacht people.

Those uninsured before the availability of health insurance under the ACA remain uninsured. Hospitals still see them in the emergency rooms as unpaid clinics. They find it easier to get their healthcare that way rather than use ACA--with its high deductibles and co-payments. That's the truth.

We have to remember uninsured does not mean poor and it never did. There are many reasons people don't buy HI. In fact the original ACA was mean to put financial penalties on people choosing not to buy insurance and also make insurance easier and more affordable.


I'll take issue with your cheaper comment...if you get a very large subsidy based on a silver plan and choose to buy a bronze plan to get the cheapest insurance possible you can pay more out of pocket.



I'll have to disagree with your definition of truth.

 

[GTFan]

Since I have coverage through the ACA, Medical bankruptcy isn’t a concern - that’s what the insurance is for. However, the cost of insurance is my top expense in early retirement. Some years we qualify for the subsidy, but in the years we don’t, our annual premium is more than $20k and that comes with a $6500 per person deductible. So we’d have to spend nearly $30k in order to gain a penny of coverage. The system is broken.

Even with the current 8.5% of income cap for premiums now? I find that hard to believe unless you're making north of $200k.

 

[GTFan]

The stuff Sengsational brings up are really irritating. The old colonoscopy story seems to change year to year. Insurance is always muddling with ways to not pay, even if it is one of those procedures that should be covered.

Here's another one - dropping a major provider network right after the new year, when you've already signed up for a policy in open enrollment with that insurer. Anthem BCBS pulled that crap here in the ATL a couple of years ago when they dropped Wellstar in January, IIRC. You picked a plan going by their provider directory, then they dumped those providers and KNEW they were going to do it and said nothing.

Lots of hue and cry, legislature took no action that I know of.

 

[MichaelB]

Life is too short to get into yet another senseless debate about the ACA. Time to move on, folks.

 

[TripleLindy]

Even with the current 8.5% of income cap for premiums now? I find that hard to believe unless you're making north of $200k.

I was wrong, annual premium was just under $20k, not over, but I don’t know where the premium cap of 8.5% of income is coming from. Premiums are based on the different tiers (Bronze, Silver and Gold) and have nothing to do with income. The ACA subsidy is based on income, but phases out at roughly $70k for a couple (400% of the federal poverty level, which for 2021 is $17,420 for 2 people). So if you make more than $70k, you pay the full premium, which is much more than 8.5% of $70k, even for a Bronze plan. An $18k premium is more than 25% of a $70k income.

 

[SecondCor521]

I was wrong, annual premium was just under $20k, not over, but I don’t know where the premium cap of 8.5% of income is coming from. Premiums are based on the different tiers (Bronze, Silver and Gold) and have nothing to do with income. The ACA subsidy is based on income, but phases out at roughly $70k for a couple (400% of the federal poverty level, which for 2021 is $17,420 for 2 people). So if you make more than $70k, you pay the full premium, which is much more than 8.5% of $70k, even for a Bronze plan. An $18k premium is more than 25% of a $70k income.

ACA subsidies were changed significantly in the American Rescue Plan Act which became law last spring. These changes were extended through the end of 2025 by the Inflation Reduction Act passed a few weeks ago.

In particular, there is no 400% FPL cliff now or for the next few years. Above 400% FPL, there is a subsidy to the extent that the premiums exceed 8.5% of ACA MAGI. Of course, at very high income levels, this subsidy does go to zero, but it's a ramp rather than a cliff.

 

[TripleLindy]

Thanks for that info! I’ll have to look into that.

 

[jim584672]

It is 8.5% max cost for the SLCSP Silver benchmark through 2025. No 4x FPL income cap either.

 

[cloudeleven]

I read the very lengthy PM the OP sent me and honestly I still don't understand what he is looking for.

You can get a 100 people to tell their HI stories and every one will be different. OP you needed cardio workup and call your insurance to figure out the coding and billing before it even happens? Get the workups let the bills come and then call if you have specific questions.

I'm getting a little bit of OCD just off the wording of these questions. And that's really hard for the OP, they have my sympathy. As we have posted make a HC line item budget make sure you have it funded for retirement . retire and enjoy your life.

I hope you figure this out as it's obviously bothering you a great deal.

I called insurance before the cardiologist visit because my insurance has no charge for basic tests & x-rays but charges 30% coinsurance if it's coded as an outpatient facility visit (this cardiologist office was at a big hospital). They told me "The tests like echocardiogram should be covered under specialist visit no charge, prior authorization required though." Insurance told me to tell the doctor to code it as a basic test, specialist visit and not an outpatient facility visit. Could be the difference between paying $0 and hundreds out of pocket.

I just like to be pro-active about things. After the bill comes, they may not be willing to change & resubmit the codings.

 

[cloudeleven]

I posted the same question on another forum I frequent and got this answer. This is exactly one of the things I'm afraid of with insurance.

"Over the past several years I have undergone extensive cancer treatment that took me to my OOP max each year, about $10k total. On top of that I have another $20k in bills that I am disputing with the insurance company. These are for procedures that were pre-authorized and I had every reason to expect would be covered but now the insurance company is denying that they were pre-authorized even though I have the actual physical letters they sent with the pre-authorization. This dispute has gone on for almost 2 years now. It is very stressful. I don't know what I could have done to avoid the mess aside from not getting sick in the first place. My doctors say I had no risk factors that I could have controlled so not getting sick also seems to have been out of my control."

 

[Aerides]

I posted the same question on another forum I frequent and got this answer. This is exactly one of the things I'm afraid of with insurance.

Since that quote is from another thread on another forum, it's not really helpful to this discussion, any more than cross posting here over there, wherever. Why don't you take it up with that poster on that forum to get more info?

As I said before, keep looking, you'll always find an example to match your hypothesis. But in the grand scheme of things, financial risks for the insured will be extremely rare. You have two choices: Accept that it is a rare risk, like most things in life, or plan to have enough money and save another 5M before you retire on top of your current goals.

 

[RetMD21]

I called insurance before the cardiologist visit because my insurance has no charge for basic tests & x-rays but charges 30% coinsurance if it's coded as an outpatient facility visit (this cardiologist office was at a big hospital). They told me "The tests like echocardiogram should be covered under specialist visit no charge, prior authorization required though." Insurance told me to tell the doctor to code it as a basic test, specialist visit and not an outpatient facility visit. Could be the difference between paying $0 and hundreds out of pocket.

I just like to be pro-active about things. After the bill comes, they may not be willing to change & resubmit the codings.

Usually outpatient visits at hospitals are billed as outpatient facility visits since that's what they are. If you can get the cardiologist to bill otherwise let us know. Also there is no code for "basic test" and it is hard for me to believe that any facility would include it in the specialist office visit code with no additional charge.

 

[Yipper]

Anxiety can be reduced by focusing on things one can control and letting go of things one cannot control.

Things one can control (generally):

• how often one exercises
• the quality and quantity of food consumed
• how regularly one gets checkups, vaccines, preventive screenings, etc.
• how carefully one evaluates available health insurance and care options
• the kind and amount of health insurance purchased
• how well informed one is about their chosen health insurance
• how well one arranges their financial affairs to be able to handle financial setbacks
• how often one reads news articles which seek more to instill fear or anger rather than provide reasonable guidance or information
• one's reactions to external stimuli of any sort
• where and how one chooses to focus their thoughts, actions, and responses

Things one cannot control (generally):

• Congress
• insurance companies' behavior
• doctor's offices' behavior
• hospital billing offices' behavior
• future changes to the law
• getting hit by a bus or contracting an unusual or expensive disease or condition
• what the media chooses to publish

this is BRILLIANT.

 

[SecondCor521]

I posted the same question on another forum I frequent and got this answer. This is exactly one of the things I'm afraid of with insurance.

Based on your posts in this thread, it seems that you are deliberately choosing to live in fear. I'm not sure why specifically, but you probably are deriving some advantage by doing so. I expect you'll continue to do so as long as it works for you.

Now I will focus on what I can control, which is to offer you some suggestions which I thought might help (see my earlier post), and to let go of trying to persuade you from your path. I view your path as sad and self destructive, but obviously YMMV.

 

[gauss]

Thanks for the replies. Do you folks with ACA plans (or other health insurance) and 5-15+ years from Medicare ever worry about having to declare medical bankruptcy at some point? Medical bankruptcy is the #1 type of bankruptcy in America, and a lot of them (most?) had health insurance, which has me concerned. The story I linked in OP could be a scenario (the $60k drug).

If so, are your assets set up so they are protected in such an event?

Not any more since the ACA went into effect.

Prior to this I was a part of an employer group plan so there was a fair amount of protection. I used to worry that if the job went away, and for some reason I got sick then I would have issues to worry about.

Fortunately, the ACA was specifically designed to address this issue.

FWIW DW had major brain surgery last year and her our of pocket costs were ~ $7000. The exact OOP max for one of us on our family policy. The actual discounted bill the insurance company paid was on the order of $175,000. This was the discounted rate -- not the rack rate.

As far as the providers getting prior authorizations, it is in their interest to do a good job with this and I suspect that the larger outfits will have lots of checks and balances to ensure that it happens. Otherwise they may be left holding the bag.

Also, if all of your assets are held in 401ks and IRAs and pensions, then you should not need to worry about ths. These assets are generally exempt assets in Federal Bankruptcy. Pensions and 401ks are generally protected by the Federal ERISA laws. IRAs in many states are protected up to $1,000,000 (inflation adjusted) by the Federal bankruptcy code and may have additional state protections. There may be some issues in some states, depending on their local bankruptcy laws that may interfere with the IRA protections, so YMMV.

If you are purchasing an actual ACA compliant health plan, you should not need to worry about more than the annual OOP max. Also with ACA plans, they can not charge your more for premiums if you get sick. This was not the case for individual policies prior to the ACA.

-gauss

 

[JohnRM]

hoo boy

I have "retiree medical", basically the same HMO I was on while working except the union negotiated monthly premium is now just $20.

I had a mishap involving broken bones plus existing internal problems, spent 10 days in a hospital, then a month in a rehab (old folks home in my opinion)

The main hospital bill was 242k or so, I paid about $1750. My out of pocket is capped at $2000 a year, but there are exceptions, I had a $100 copay for ambulance, I was surprised the insurance company paid anything on that. I had to buy medical equipment, a wheelchair, then a walker, then a cane, all at my expense. So I think my cost for the whole ordeal was closer to $3000.

I think that's pretty good insurance! YMMV

 

[RaySharpton]

I'm retired with Medicare BCBS Plan F. I had an Emergency Room and inpatient hospital stay out of state with zero owed. I was shocked.

 

[RetMD21]

I'm retired with Medicare BCBS Plan F. I had an Emergency Room and inpatient hospital stay out of state with zero owed. I was shocked.

You can't beat plan F. Of course, the young folks can't get it anymore.

 

[teej1985]

You can't beat plan F. Of course, the young folks can't get it anymore.

Plan G is almost just as good. And probably cheaper for most people.

 

[indiajust]

Make appointments at the Oklahoma Surgical Center for the big stuff, their cash prices are lower than almost all deductibles.

Meanwhile, get a Direct Care Primary doc and pay 50 bucks a month for all the little stuff.

Health Sharing Ministry is also an excellent low risk low cost solution to the monopoly juggernaut of the medical industrial complex.

 

[ncbill]

Make appointments at the Oklahoma Surgical Center for the big stuff, their cash prices are lower than almost all deductibles.

Meanwhile, get a Direct Care Primary doc and pay 50 bucks a month for all the little stuff.

Health Sharing Ministry is also an excellent low risk low cost solution to the monopoly juggernaut of the medical industrial complex.

Health share ministries are not low risk.

One of the major ones has had multiple complaints about not paying, usually claiming that de novo expensive illnesses were really pre-existing conditions not disclosed.

But there's no realistic way to appeal their decision...appeals are only handled internally, with no independent 3rd party review.