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

[cloudeleven]

I'm 41. Thankfully I'm currently healthy and have never had a hospital stay or expensive treatment, but I was wondering about Americans here who have and had health insurance (not Medicare, Medicaid or other govt program), especially in ACA era (since 2010). How much out of pocket did you end up owing and paying? Any nightmare stories?

I'm pretty scared of healthcare, even just visiting a specialist office for some tests, because of the potential for astronomical bills, even though I have an ACA Silver plan. The only thing I'm comfortable with is my annual physical with my PCP. Although I could easily cover the $1,575 out-of-pocket max (in-network...out of network is $12k!) of my current ACA plan. But there's always the potential for denials, "prior approval required" denials, uncovered stuff, incorrect bills (90% of hospital bills have errors), etc.


A nightmare story like this has me concerned (occurred in 2012. ACA went into effect in 2010, but I'm not sure if it helped her situation or not, seems like it didn't):

https://www.huffpost.com/entry/your...-as-painful-as-the-treatment-itself_b_8926910

She was 39 and had Texas BCBS health insurance which denied coverage of the $60,000 drug her doctors said she needed for survival, and she was totally denied treatment by the hospital with the drug until she paid for the drug upfront. They wouldn't even allow a payment plan. Even the pharma company wouldn't help her. She paid the full $61,131 by having to sell some of her property. They charged her more than 3x what they would charge an insurance company.

The only state that has medical price anti-gouging laws is Maryland that I'm aware of. I live in Arkansas.

 

[mystang52]

I'm on a retiree Medicare Advantage plan with Aetna. I had 2 inpatient stays, earlier this year, involving heart surgeries. Gross bill was something on the order of $340,000, my out of pocket was zero. But originally the hospital sent me a balance due bill of $6,000, before they corrected it.

 

[cloudeleven]

I'm on a retiree Medicare Advantage plan with Aetna. I had 2 inpatient stays, earlier this year, involving heart surgeries. Gross bill was something on the order of $340,000, my out of pocket was zero. But originally the hospital sent me a balance due bill of $6,000, before they corrected it.

Did you have to do anything yourself in regards to getting "prior approval" for things that needed that for coverage? Did you have to "fight" with the hospital to get the $6,000 corrected? Or just a simple phone call?

 

[mystang52]

Did you have to do anything yourself in regards to getting "prior approval" for things that needed that for coverage? Did you have to "fight" with the hospital to get the $6,000 corrected? Or just a simple phone call?

Maybe because my issues were cardiac, but no I did not have to do anything regarding pre-approval. Of course, I have no knowledge if there were any behind-the-scenes issues between the insurer and the hospital. I made one call to Aetna when I got that balance due bill, and got a call back in less than 2 hours that it was resolved with no balance due.

 

[Yipper]

A nightmare story like this has me concerned (occurred in 2012. ACA went into effect in 2010, but I'm not sure if it helped her situation or not, seems like it didn't):

https://www.huffpost.com/entry/your...-as-painful-as-the-treatment-itself_b_8926910

She was 39 and had Texas BCBS health insurance which denied coverage of the $60,000 drug her doctors said she needed for survival, and she was totally denied treatment by the hospital with the drug until she paid for the drug upfront. They wouldn't even allow a payment plan. Even the pharma company wouldn't help her. She paid the full $61,131 by having to sell some of her property.

So is this a common occurrence? Are most brand-named drugs not covered since they aren't explicitly named in the policy? Maybe I just don't know how that works since like you, I've been very healthy thus far and haven't needed any crazy longer-term prescriptions. I know that's likely to change as age takes it's toll and I worry like you.

What's the point of having insurance to cover prescription drugs if the insurance company can deny something that your doctors think is critically important?

 

[braumeister]

Cancer drugs seem to be in a class of their own.
DW is taking one that has a list price of $15,000 a month.
She is enrolled in a clinical trial where the manufacturer provides it at no charge, so I have no idea what would happen otherwise.

 

[target2019]

I'm 41. Thankfully I'm currently healthy and have never had a hospital stay or expensive treatment, but I was wondering about Americans here who have and had health insurance (not Medicare, Medicaid or other govt program), especially in ACA era (since 2010). How much out of pocket did you end up owing and paying? Any nightmare stories?

I'm pretty scared of healthcare, even just visiting a specialist office for some tests, because of the potential for astronomical bills, even though I have an ACA Silver plan. The only thing I'm comfortable with is my annual physical with my PCP. Although I could easily cover the $1,575 out-of-pocket max (in-network...out of network is $12k!) of my current ACA plan. But there's always the potential for denials, "prior approval required" denials, uncovered stuff, incorrect bills (90% of hospital bills have errors), etc.

A nightmare story like this has me concerned (occurred in 2012. ACA went into effect in 2010, but I'm not sure if it helped her situation or not, seems like it didn't):

https://www.huffpost.com/entry/your...-as-painful-as-the-treatment-itself_b_8926910

She was 39 and had Texas BCBS health insurance which denied coverage of the $60,000 drug her doctors said she needed for survival, and she was totally denied treatment by the hospital with the drug until she paid for the drug upfront. They wouldn't even allow a payment plan. Even the pharma company wouldn't help her. She paid the full $61,131 by having to sell some of her property. They charged her more than 3x what they would charge an insurance company.

The only state that has medical price anti-gouging laws is Maryland that I'm aware of. I live in Arkansas.

We have -0- experience with ACA.

We just transitioned from employer group insurance to Medicare, Part G and Drug plan.

Employer group insurance paid everything. In my case that was a lot. Surgeries, chemo, follow up immunotherapy and other things. It had to be more than $500K.

Now we've switched to Medicare, and it is a work in progress. I botched the yearly inspection, and owe $400 for that. The drug went from $5.00 monthly to $3200. I get papers from drug company, specialty pharmacy, UHI, etc. To be frank, it leaves me with an unsettled feeling each day. There are about 4-5 institutional hands in my care, and it is clear that each does not understand the totality of this and the impact it has on patient.

As for pre-approval, for operations, etc. our health system does pre-check everything. Obviously if something catastrophic happens process may go out the door, and you get surprises.

I checked the drug cost while signing up for Medicare drug plan, and 10 medications are covered by drug plan. The immuno drug was quoted as $1000 through the Medicare site. After signing up I double-checked through insurance site and it was $3200. WTF?

I guess this post is a flame. LOL.

 

[scrabbler1]

I'm 41. Thankfully I'm currently healthy and have never had a hospital stay or expensive treatment, but I was wondering about Americans here who have and had health insurance (not Medicare, Medicaid or other govt program), especially in ACA era (since 2010). How much out of pocket did you end up owing and paying? Any nightmare stories?

I'm pretty scared of healthcare, even just visiting a specialist office for some tests, because of the potential for astronomical bills, even though I have an ACA Silver plan. The only thing I'm comfortable with is my annual physical with my PCP. Although I could easily cover the $1,575 out-of-pocket max (in-network...out of network is $12k!) of my current ACA plan. But there's always the potential for denials, "prior approval required" denials, uncovered stuff, incorrect bills (90% of hospital bills have errors), etc.


A nightmare story like this has me concerned (occurred in 2012. ACA went into effect in 2010, but I'm not sure if it helped her situation or not, seems like it didn't):

https://www.huffpost.com/entry/your...-as-painful-as-the-treatment-itself_b_8926910

She was 39 and had Texas BCBS health insurance which denied coverage of the $60,000 drug her doctors said she needed for survival, and she was totally denied treatment by the hospital with the drug until she paid for the drug upfront. They wouldn't even allow a payment plan. Even the pharma company wouldn't help her. She paid the full $61,131 by having to sell some of her property. They charged her more than 3x what they would charge an insurance company.

The only state that has medical price anti-gouging laws is Maryland that I'm aware of. I live in Arkansas.

I am 59 and have been on the ACA with a Silver plan since 2014. In July, 2015, I had a 12-day hospital stay, stemming directly from an ER visit. That is important because even though the hospital was OON, because my 12-day stay there began with the ER visit, I was covered. (I'm not sure if this was an ACA feature or a New York State law; it might have been the latter.)

I had my share of discussions with providers and my insurance company in the months after I was discharged from the hospital. For example, the provider once used a lab which was OON. I filed an official complaint and never heard from the lab (which had billed me) again.

Keeping track of all the EOBs which arrived in the weeks and months afterward was a nuisance, but it also kept me organized. I saw when I hit my max OOP, so any charges I incurred for the rest of the year were 100% covered.

The hospital's EOB was the biggie, of course. The hospital and insurance company fought each other for 5 months until I finally got an EOB for my stay. Even then, the final hospital bill didn't match the IC's EOB even though the EOB matched an earlier estimate from the hospital. One trip to the hospital's billing office (with my records) cleared that up.

A few scattered bills from the hospital stay kept arriving in 2016 and later. I made a mistake on one of them I thought I had paid. But another one the hospital had turned over to a collections agency! I checked my records and saw the hospital was in error. I called them and straightened it out. By the time I called the collections agency the next day, they told me the hospital had already told them there was no outstanding debt.

One issue which had gotten worse after the hospital stay was the prescription drugs I had begun taking. After 1 refill, I had to start using Express Scripts. What a nightmare dealing with them! Drugs were late arriving, then they and my doctors pointed fingers at each other, to everyone's annoyance. I knew for 2016 I had to change to another IC, one which did not require using Express Scripts. I found one which uses CVS, my local pharmacy, and had my doctors still in-network.

It has been pretty smooth sailing since then. No further hospital stays, thankfully. Just doctors, labs, other medical services, and drugs.

 

[cloudeleven]

I am 59 and have been on the ACA with a Silver plan since 2014. In July, 2015, I had a 12-day hospital stay, stemming directly from an ER visit. That is important because even though the hospital was OON, because my 12-day stay there began with the ER visit, I was covered. (I'm not sure if this was an ACA feature or a New York State law; it might have been the latter.)

Did you have to do prior authorizations with the insurance company yourself or did your hospital/doctors get them for you? I've always been concerned about that part...what if the doctor/hospital forgot to get prior authorization, then what? Screwed?

 

[daylatedollarshort]

We haven't had any very high medical expense bills since we've been on and ACA policy and California eliminated surprise billing. We still had insanely high bills compared to other countries because of $7Kish per person deductible, like $5K for a routine MRI (that was the insurance rate, down from $7K!, the charge master rate), and $2K for a 60 second doctor chat to get steroids for poison ivy (holiday, had to go to ER), but that is all.

We don't go to the doctor that often so I didn't know I had to price shop for an MRI like I would for a used car. If I had done that it would have been much cheaper. I had a chest X-ray from the same hospital before that for something like $65 for bronchitis, so I had no idea the MRI was going to be thousands of dollars. What makes it even better is the MRI was for a serious heart issue the hospital said was identified on the chest X-ray, even though I had no symptoms, but then the heart issue miraculously disappeared a few weeks later when I had the MRI. So miracle healing or are overpriced MRIs money generators hospitals? I'll probably never know the real answer, but I know which scenario is more probable.

 

[N02L84ER]

We have been on ACA bronze plans since 2015. We had one emergency visit in 2016 that turned into a 5 day hospital stay and resulted in the removal of a gangrenous gallbladder. All of this was out of state and the hospital assured us that they would be able to work with our insurance company since they insisted on the hospitalization instead of removing the gallbladder immediately. We paid the max out of pocket. The hospital wanted tens of thousands more, but did not try to get it from us. We do not know how long they tried to get money from the insurance company or even if they did get any more from them. All other years have had minimal medical costs. We still have 3+ more years before Medicare.

 

[daylatedollarshort]

We have one family member who had an in network hospital stay get bills from an out of network doctor who saw them in the hospital, but this was after the surprise billing law here went into effect. The doctor did try to send us bills for the excess amount. We ignored it and the insurance statement clearly said it was not our responsibility to pay the excess for that doctor, and after that the doctor dropped it.

 

[MichaelB]

I'm 41. Thankfully I'm currently healthy and have never had a hospital stay or expensive treatment, but I was wondering about Americans here who have and had health insurance (not Medicare, Medicaid or other govt program), especially in ACA era (since 2010). How much out of pocket did you end up owing and paying? Any nightmare stories?

I'm pretty scared of healthcare, even just visiting a specialist office for some tests, because of the potential for astronomical bills, even though I have an ACA Silver plan. The only thing I'm comfortable with is my annual physical with my PCP. Although I could easily cover the $1,575 out-of-pocket max (in-network...out of network is $12k!) of my current ACA plan. But there's always the potential for denials, "prior approval required" denials, uncovered stuff, incorrect bills (90% of hospital bills have errors), etc.


A nightmare story like this has me concerned (occurred in 2012. ACA went into effect in 2010, but I'm not sure if it helped her situation or not, seems like it didn't):

https://www.huffpost.com/entry/your...-as-painful-as-the-treatment-itself_b_8926910

She was 39 and had Texas BCBS health insurance which denied coverage of the $60,000 drug her doctors said she needed for survival, and she was totally denied treatment by the hospital with the drug until she paid for the drug upfront. They wouldn't even allow a payment plan. Even the pharma company wouldn't help her. She paid the full $61,131 by having to sell some of her property. They charged her more than 3x what they would charge an insurance company.

The only state that has medical price anti-gouging laws is Maryland that I'm aware of. I live in Arkansas.

There are 3 separate issues here. One is if insurance will cover a treatment. The second is, if the patient has to pay, what that price will be. Finally, drug coverage.

The second issue is easier to answer. Providers of health care services and treatments tend to charge much higher prices for cash paying customers. Economic theory says this should not be so, but nonetheless is, and it is very difficult to change without implementing price controls. Provider pricing is exploitative, and because of this, comprehensive health insurance coverage is very important.

The first issue is more common. Not all insurance plans are alike. Some, like HMOs, require prior authorization for all services. Others, like PPOs, give some flexibility to the policyholder, don’t require pre-authorization for many services, and will cover services provided within their provider network. The ACA mandates certain coverage requirements. It is critical to understand this when selecting a health care policy.

Regarding coverage of pharmaceuticals, insurers have “formularies”, or lists of drugs they cover for specific conditions. These formulary lists spell out which drugs are covered and what is the cost sharing for the policyholder. The ACA mandates that most conditions have at least one drug on a formulary list. There is no guarantee, however, that a specific drug will be covered. A patient must work with her physician to insure that treatment options are covered by insurance. Most physicians are well experienced in this and are expert at finding the better options given the restrictions of a specific health care policy.

 

[scrabbler1]

Did you have to do prior authorizations with the insurance company yourself or did your hospital/doctors get them for you? I've always been concerned about that part...what if the doctor/hospital forgot to get prior authorization, then what? Screwed?

Because my hospital stay came from an ER visit, I didn't end up need to contact my IC beforehand. But when I got back home from the hospital, I saw a letter from the IC telling me they had authorized the stay. I didn't really have a choice when I was admitted because it came from the ER visit, and I was allowed to go to any hospital for an ER visit. This basically OON hospital stay was the root cause of the dispute between the hospital and the IC when it came to the long delay in getting the EOB 4 months later.

I did need to get referrals to see doctors, though. That was a minor ordeal at times because it was tough to get in touch with my original PCP. I was able to quickly change to a different PCP who had a special staffer who did and sent out referrals. That was in 2015, when I first got sick. When I changed insurance companies in 2016, the new IC didn't require referrals.

 

[cloudeleven]

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?

 

[ivinsfan]

Why do you keep going back to a 10 year old story?


As far as need pre approval believe me if it's more then a hangnail your provider with be all over that.



And what are you actually hoping get from this thread? Your questions are all over the place. Do you want to plan a healthcare budget for ER.?..help picking the best plan for your income.? You've had no health issue and concerned about being bankrupt?


It would be nice if you could flesh out your questions instead shooting from the hip.


Are you a writer or reporter of some sort? You had a thread just like this in 2017 when you would have been what 35 and it was chock full of questions about Medicare...what's actually going on here.

 

[Bamaman]

Medical Insurance. Cannot afford it, but sure cannot afford not having it. I'm just thankful to have Medicare with a supplement and a prescription plan.

After spending many nights in Emergency Rooms, I still see the same uninsured poor people there for an unpaid clinic. They never even thought about using the ACA--like our politicians thought--since they cannot afford the high deductibles and co-pays. I do see those early retirees and full time RVers with ACA plans.

There's a huge hospital chain to the north of me, and they've bought out many doctors' practices. The hospitals in their chain accept Medicare, but not Medicare Advantage. And their 1700 doctors in their chain don't accept Advantage plans either. This has made many patients to have to leave their small towns to find doctors and hospitals that accept Advantage. Seems like many doctors accepting Advantage practices are from foreign medical schools. Just beware that this is rather common of some hospitals.

Another angle is that many hospitals use non-employees to staff specialties like Emergency Rooms, Radiologists and Pathologists. The ER doctors often work for what they can squeeze out of insurance companies as out of network--and bill the patients for the balance. The mega hospital chain mentioned above at least has Emergency Room physicians in their employment.

Just be aware that not all hospitals are created equal, and it doesn't cost anything to ask before you take their services.

 

[Aerides]

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?

No more than I have a plan for how to handle a plane crash. Such events are pretty rare, and more often apply to those without any insurance, or without comprehensive coverage.

I have another 12 years till Medicare, and don't think about this sort of thing one bit. I know my deductibles, and my out of network max, and I can live with it.

 

[MBSC]

There's a huge hospital chain to the north of me, and they've bought out many doctors' practices. The hospitals in their chain accept Medicare, but not Medicare Advantage. And their 1700 doctors in their chain don't accept Advantage plans either.

Vanderbilt Health only had an issue with BCBS-TN Medicare Advantage. They continued to accept all major Advantage plans during the 6 year impasse. Vanderbilt is back in the BCBS-TN Advantage network for 2022.

December 2, 2015: The letters state that Vanderbilt University Medical Center and its affiliated providers are leaving the BlueCross BlueShield of Tennessee Medicare Advantage network at the end of the year.

The changes means these customers will need to change doctors or pay higher, out-of-network rates to stay with their existing treatment plans.

We (VUMC) have been communicating with the affected individuals since September to make them aware of this change. The website and Tennessean ads include a list of the other Medicare Advantage plans that will provide in-network access to VUMC’s hospitals, clinics and physicians for 2016.

Reference: https://www.distilnfo.com/payer/201...shield-splits-from-vanderbilt-medical-center/

Accepted Insurance Plans:
Aetna Medicare Advantage
Amerivantage Medicare Advantage
Cigna-(aka HealthSpring) Medicare HMO and PPO
Humana Medicare Advantage HMO, PPO, POS
UnitedHealthcare Medicare Advantage Plans
WellCare Medicare Advantage

Oct 26, 2021: Beginning Jan. 1, 2022, BlueCross BlueShield of Tennessee will expand its BlueAdvantage network to include Vanderbilt Health. We are excited to build on our current relationship with Vanderbilt and provide more in-network options for our Medicare Advantage members.

The Vanderbilt Health system is one of the largest academic medical centers in the Southeast and is the primary resource for specialty and primary care in hundreds of adult and pediatric specialties for patients throughout Tennessee and the Mid-South.

Source: https://bcbstnews.com/pressreleases/bluecross-senior-care-network-adds-vanderbilt-health/

 

[cloudeleven]

No more than I have a plan for how to handle a plane crash. Such events are pretty rare, and more often apply to those without any insurance, or without comprehensive coverage.

I have another 12 years till Medicare, and don't think about this sort of thing one bit. I know my deductibles, and my out of network max, and I can live with it.

Thanks. That helps me feel better about this, some perspective.

 

[cloudeleven]

Why do you keep going back to a 10 year old story?


As far as need pre approval believe me if it's more then a hangnail your provider with be all over that.



And what are you actually hoping get from this thread? Your questions are all over the place. Do you want to plan a healthcare budget for ER.?..help picking the best plan for your income.? You've had no health issue and concerned about being bankrupt?


It would be nice if you could flesh out your questions instead shooting from the hip.


Are you a writer or reporter of some sort? You had a thread just like this in 2017 when you would have been what 35 and it was chock full of questions about Medicare...what's actually going on here.

No, not a writer or reporter. Just someone planning for an ER in my 40s who tends to be on the anxious side and assume the "worst case scenario" (or at least "bad case scenario") about things, and then I try to plan for that.

 

[ivinsfan]

No, not a writer or reporter. Just someone planning for an ER in my 40s who tends to be on the anxious side and assume the "worst case scenario" (or at least "bad case scenario") about things, and then I try to plan for that.

Ok well that's why people make budgets random stories of outlier cases aren't going to help. Asking about Medicare or Medicare Advantage 30 years before you need it is a complete waste of time. You can narrow down your questions and get helpful answers

 

[cloudeleven]

Ok well that's why people make budgets random stories of outlier cases aren't going to help. Asking about Medicare or Medicare Advantage 30 years before you need it is a complete waste of time. You can narrow down your questions and get helpful answers

I sent you a PM. Appreciate your advice when you have time. Thanks

 

[Bamaman]

My wife and an AFIB episode a year ago. Her cardiologist wanted her to have an ablation after a few months in order to get her off some long term meds that were somewhat unhealthful.

The bill came in last week, and it was $101K--with me being liable for $2K max.

She just returned home 2 days ago after being in the hospital and rehab 6 weeks for back surgery and later a broken leg in a fall. I cannot imagine what bills to expect.

But I'm so thankful for Medicare and Plan F.

 

[sengsational]

The financial side of the US medical system is horrifically broken. The best you can hope for is some fix by the time you need to use it. If you make it until 65, and you elect to use traditional Medicare plus medigap, and that stays similar or better, you're probably ok.

But this whole thing where your insurance company won't tell you how much things will cost is absurd. They have boatloads of data on people who are facing the same medical problem you're facing, and they know all 700 pages of the policy you purchased (oh, but you don't even have access to those pages, BTW, you get a fluff summary and that's it). Anyway, they could easily give you a range of costs, based on their experience, but they don't. You must wait until AFTER the services have been administered to find out the coverage. Sure, you can get "pre-approved" for something, but that only means they'll look at the claims, not that they will pay them.