cheradenine

Yeah that is my experience! I had to run the gauntlet with my last claim and when i rang up and spoke to someone, the nice lady said that what should have been resolved over a wrong 'out of network', was reversed with no explanation so it was back in out of network. even she was flabbergasted.

Steerpike

I just signed up for health insurance in CA on the 'Covered California' exchange for 2022, rather than continuing with my policy in AZ, for a variety of reasons. In order to get a head-start on my care, I visited my trusty old Primary Care Physician in CA who I've been seeing for over 20 years. I have confidence in him. This was a 'cash' visit, since I'm not yet covered by insurance in CA, but I felt it was worth it to get the ball rolling. He spent almost an hour with me, which was very reassuring (I haven't seen the bill yet, though ). He's already given me a referral to an EP (electrophysiologist) for next year and has recommended a 14-day 'zio telemetry' monitor (sounds like a 14 day version of the 3 day monitor I already had) and an 'echo stress test' (involves a treadmill). Based on what you said above, Durham_Lad, I wonder if these are appropriate for my situation or not (SVT). Regardless, I'm a fan of testing in general so if I can get it paid for, I'm not going to complain! Now, when I called the EP's office to schedule a consultation, the earliest was in March, which was a bit disappointing ... but my doc said this guy knows his stuff and has been around for ages. My doc also made the casual comment that 'no one has ever died of SVT', which no one else has bothered to tell me, so that alone was worth quite a bit!

Note - for those that don't know, the Biden administration passed some pretty helpful legislation this year that has made health insurance more affordable (or less unaffordable ...). As of this year, everyone is entitled to the 2nd lowest cost 'silver' plan on the exchanges for no more than 8.2% of your gross income. So if your income is $50k, you can get the 2nd lowest cost silver plan for about $342/mo. The second lowest 'silver' plan in my zip code for my age (63) costs about $1,200/mo, This translates to a subsidy of about $800/mo at an income of $50k. You can actually use that same subsidy amount on any plan; so you can get a cheaper 'bronze' plan for about $90/mo, or a 'gold' plan for about $500/mo, and so on. This handy calculator from the Kaiser Foundation - Health Insurance Marketplace Calculator | KFF - lets you figure out your costs in your zip code. Once you enter all the data, the results page explains more details of the law (why they don't put it on the first page I don't know ...). It also explains that the maximum out-of-pocket costs are limited to $8,700 for any plan. Be sure to change from 'US average' to your own state and zip code, and of course enter your age, to get meaningful numbers.

Giantaxe

The other big change is that the subsidy elimination "cliff" of 400% of the federal poverty level is gone, so those with a Modified Adjusted Gross Income above that level will still receive a premium subsidy based on that 8.2% cap. That's especially valuable for older people with an income a little above that level. All these improvements will expire at the end of 2022 without further pending legislative action passing Congress.

https://www.kff.org/health-reform/is...rollment-2022/

vespucci

Thank you for posting, these are helpful to know about.

Unfortunately they've quietly ditched Medicare at 60 that they'd promised, which would have been better than these measures.

durham_lad

@steerpike, that echo stress test does sound like something that should be done in your case. In both the US and in the UK I had an echocardiogram done which checks the structure of the heart, valves and blood vessels which can be damaged leading to or caused by arrhythmia. The echo stress test is an echocardiogram done after the heart is put under stress by running or walking on a treadmill.

it is good that you are receiving reassurances that your SVT is not likely to be fatal. It will be worth the wait to get under the care of an experienced EP.

SpoogleDrummer

That's all well and good but under the Trump administration they let in a bunch of providers that weren't really in the state. The result is they're cheaper than BCBS etc so you get less subsidies but if you have a heart attack or something you'd better hope you can make the 2 hour journey to the hospital that's in network because none of the local hospitals are. End result being that if you actually want coverage that's in network you're going to pay more rather than less. Unfortunately a lot of people will just go for the lowest price so these providers will still get the premiums and not have to pay a penny out as everything will be considered out of network.

Prime example: I can get a plan for $0 if I don't mind going to Mississippi to take my kids to the dentist.

Steerpike

Yes, I ran the numbers for incomes of $50k, $60k, $70k, $80k, etc and the subsidy drop-off was gradual, so the cliff is gone. This is going to be very helpful to me in 2022. I turn 65 in 2023, so I need to brace myself for a more expensive year! My g/f already uses medicare, and she couldn't be happier. She's had an emergency appendectomy and a detached retina this year, and is now scheduled for cataract surgery and she's hardly had to pay anything.

Steerpike

Can you clarify what you mean by 'provider' in this? To me, in medical discussions, a 'provider' is a doctor or nurse or whatever, but it sounds like you are talking about insurers?

What I do know is that Trump removed the requirement that all policies offered had to be 'ACA compliant'. I signed up for such a non-compliant plan in 2020, taking a risk that I would not need to use it much. The premiums were quite a bit lower, but it had a cap of $1m, excluded any pre-existing conditions, and they had the right to drop me at any time. Thankfully, I signed up for an ACA-compliant plan for 2021.

But I think even those crappy plans were obligated to cover an emergency, so your example about having a heart-attack and needing to go to an 'in-network' hospital may not be accurate.

Steerpike

Thinking more about your comment earlier -
Is it not reasonable to do such tests to rule out 'other' factors perhaps? I mean, does the presence of 'AFib' guarantee you don't have any other conditions? Was AFib 'proven' at the time of the test?

I'm new to the rich world of 'heart problems' so at the moment, these terms (AFib, SVT, etc) are largely just acronyms so I'm still learning ...

durham_lad

AFib was already proven conclusively through ekgs including a 48 hour heart monitor I wore. The echocardiogram showed there were no heart issues in terms of enlargement, thickened walls, scars, blood vessels (they even did the vessels in my neck), and heart valves. (An echo shows the blood flows quite clearly)

I didn’t mind the nuclear stress test, I’ve done plenty of regular stress tests, and this was the same except first they inject a radioactive substance into a vein then put me through a chest Geiger counter affair to get a picture of the blood vessels and heart after the radioactive stuff had flowed through. Then I went onto a treadmill and the speed and incline increased until my heart was up to 70 or 80% of maximum at which point they inject the radioactive dye again. Since I was very fit it took 15 minutes and I was running at this point so it was pretty tricky for the technician to keep my arm steady enough to inject the dye. The treadmill is then stopped and I am scanned again by the Geiger counter so they can compare the at-rest and under-stress results.

If it hadn’t been for the docs here and my subsequent googling I wouldn’t know that it was not a test normally done once AFib was established. However, the insurance paid, and I survived the stress test so all was well.

A couple of years earlier I had a small lump on my cheek that was bothering me, occasionally cutting it while shaving. The GP said it was just a sebaceous cyst and nothing to worry about but I took my self off to a dermatologist anyway and asked him to remove it. He told me the same as the GP and that the insurance wouldn’t pay for it since it was considered cosmetic. I asked him how much and then said I’d pay it. The cost was $150 including having it tested and it was exactly as predicted, a small hard benign waxy lump, but he sent in an insurance claim anyway as if he had needed to excise and test to see if it was cancer. He got paid $200 and I only had to pay $50. That was a clear insurance scam in my view but I wasn’t going to file a complaint. He knew the test was not needed for anything more than to get more money out of the insurance company.

SpoogleDrummer

Yes I mean insurance companies when I say providers in this case.

Allowing the cheaper non-compliant plans completely breaks the calculation though when using the second cheapest silver plan.

I just found the following information about how much premiums changed in Tennessee by company on Healthinsurance.org. Guess which companies have pretty much no network in Tennessee so don't really incur costs.

Giantaxe

You'll be eligible for Medicare on the 1st of the month you turn 65. Be aware of a "gotcha" if you're transitioning from employment when you first sign up for Medicare. Unlike the ACA, premiums are set based on the latest tax return Medicare has available before the start of a year. For example, 2021 premiums are set of your 2019 return (because in late 2020 your 2020 return, obviously, is not available). If your income is higher than $91k (if you are single filer) you get stung for higher Medicare premiums, considerably higher in some cases. For various reasons, my 2019 taxable income was extremely high (I know, first world problem...) but my income by the end of 2020 was extremely low. I appealed against the higher premium. It took them 11 months but my appeal was succcessful - and backdated those 11 months.

https://www.healthline.com/health/me...-b-irmaa-costs

Giantaxe

California and a number of other states ban these crappy plans.

Steerpike

My g/f had exactly the same issue; she worked right up until Dec 31, 2019 before retiring, and was making over the $91k limit, then went to almost zero income in 2020 (hardly had to withdraw anything from IRA since 2020 was such a 'cheap' year due to lockdowns, etc!). She appealed and just recently got a refund. As you say, 'first world problem'! I retired from full-time work in 2013, but gradually eased down in income (and effort!) by doing part-time consulting. 2021 was the first year I made almost nothing, and was forced for the first time to withdraw money from my IRA - that felt so odd! It doesn't matter how much you have saved; spending your own savings rather than getting a paycheck was decidedly scary to me!

Steerpike

I signed up for health insurance on the 'exchanges' (Covered California) in December for 2022 coverage. Because I anticipate a fair amount of medical 'needs' this year, and influenced by the fact that the subsidies are now substantial, I chose a 'Silver 70 HMO' plan. Without subsidy, as a 63-year old non-smoker in my county, the rate was circa $1150/mo. The subsidy was over $800/mo and my monthly premium is thus around $350/mo (the subsidy is calculated such that your monthly premium for a silver plan is no more than 8.2% of your gross income). I would have preferred a PPO or EPO plan (more flexibility) but the rates on those were even higher so I ended up with an HMO plan, which requires everything to go through a PCP (Primary Care Physician). Further, I chose to go with an unknown insurance company - 'Bright Healthcare' - rather than the 'name brands' such as Anthem, Blue Cross, etc, again because those rates were much higher. Bright Healthcare have been around a while but are new to California this year.

I saw my PCP in early Jan and got a referral to an ElectroPhysiologist (Heart wiring guy). Earliest date available was March 3, which sucks but I'll live with that. But before that appointment with the specialist, my PCP also referred me for a 'stress test' and the fitting of a '14-day zio monitor', and that was scheduled for Jan 11. When I called to make the appointments, they told me my insurance was not valid for them; they said the 'Medical Group' was (some other group). As an HMO plan, apparently you don't just have to pick a PCP, you are also assigned to a 'Medical Group', and all services must come from that Medical Group. My PCP IS a member of the appropriate Medical Group - I've double-checked that. They went ahead and gave me an appointment anyway, but said it would need to be resolved before the actual date or I would lose the appointment. I called the insurance company, and they say there isn't a 'Medical Group' assignment in my 'record'. I've since made about 6 calls, each time on hold for about an hour, the last call requesting escalation to a supervisor, all to no avail. Everyone at the insurance company is insisting there is no 'Medical Group' that they can see. I got the supervisor to admit that, as an HMO plan, there 'must be' or 'needs to be' a Medical Group assigned, but she said she simply cannot see it. Meanwhile, my appointments are 2 days away and there's a good chance I'll either get refused service, or, have to pay cash.

I read that Bright Healthcare is a relative newcomer to the health insurance world, and they are new to California this year. Judging by the hold times, and the 'quality' of the people I'm talking to when I finally get through, I get the impression they hired a bunch of new people for the California rollout and they are woefully inexperienced and under-trained. Further, my guess is, for the California rollout they had to make changes to their 'systems' (add/modify fields, etc) and they messed it up. I asked my local Medical Group 'insurance division' if anyone else has called with a 'Bright Healthcare' policy, and I'm the first ... . This underscores two related problems - choosing an inexperienced insurer, and trying to schedule service very early in the year before the kinks are worked out ...

The supervisor promised to call me back Monday but I'm not optimistic; so far they've promised to call me back several times and not done so. I'm hoping that when I show up for my appointments on Tuesday they are willing to take my word for it that 'things will get worked out', but that's probably being over-optimistic. Paying cash to see a specialist is one thing (maybe a few hundred $) but paying cash for a stress test and a 14-day monitor is probably going to hit $10,000 or more, so I don't think I'll offer to pay cash ... The other alternative is to wait until the insurance situation is resolved, which means I lose my 'place in line' on these hard-to-get appointments. Luckily, I've calmed down on my 'heart' issues, as in, I've convinced myself I'm not in imminent danger of keeling over and dying, but I really would like to get these things moving!