Author Topic: Insulating against medical bankruptcy  (Read 4312 times)

dblaace

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Re: Insulating against medical bankruptcy
« Reply #50 on: January 21, 2022, 04:37:42 PM »
There is no way in hell thats a good deal unless you're certain you're going to get cancer, you'd be much better off using the amount of the premiums to invest in something and keeping the benefit amount in savings in case its needed.
Probably not if you are young. I didn't add it until I was 58. Both parents died from cancer, both had heart problems. The odds were not in my favor. And it's not that much, $44 a month for $10K. A hedge against critical illness.

I hit the cancer lottery, 'the good cancer' if there is such a thing. No treatment needed currently and possibly never. If I do it will pay differing amounts monthly dependent on treatment and hospitalization.

It's pretty much paid for itself for the next 15-20 years. I will probably drop it at 65 when I get Medicare.

dblaace

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Re: Insulating against medical bankruptcy
« Reply #51 on: January 21, 2022, 04:46:38 PM »
Out-of-network is the biggest risk.  (1.) What hospital is an ambulance going to take you to in an emergency?  Is it in your network?  If that hospital is not, you need a different health plan.  (2.) If you get cancer, where are you going for treatment?  If those providers are not in your network, who is?  If you arenít happy with that, you need a different health plan.  (3.) Are there any other doctors or hospitals you want access to if you get sick?
I ran into this when I was shopping ACA. My preferred specialist and hospital only accepts Commercial or Medicare/Medicaid insurance. My only option would have been COBRA.

afox

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Re: Insulating against medical bankruptcy
« Reply #52 on: January 21, 2022, 05:06:33 PM »
Out-of-network is the biggest risk.  (1.) What hospital is an ambulance going to take you to in an emergency?  Is it in your network?  If that hospital is not, you need a different health plan.  (2.) If you get cancer, where are you going for treatment?  If those providers are not in your network, who is?  If you arenít happy with that, you need a different health plan.  (3.) Are there any other doctors or hospitals you want access to if you get sick?
I ran into this when I was shopping ACA. My preferred specialist and hospital only accepts Commercial or Medicare/Medicaid insurance. My only option would have been COBRA.

First world problems that don't concern me. I'm just happy to get treatment from a qualified provider, I don't care who it is or if they are new to me.

I think a lot of you would be shocked and immensely disappointed if single payer care ever came to the U.S. careful what you wish for!

Anon-E-Mouze

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Re: Insulating against medical bankruptcy
« Reply #53 on: January 21, 2022, 05:34:40 PM »

I think a lot of you would be shocked and immensely disappointed if single payer care ever came to the U.S. careful what you wish for!

Mustachians like me who live in single-payer countries are giggling at your suggestion.
https://www.youtube.com/watch?v=iYOf6hXGx6M

I'm not worried about medical bankruptcy.




afox

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Re: Insulating against medical bankruptcy
« Reply #54 on: January 21, 2022, 08:54:41 PM »

I think a lot of you would be shocked and immensely disappointed if single payer care ever came to the U.S. careful what you wish for!

Mustachians like me who live in single-payer countries are giggling at your suggestion.
https://www.youtube.com/watch?v=iYOf6hXGx6M

I'm not worried about medical bankruptcy.

That's good news! I just wonder if the American consumer with their extreme particularities would appreciate a medical care system where they have less choice but cheaper costs.

Im not worried about medical bankruptcy either but I expect to pay a fortune for medical care, approx $4000 per year for premiums and $10,000 out of pocket max = $14,000 per year for my family of 4 and this does not include dental. And the pleasure of paying this much is only due to my employment. I cannot leave my job or I will pay much more, an early retirement is not an option for me due to healthcare expenses.


Ron Scott

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Re: Insulating against medical bankruptcy
« Reply #55 on: January 21, 2022, 09:38:54 PM »
In terms of how to insulate against medical bankruptcy, in which I include things like possible need for long term care, aids, etc. when elderly, our plan is to just budget a lot of money for that just in case. 

This is the obvious and correct solution.

rmorris50

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Re: Insulating against medical bankruptcy
« Reply #56 on: January 22, 2022, 07:35:55 AM »
Some general thoughts that might help mitigate the risk.
1. Keep money in retirement accounts that are protected from creditors. Donít go pulling out excess money
2. Work on setting up a cash flow stream for retirement, like social security, rental income and converting some assets to a payout annuity.
3. Allocated a retirement account just to medical if possible. We plan to just use our Roths for medical and LTC type needs if need be.


Sent from my iPhone using Tapatalk

Anon-E-Mouze

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Re: Insulating against medical bankruptcy
« Reply #57 on: January 22, 2022, 01:08:23 PM »
That's good news! I just wonder if the American consumer with their extreme particularities would appreciate a medical care system where they have less choice but cheaper costs.

I've lived in Canada for more than 40 years. I also lived in the US for 10 years, France for 2 years, and the UK for 1 year.

The only country where I experienced practical constraints on my choice of medical and dental service providers was the United States, where the financial consequences of using an out-of-network service provider were punitive.

Abe

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Re: Insulating against medical bankruptcy
« Reply #58 on: January 22, 2022, 06:00:34 PM »
Most excessive costs are due to non-indicated use of various medications or excess testing to alleviate anxiety on the patient or physicianís part. I think Americans in general are less tolerant of mistakes of omission. We thus pay a premium in our healthcare system to know that ďwe looked at all possibilitiesĒ rather than ďwe looked at the most likely possibilitiesĒ, be that in diagnosing or treating a disease. Itís part of our culture of feeling that we are all unique and different (when those differences within a biological gender are in the grand scheme of things relatively minor). Also our culture of never accepting death unless it makes us.

Some good examples in diagnostics:
- Excess surveillance imaging for various cancers (not screening - that has good evidence and is much cheaper).
- excess lab tests to Ďrule outí rare diseases that mimic much more common diseases.

Examples in treatment:
- emergency thoracotomies for trauma patients
- ventricular assist devices for non heart-transplant candidates
- ICU for people with no recoverable cognitive function
- certain cancer treatments with median 1-2 month survival benefit.


All of us pay for this because us doctors donít want to miss something, and then be sued.  I work in a field where itís generally clear what does and doesnít work, and am somewhat insulated from that, but in fields where treatment has a huge range of good and bad outcomes for reasons that arenít well understood, the risk of lawsuit is fairly high.


The other part is so many uninsured people compared to other developed countries. We pay for them anyway, federal law requires it.

Ron Scott

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Re: Insulating against medical bankruptcy
« Reply #59 on: January 23, 2022, 08:31:22 AM »

I think a lot of you would be shocked and immensely disappointed if single payer care ever came to the U.S. careful what you wish for!

Mustachians like me who live in single-payer countries are giggling at your suggestion.
https://www.youtube.com/watch?v=iYOf6hXGx6M

I'm not worried about medical bankruptcy.

I just wonder if the American consumer with their extreme particularities would appreciate a medical care system where they have less choice but cheaper costs.

I for one am not interested.

lutorm

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Re: Insulating against medical bankruptcy
« Reply #60 on: January 24, 2022, 12:10:32 AM »
I think a lot of you would be shocked and immensely disappointed if single payer care ever came to the U.S. careful what you wish for!
Ahem, isn't Medicare a single payer system? (This is why the single-payer proposal is typically called "Medicare for All".) Its customers seem to be happy, from what I hear.

jim555

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Re: Insulating against medical bankruptcy
« Reply #61 on: January 24, 2022, 03:51:48 AM »
I think a lot of you would be shocked and immensely disappointed if single payer care ever came to the U.S. careful what you wish for!
Ahem, isn't Medicare a single payer system? (This is why the single-payer proposal is typically called "Medicare for All".) Its customers seem to be happy, from what I hear.
I have no idea why people think Medicare is great coverage, it isn't.  It is so bad you need an additional "Medigap" policy to cover the holes.  And it isn't really cheap.

Ron Scott

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Re: Insulating against medical bankruptcy
« Reply #62 on: January 24, 2022, 09:23:52 AM »
I think a lot of you would be shocked and immensely disappointed if single payer care ever came to the U.S. careful what you wish for!
Ahem, isn't Medicare a single payer system? (This is why the single-payer proposal is typically called "Medicare for All".) Its customers seem to be happy, from what I hear.
I have no idea why people think Medicare is great coverage, it isn't.  It is so bad you need an additional "Medigap" policy to cover the holes.  And it isn't really cheap.

Opting for original Medicare with a supplemental plan is actually a very good plan that offers significant freedom of choice. From my experience people on Medicare really like it.

Medicare is not cheap, but the alternative is to force the costs on those not under the plan. So long as the US healthcare system is expensive (and inefficient) someone has to pay.

I donít understand why having just a single payer, without systemic change in the healthcare system itself, changes the cost dynamics.

dividendman

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Re: Insulating against medical bankruptcy
« Reply #63 on: January 24, 2022, 09:27:46 AM »
Since this thread was created I have googled long term care insurance... but to no avail.

It seems like medical plans will cover most immediate things and it's any type of long term care that can really put a dent in the finances.

Has anyone bought or used some kind of long term care insurance?

afox

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Re: Insulating against medical bankruptcy
« Reply #64 on: January 24, 2022, 10:03:16 AM »
Most excessive costs are due to non-indicated use of various medications or excess testing to alleviate anxiety on the patient or physicianís part. I think Americans in general are less tolerant of mistakes of omission. We thus pay a premium in our healthcare system to know that ďwe looked at all possibilitiesĒ rather than ďwe looked at the most likely possibilitiesĒ, be that in diagnosing or treating a disease. Itís part of our culture of feeling that we are all unique and different (when those differences within a biological gender are in the grand scheme of things relatively minor). Also our culture of never accepting death unless it makes us.

Some good examples in diagnostics:
- Excess surveillance imaging for various cancers (not screening - that has good evidence and is much cheaper).
- excess lab tests to Ďrule outí rare diseases that mimic much more common diseases.

Examples in treatment:
- emergency thoracotomies for trauma patients
- ventricular assist devices for non heart-transplant candidates
- ICU for people with no recoverable cognitive function
- certain cancer treatments with median 1-2 month survival benefit.


All of us pay for this because us doctors donít want to miss something, and then be sued.  I work in a field where itís generally clear what does and doesnít work, and am somewhat insulated from that, but in fields where treatment has a huge range of good and bad outcomes for reasons that arenít well understood, the risk of lawsuit is fairly high.


The other part is so many uninsured people compared to other developed countries. We pay for them anyway, federal law requires it.

Good info. But there actually arent that many uninsured people, 8.6% of the population in 2020, i mean 8.6% is a lot but there are probably a lot of special circumstances there too. A bigger concern to me is underinsured people, people with plans that get around ACA standards.
And is'nt only life saving emergency care to stabilize a patient required? For example, a person with no money/no insurance cant actaully sit down with a doc to develop a treatment plan to treat their cancer can they? Almost none of my family's care would qualify as "emergency/life saving/to stabilize the patient".


My employer offers long term care insurance, just looked it up roughly $60 month premiums for 100k of long term care. For such a relatively small benefit (100k) I think most of us would self-insure by keeping that amount available in savings.

I cant belive that my health insurance offers no long term care benefits but I dont know what it covers regarding long term care.





Dr Kidstache

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Re: Insulating against medical bankruptcy
« Reply #65 on: January 24, 2022, 12:25:29 PM »
I have no idea why people think Medicare is great coverage, it isn't.  It is so bad you need an additional "Medigap" policy to cover the holes.  And it isn't really cheap.

????? Medicare is really good coverage. Yes, people often buy supplemental plans in addition to original Medicare but they often buy those because for zero or low $ you can limit your out-of-pocket expenses even more. Supplemental plans are regulated and are not permitted to offer less than original Medicare covers (though they are welcome to cover more).
It's true that Medicare is not particularly cheap for everyone (your premium is based on your taxes from 2 years prior). But it's cheaper than many other health insurance options and provides way better coverage.
If anyone is curious about what Medicare covers, it's searchable online https://www.medicare.gov/coverage
Becoming Medicare-eligible through SSDI was a massive benefit to me and my bank account.

Dr Kidstache

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Re: Insulating against medical bankruptcy
« Reply #66 on: January 24, 2022, 12:36:03 PM »
If anyone is interested in actually learning about why single-payer healthcare would be a massive improvement in the US, may I suggest checking out Physicians for a National Health Program https://pnhp.org/ or the Congressional Budget Office report https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf
For those of us who have been involved in researching health outcomes, the case for a single-payer healthcare system is so painfully obvious that I don't have the energy to lay it out here. But know, as has been mentioned above, the US pays through the nose for a quality of health care that results in Americans living shorter, sicker, more disabled lives than residents of any other developed (and many developing) countries. Also, all health care in all countries is rationed. In the US, it is rationed by ability to pay. If you're wealthy and privileged, you can go get a totally unnecessary MRI today if you want. If you're less wealthy or less privileged or lose your job, you can't access basic primary care let alone specialty medicine. It's up to you if you continue to be cool with that value system as the way to distribute healthcare resources.

jim555

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Re: Insulating against medical bankruptcy
« Reply #67 on: January 24, 2022, 01:11:05 PM »
????? Medicare is really good coverage. Yes, people often buy supplemental plans in addition to original Medicare but they often buy those because for zero or low $ you can limit your out-of-pocket expenses even more. Supplemental plans are regulated and are not permitted to offer less than original Medicare covers (though they are welcome to cover more).
It's true that Medicare is not particularly cheap for everyone (your premium is based on your taxes from 2 years prior). But it's cheaper than many other health insurance options and provides way better coverage.
If anyone is curious about what Medicare covers, it's searchable online https://www.medicare.gov/coverage
Becoming Medicare-eligible through SSDI was a massive benefit to me and my bank account.
It has no out of pocket limit, no drug coverage (Part D is extra $$), only covers 80% of actuarial value.   ACA Silvers with CSRs cover 94% of AV, cover drugs, limit max OOP costs.  Medicaid is even better with vision and basic dental.

afox

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Re: Insulating against medical bankruptcy
« Reply #68 on: January 24, 2022, 01:38:10 PM »
If anyone is interested in actually learning about why single-payer healthcare would be a massive improvement in the US, may I suggest checking out Physicians for a National Health Program https://pnhp.org/ or the Congressional Budget Office report https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf
For those of us who have been involved in researching health outcomes, the case for a single-payer healthcare system is so painfully obvious that I don't have the energy to lay it out here. But know, as has been mentioned above, the US pays through the nose for a quality of health care that results in Americans living shorter, sicker, more disabled lives than residents of any other developed (and many developing) countries. Also, all health care in all countries is rationed. In the US, it is rationed by ability to pay. If you're wealthy and privileged, you can go get a totally unnecessary MRI today if you want. If you're less wealthy or less privileged or lose your job, you can't access basic primary care let alone specialty medicine. It's up to you if you continue to be cool with that value system as the way to distribute healthcare resources.

yes of course. i dont think anyone disputes that single payer would result in better health outcomes for the population as a whole and save money, opponents to single payer acknowledge that and say so what.

Americans are generally not into sharing, healthcare is no different. The goal has always been to preserve a very high level of care for some at the cost of zero or no care for others.

Everyone in the U.S. that has the power to change things has the best healthcare in the world.


kite

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Re: Insulating against medical bankruptcy
« Reply #69 on: January 24, 2022, 01:56:02 PM »
Claims that Obamacare capped OOP expenses have plenty of exceptions.  Addiction treatment is one of those things.   Some can be covered, but there isnít an endless pool of insurance money available.  It costs more than an Ivy League school to get off the junk for some people.  My friends who had their son in rehab 6x did go bankrupt.

Not true about addiction treatment, its the fifth bullet here:
https://www.healthcare.gov/coverage/what-marketplace-plans-cover/

I honestly would like to know what the major holes are in covered services. Im not interested in non covered services from healthcare sharing plans, other plans that get around the ACA rules in some way.

Didn't claim addiction treatment wasn't covered at all. Just that it is possible to get beyond the limits that the plan will cover. It's not only possible, it's incredibly likely because addiction is such a tricky beast.  Limits apply. You don't get to spend an infinite number of days in rehab, just like you won't get an unlimited number of IVF cycles covered by your insurer either.  If this isn't obvious, I'm not sure we'll profit from further discussion. 
I don't mean it as a dig against the ACA.  It was wonderful, necessary legislation that improved coverage.
But every treatment, diagnostic test and medication is not covered for every patient who wants it. I don't consider these to be "major holes' but rather reasonable limits based on medical evidence and finite resources.   

afox

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Re: Insulating against medical bankruptcy
« Reply #70 on: January 24, 2022, 03:33:08 PM »
Claims that Obamacare capped OOP expenses have plenty of exceptions.  Addiction treatment is one of those things.   Some can be covered, but there isnít an endless pool of insurance money available.  It costs more than an Ivy League school to get off the junk for some people.  My friends who had their son in rehab 6x did go bankrupt.

Not true about addiction treatment, its the fifth bullet here:
https://www.healthcare.gov/coverage/what-marketplace-plans-cover/

I honestly would like to know what the major holes are in covered services. Im not interested in non covered services from healthcare sharing plans, other plans that get around the ACA rules in some way.

Didn't claim addiction treatment wasn't covered at all. Just that it is possible to get beyond the limits that the plan will cover. It's not only possible, it's incredibly likely because addiction is such a tricky beast.  Limits apply. You don't get to spend an infinite number of days in rehab, just like you won't get an unlimited number of IVF cycles covered by your insurer either.  If this isn't obvious, I'm not sure we'll profit from further discussion. 
I don't mean it as a dig against the ACA.  It was wonderful, necessary legislation that improved coverage.
But every treatment, diagnostic test and medication is not covered for every patient who wants it. I don't consider these to be "major holes' but rather reasonable limits based on medical evidence and finite resources.   

yeah but there are reasonable out of pocket (OOP) max's. are you saying that addiction treatment is likely to hit the OOP max and be covered or are you saying that some addiction treatment is likely to be qualified as a not covered service and not be covered at all even if one has reach the OOP max? To be qualified as a non-covered service it seems like that has to be explicitly stated in the plan brochure.

What im really wondering is: are there conventional medicine treatments, non-fufu, not out of desperation and unlikely to be successful, non experimental medical services that are not covered by a standard ACA conforming plan? I get that everyone's definition of "conventional and reasonable treatments" may be different too.

reeshau

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Re: Insulating against medical bankruptcy
« Reply #71 on: January 25, 2022, 05:47:45 AM »
What im really wondering is: are there conventional medicine treatments, non-fufu, not out of desperation and unlikely to be successful, non experimental medical services that are not covered by a standard ACA conforming plan? I get that everyone's definition of "conventional and reasonable treatments" may be different too.

IVF And other fertility treatments are almost never covered.

It's an interesting world, actually, where price is part of the conversation with providers, including options to mitigate the price.  Almost like other consumer conversations.  It makes me question the notion that price *can't* be part of a medical conversation, because it involves health, or even life & death.

We went through four rounds before we finally got our son.  I joked that if the average child cost $250k to raise, then we were already well on our way to that figure.
« Last Edit: January 25, 2022, 05:51:45 AM by reeshau »

afox

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Re: Insulating against medical bankruptcy
« Reply #72 on: January 25, 2022, 08:54:11 AM »
What im really wondering is: are there conventional medicine treatments, non-fufu, not out of desperation and unlikely to be successful, non experimental medical services that are not covered by a standard ACA conforming plan? I get that everyone's definition of "conventional and reasonable treatments" may be different too.

IVF And other fertility treatments are almost never covered.

It's an interesting world, actually, where price is part of the conversation with providers, including options to mitigate the price.  Almost like other consumer conversations.  It makes me question the notion that price *can't* be part of a medical conversation, because it involves health, or even life & death.

We went through four rounds before we finally got our son.  I joked that if the average child cost $250k to raise, then we were already well on our way to that figure.

Good example, although I can see why IVF is ranked lower than other health conditions though. Also, a quick google search it sounds like IVF is rarely covered in other countries by national healthcare systems or only covered for one treatment (canada)...

With the doomy trends with human fertility rates in the U.S. and world I think this is likely to change. The govt is going to have to do everything it can to promote child bearing to prevent serious population decline. China has already put the kibosh on men getting vasectomies. I think its likely that vasectomy coverage in the U.S. goes away.

kite

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Re: Insulating against medical bankruptcy
« Reply #73 on: January 25, 2022, 02:27:24 PM »
Claims that Obamacare capped OOP expenses have plenty of exceptions.  Addiction treatment is one of those things.   Some can be covered, but there isnít an endless pool of insurance money available.  It costs more than an Ivy League school to get off the junk for some people.  My friends who had their son in rehab 6x did go bankrupt.

Not true about addiction treatment, its the fifth bullet here:
https://www.healthcare.gov/coverage/what-marketplace-plans-cover/

I honestly would like to know what the major holes are in covered services. Im not interested in non covered services from healthcare sharing plans, other plans that get around the ACA rules in some way.

Didn't claim addiction treatment wasn't covered at all. Just that it is possible to get beyond the limits that the plan will cover. It's not only possible, it's incredibly likely because addiction is such a tricky beast.  Limits apply. You don't get to spend an infinite number of days in rehab, just like you won't get an unlimited number of IVF cycles covered by your insurer either.  If this isn't obvious, I'm not sure we'll profit from further discussion. 
I don't mean it as a dig against the ACA.  It was wonderful, necessary legislation that improved coverage.
But every treatment, diagnostic test and medication is not covered for every patient who wants it. I don't consider these to be "major holes' but rather reasonable limits based on medical evidence and finite resources.   

yeah but there are reasonable out of pocket (OOP) max's. are you saying that addiction treatment is likely to hit the OOP max and be covered or are you saying that some addiction treatment is likely to be qualified as a not covered service and not be covered at all even if one has reach the OOP max? To be qualified as a non-covered service it seems like that has to be explicitly stated in the plan brochure.

What im really wondering is: are there conventional medicine treatments, non-fufu, not out of desperation and unlikely to be successful, non experimental medical services that are not covered by a standard ACA conforming plan? I get that everyone's definition of "conventional and reasonable treatments" may be different too.

For starters, the brochure is not the fine print.

But yes, there are conventional medicine treatments that may be prescribed by a doctor but are declined by insurance companies.  Just because your doctor says you need it doesn't obligate the insurer to pay for it. The ACA wasn't an open ended purchase order that allows you to have a CT Scan or MRI every time you feel like it.  There are limits to the number of days for which you can stay in a rehab for physical therapy, number of occupational therapy visits, number (and type) of pain pills your insurer will cover.  An insurer may prioritize medication over stents for cardiac patients and physical therapy in place of knee surgery or back surgery.  And they can certainly limit you to a set number of days in rehab or number of therapy visits for mental health treatment. If you needed opioids or benzo's, you are going to hit an insurance limit.  If you doctor shop and get multiple scripts, insurance is one way of capping the number of pills you are allowed to buy. My niece slid in the snow in a pair of Uggs and busted her tailbone. ER doc wrote a script for 30 pills.  Insurance allowed her 6.  The pharmacy would honor the balance of the prescription, but she'd have to pay full retail price. I know of a few people with excellent insurance. They still have to buy their Lyrica at full retail and pay upwards of $400/month for it.  Friends pay a similar rate for their migraine medicine when they need the a brand name because the generic didn't work for them. If the drug isn't on your insurer's formulary, they don't cover it and aren't obligated to cover it.

For Medicare & Medicaid, CMS determines the limits.  You can download their guidelines from the gov't website.  Private insurers will have similar, but in my experience, they'll hew pretty close to CMS. These limits are informed by reams of patient data and evidence based medicine. 



 

afox

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Re: Insulating against medical bankruptcy
« Reply #74 on: January 25, 2022, 04:07:42 PM »
Claims that Obamacare capped OOP expenses have plenty of exceptions.  Addiction treatment is one of those things.   Some can be covered, but there isnít an endless pool of insurance money available.  It costs more than an Ivy League school to get off the junk for some people.  My friends who had their son in rehab 6x did go bankrupt.

Not true about addiction treatment, its the fifth bullet here:
https://www.healthcare.gov/coverage/what-marketplace-plans-cover/

I honestly would like to know what the major holes are in covered services. Im not interested in non covered services from healthcare sharing plans, other plans that get around the ACA rules in some way.

Didn't claim addiction treatment wasn't covered at all. Just that it is possible to get beyond the limits that the plan will cover. It's not only possible, it's incredibly likely because addiction is such a tricky beast.  Limits apply. You don't get to spend an infinite number of days in rehab, just like you won't get an unlimited number of IVF cycles covered by your insurer either.  If this isn't obvious, I'm not sure we'll profit from further discussion. 
I don't mean it as a dig against the ACA.  It was wonderful, necessary legislation that improved coverage.
But every treatment, diagnostic test and medication is not covered for every patient who wants it. I don't consider these to be "major holes' but rather reasonable limits based on medical evidence and finite resources.   

yeah but there are reasonable out of pocket (OOP) max's. are you saying that addiction treatment is likely to hit the OOP max and be covered or are you saying that some addiction treatment is likely to be qualified as a not covered service and not be covered at all even if one has reach the OOP max? To be qualified as a non-covered service it seems like that has to be explicitly stated in the plan brochure.

What im really wondering is: are there conventional medicine treatments, non-fufu, not out of desperation and unlikely to be successful, non experimental medical services that are not covered by a standard ACA conforming plan? I get that everyone's definition of "conventional and reasonable treatments" may be different too.

For starters, the brochure is not the fine print.

But yes, there are conventional medicine treatments that may be prescribed by a doctor but are declined by insurance companies.  Just because your doctor says you need it doesn't obligate the insurer to pay for it. The ACA wasn't an open ended purchase order that allows you to have a CT Scan or MRI every time you feel like it.  There are limits to the number of days for which you can stay in a rehab for physical therapy, number of occupational therapy visits, number (and type) of pain pills your insurer will cover.  An insurer may prioritize medication over stents for cardiac patients and physical therapy in place of knee surgery or back surgery.  And they can certainly limit you to a set number of days in rehab or number of therapy visits for mental health treatment. If you needed opioids or benzo's, you are going to hit an insurance limit.  If you doctor shop and get multiple scripts, insurance is one way of capping the number of pills you are allowed to buy. My niece slid in the snow in a pair of Uggs and busted her tailbone. ER doc wrote a script for 30 pills.  Insurance allowed her 6.  The pharmacy would honor the balance of the prescription, but she'd have to pay full retail price. I know of a few people with excellent insurance. They still have to buy their Lyrica at full retail and pay upwards of $400/month for it.  Friends pay a similar rate for their migraine medicine when they need the a brand name because the generic didn't work for them. If the drug isn't on your insurer's formulary, they don't cover it and aren't obligated to cover it.

For Medicare & Medicaid, CMS determines the limits.  You can download their guidelines from the gov't website.  Private insurers will have similar, but in my experience, they'll hew pretty close to CMS. These limits are informed by reams of patient data and evidence based medicine.

Hmmm, my plan's "brochure" is 136 pages and appears to be the most detailed description of coverage available? Is it possible other insurers call this document something other than "brochure". I get how this could be confusing because when I think of the term "brochure" I think of a glossy 2 page document with some highlights not the 136 page fine print document that I am referring to.

If your point is that doctors may recommend or prescribe treatments that are in excess of an ACA compliant plan then I agree with you.

Just out of curiosity I checked my plan and it does cover Lyrica. Its also available as a generic (pregabalin), Medicare prescription plans cover it. and the generic is very cheap: https://www.goodrx.com/pregabalin


jim555

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Re: Insulating against medical bankruptcy
« Reply #75 on: January 25, 2022, 05:36:13 PM »
...My niece slid in the snow in a pair of Uggs and busted her tailbone. ER doc wrote a script for 30 pills.  Insurance allowed her 6.  The pharmacy would honor the balance of the prescription, but she'd have to pay full retail price. I know of a few people with excellent insurance.
A lot of states have restricted opioid coverage to 7 days to try to prevent addiction problems.

fuzzy math

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Re: Insulating against medical bankruptcy
« Reply #76 on: January 26, 2022, 05:15:13 PM »


Examples in treatment:

- ventricular assist devices for non heart-transplant candidates

- certain cancer treatments with median 1-2 month survival benefit.


Putting a patient on a destination therapy VAD and giving them an extra 1-4 years of life is fairly similar to treating someone's cancer if their ultimate best case scenario with treatment is 1-4 years. Why not advocate for no chemo in patients with a fatal diagnosis?


Abe

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Re: Insulating against medical bankruptcy
« Reply #77 on: January 26, 2022, 07:52:15 PM »


Examples in treatment:

- ventricular assist devices for non heart-transplant candidates

- certain cancer treatments with median 1-2 month survival benefit.


Putting a patient on a destination therapy VAD and giving them an extra 1-4 years of life is fairly similar to treating someone's cancer if their ultimate best case scenario with treatment is 1-4 years. Why not advocate for no chemo in patients with a fatal diagnosis?

Good point. VAD outcomes have improved quite a bit since I last looked, and I stand corrected. Median survival is about a year, and 40% alive at 4 years is a good outcome.

Plina

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Re: Insulating against medical bankruptcy
« Reply #78 on: January 26, 2022, 11:58:45 PM »
That's good news! I just wonder if the American consumer with their extreme particularities would appreciate a medical care system where they have less choice but cheaper costs.

I've lived in Canada for more than 40 years. I also lived in the US for 10 years, France for 2 years, and the UK for 1 year.

The only country where I experienced practical constraints on my choice of medical and dental service providers was the United States, where the financial consequences of using an out-of-network service provider were punitive.

It seems to be a major pain in the ass to negotiate yourself through the system and with the bills instead of focusing on getting back your health. Our system is not perfect but I take it anytime over the US.

Abe

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Re: Insulating against medical bankruptcy
« Reply #79 on: January 29, 2022, 08:03:00 PM »
That's good news! I just wonder if the American consumer with their extreme particularities would appreciate a medical care system where they have less choice but cheaper costs.

I've lived in Canada for more than 40 years. I also lived in the US for 10 years, France for 2 years, and the UK for 1 year.

The only country where I experienced practical constraints on my choice of medical and dental service providers was the United States, where the financial consequences of using an out-of-network service provider were punitive.

It seems to be a major pain in the ass to negotiate yourself through the system and with the bills instead of focusing on getting back your health. Our system is not perfect but I take it anytime over the US.

Most would agree!