Glenda's journey with prescribed treatments

[jiml]

Makes a lot of sense, what a shame the insurance won't cover the correct dose ...

[Fred]

There is no free insurance in America like some countries in other parts of the world.I hope this makes sense!

Sorry I keep forgetting you have a very odd health care system in the USA. Like Jim said it's shame they won't pay for the recommended dose. Very Odd.

[Kat]

Glenda, with the Affordable Act Plan now in place, I'm not totally sure how it would work for you once you can get Medicare. I've never even looked at the Insurance Marketplace so have no clue what options there may be. But, instead of opting out of Medicare you may want to look for a supplement if that proves to be a better option than paying for a different primary health plan. We have Blue Cross and I believe our cost is just under $500 per month for my husband to cover both of us. His company pays half so that would mean our policy runs around $1000 per month (yes, it's ridiculous!!) Our deductible is $2400 each (for those not familiar with our insurance that means you have to pay that much out of pocket before the insurance even starts to pay on anything, and then it only pays a percentage usually)

Actually I have plenty of bills so here's an example of one. Mr. Kat only has BlueCross and this is his bill for the anesthesia from his colonoscopy AFTER meeting the deductible.

Total cost $1688.00
Insurance write off (this is always a bit weird, it has to do with agreements between hospitals, doctors and the insurance company) -$1272.00
Insurance paid $332.80
Leaving Mr. Kat responsible to pay $83.20.

I have Medicare as a secondary insurance, so if that were my bill the Medicare would pay the $83.20.

Prescriptions and medicine is an entirely different thing though as policies differ so very much in what they will pay (and in some cases even allow) There are prescription plans available that can be used to supplement the insurance, but it's difficult to find one that is actually worth having that doesn't cost quite a bit. My mom had Medicare and supplemented her prescriptions and even then had to pay out of pocket about $300 per month for her medications.

I know that Glenda knows a lot of this already (having to deal with the US insurance) but thought it would help clarify the challenges that are faced here when it comes to our insurance.

But there are some who get free insurance here. It's usually a state program for those who are struggling (and sometimes those who just know how to work the system to be honest.) Then there are times when lawyers have you work the system as in my daughter's case. Her ex makes good money and he is responsible for medical expenses for their kids. He can carry insurance on them through his work however he knew my daughter would go back to college to finish her degree so in the divorce settlement she was REQUIRED to apply for state insurance for the kids. Since she isn't working she was approved and so pays nothing for their insurance which covers just about 100% on everything.

Insurance is extremely varied here!

[Fred]

Insurance is extremely varied here!

Thank you Kat.

[jiml]

Thanks for that Kat I think I'm just as confused as ever , it's a very complicated system, you all have to deal with.

Is it the same though as over here, (we can have private health insurance that basically lets you queue jump and get seen immediately rather than wait for the health service to see you several weeks on,)
But if you want to change your private provider they won't cover existing conditions.

[Kat]

It is very confusing!  In the "old days" the doctor decided the treatment.  So had Glenda needed two injections instead of one, if the doctor prescribed it the insurance was responsible for it.  (Most policies then were pretty much an 80/20 with the insurance paying 80% and the patient paying 20% unless they had a supplemental insurance to cover that cost)

Unfortunately now, insurance companies get to decide if they feel you need it.  If they will only pay for x amount of treatments then that's all you'll get.  They make determinations based on averages and of course what can cost them the least amount of money.  Insurance companies do not distinguish between individuals (as in one person may need less or more than another.)   So Glenda is at the mercy of her insurance company to a certain degree.  There ARE exceptions to this and sometimes doctors can push them into seeing the need.

Edited to add: Basically if the insurance company is faced with ok if you won't approve this then we can say this treatment didn't work and move to a more expensive treatment which can have the insurance company then seeing that it's to their benefit to approve the lesser cost.

[jiml]

Thanks again Kat it's very confusing, I'm glad I don't have that to deal with

[glenda grant]

Kat thanks so much for helping me out to explain our Health System I go tomorrow to see what plan I am going to take.I will get a good supplement to help me with with my meds.They will explain everything to me and taking my husband with me four ears are better than two.I'll let you all know how this turns out.

[Kat]

Kat thanks so much for helping me out to explain our Health System I go tomorrow to see what plan I am going to take.I will get a good supplement to help me with with my meds.They will explain everything to me and taking my husband with me four ears are better than two.I'll let you all know how this turns out.

Good luck Glenda!

[glenda grant]

I went to see my Rheumatologist June 20 and asked about Taltz he said he had heard about it and it's 6 months on the Market in the USA but he heard it helps psoriasis more than the Psoriatic Arthritis and being I am dong so good on Embrel he would hate to change things now unless it stops helping me.I agreed with him I have my $3000 deductible in so I will let you know what I pay next month.I paid $862 for June and they said I have reached my deductible so I will see. I have Medicare which they take out $105 a month from everyone that is 65 and retired I have a supplement I pay $36.50 a month and have Champ Va that pays 20% Medicare pays 80% but not medication.