Insurance Info for the U.S.

[Kat]

Insurance in the States can be quite complicated, so this is a general guide to help those wanting information.  

First, the new Affordable Care Act (aka ObamaCare).  The official site is at: healthcare.gov

Through the Marketplace, people who previously couldn't afford insurance should be able to find a plan that fits there needs.  Some states have their own Marketplace while others use the one set up by the Federal Government.  This link provides where you would need to go (by state) to access the Marketplace.

obamacarefacts dot com/state-health-insurance-exchange

You can also call your local governement agency for information (usually through Family and Children Services)  or through this site:  

localhelp.healthcare dot gov

and also by calling the marketplace helpline at 1-800-318-2596.
Enrollment is November 15, 2014 - February 15, 2015.

For people who are able to acquire health insurance via their workplace, your human resource department is the best place to start for information.  One thing that continues to confuse people is whether they want an HMO plan or a PPO plan (depending on what is offered, there are many different plans available so it's impossible to cover them all).  So if you have a choise between HMO or PPO, this short description may help.

HMO - Health Maintenance Organization.  This plan is where doctors either work or contract for the HMO.  You are usually required to only see doctors within the HMO network (unless it's an emergency.)  You usually are required to have a PCP (Primary Care Physician) who will refer you to other doctors as needed. Premiums are usually lower for HMO plans. Your deductible and co-pays are also usually lower but you may not have an out of pocket limit.  

PPO - Preferred Provider Organization.  With a PPO you do not have to have a PCP (Primary Care Physician) and you pay less if you use doctors within the PPO network. But you are not limited to certain doctors (however, if you go out of network you will most likely pay more and MAY have to file the claim yourself, always ask!)  The deductible usually runs a bit higher but there is also (usually) a limit on your out of pocket expenses.  You also are not required to have a referral from your doctor to see another physician.

That is the general difference between the two most common health plans. I used the word "usually" a lot as there are so many plans available, there isn't a "one size fits all" answer.

Medicare Insurance is available at age 65 or sooner if you are declared disabled by the government. Their website is:

medicare dot gov

Also, Fred had this information posted, adding it to this post since it's great info:

Adalimumab - Humira Say on their website "If you cannot afford your medication, contact:  
pparx dot org or call the toll-free phone number (1-888-4PPA-NOW) for assistance.

Etanercept - Enbrel Have a dedicated payment support page:
enbrel dot com/pay-for-ENBREL.jspx

Ustekinumab – Stelara Also have a dedicated payment support page:
janssenprescriptionassistance...assistance

[Fred]

This will be a great help for people in the USA as we are often getting questions about your system.


Thank You Kat.

[jiml]

That's great information Kat it will prove very useful to many who come here from America
I have tried to fathom it out but your explanation is easy to understand from an outsiders perspective .. So anyone who is within the system should be able to follow it quite easily.
It's a complicated system thanks for putting in the effort to explain it

[Nelson]

Thank you for your tips Kat. I'm a year away from medicare and just found out through a friend that she was advised by the U.S. governmental agent she spoke to that she should get a supplemental coverage plan on top of medicare for much better prescription, Dr. appointments, hospital stays and extended care payouts than medicare offers. To rub salt in the wound the government began deducting $100 monthly from her social security check on her 65th birthday due to her last years salary which just barely exceeded (by a few dollars) the maximum amount allowed to not have to pay for medicare. Very sad. One positive note out of this, the government now offers a six month 'magic window' for people to find supplemental insurance on their 65th birthday (3 months prior to 3 months after) for a very important reason. By a recently passed law Insurance companies are not allowed to ask about any pre-existing conditions that might increase your rates or allow them to not accept you because of them within that time frame. This is a very important message to pass along because if you fail to get supplemental coverage then you'll never get a chance again not to have to supply insurance companies with pre-existing condition information. Since psoriasis and psoriatic arthritis is treated as a pre-existing condition many insurance companies won't accept you or charge you much more because of your condition. Please be warned those who have their 65th birthdays coming up suffering from psoriasis or psoriatic arthritis that do not yet have supplemental insurance coverage. Nelson

[Fred]

Thank you Nelson for adding that extra piece of information.

[Kat]

Thank you for your tips Kat. I'm a year away from medicare and just found out through a friend that she was advised by the U.S. governmental agent she spoke to that she should get a supplemental coverage plan on top of medicare for much better prescription, Dr. appointments, hospital stays and extended care payouts than medicare offers. To rub salt in the wound the government began deducting $100 monthly from her social security check on her 65th birthday due to her last years salary which just barely exceeded (by a few dollars) the maximum amount allowed to not have to pay for medicare. Very sad. One positive note out of this, the government now offers a six month 'magic window' for people to find supplemental insurance on their 65th birthday (3 months prior to 3 months after) for a very important reason. By a recently passed law Insurance companies are not allowed to ask about any pre-existing conditions that might increase your rates or allow them to not accept you because of them within that time frame. This is a very important message to pass along because if you fail to get supplemental coverage then you'll never get a chance again not to have to supply insurance companies with pre-existing condition information. Since psoriasis and psoriatic arthritis is treated as a pre-existing condition many insurance companies won't accept you or charge you much more because of your condition. Please be warned those who have their 65th birthdays coming up suffering from psoriasis or psoriatic arthritis that do not yet have supplemental insurance coverage. Nelson

Thanks Nelson! With all the changes to our medical coverage here it's good to have all the information available. I know Blue Cross used to have a good supplemental insurance to Medicare, not sure with all the changes if that's still true or not. I did not know of the 6 month window, definitely good to know! Yes, Medicare isn't free to everyone, thanks for adding that! I think most people will have $100 deducted from their checks for Medicare but I don't know what the cut off is as far as who wouldn't have to pay.

[glenda grant]

Thank you for your tips Kat.  I'm a year away from medicare and just found out through a friend that she was advised by the U.S. governmental agent she spoke to that she should get a supplemental coverage plan on top of medicare for much better prescription, Dr. appointments, hospital stays and extended care payouts than medicare offers.  To rub salt in the wound the government began deducting $100 monthly from her social security check on her 65th birthday due to her last years salary which just barely exceeded (by a few dollars) the maximum amount allowed to not have to pay for medicare.  Very sad.  One positive note out of this,  the government now offers a six month 'magic window' for people to find supplemental insurance on their 65th birthday (3 months prior to 3 months after)  for a very important reason.  By a recently passed law Insurance companies are not allowed to ask about any pre-existing conditions that might increase your rates or allow them to not accept you because of them within that time frame.  This is a very important message to pass along because if you fail to get supplemental coverage then you'll never get a chance again not to have to supply insurance companies with pre-existing condition information.  Since psoriasis and psoriatic arthritis is treated as a pre-existing condition many insurance companies won't accept you or charge you much more because of your condition.  Please be warned those who have their 65th birthdays coming up suffering from psoriasis or psoriatic arthritis that do not yet have supplemental insurance coverage.   Nelson

Thanks Nelson!  With all the changes to our medical coverage here it's good to have all the information available.  I know Blue Cross used to have a good supplemental insurance to Medicare, not sure with all the changes if that's still true or not.  I did not know of the 6 month window, definitely good to know!  Yes, Medicare isn't free to everyone, thanks for adding that!  I think most people will have $100 deducted from their checks for Medicare but I don't know what the cut off is as far as who wouldn't have to pay.

KAT I was wondering what will happen when I get my Medicare next Feb.I am on disability now and I will have to be disabled for 18 months before Medicare will kick in for me.I will be 65 Feb 2016 and heard I won't be able to get help from the Enbrel Support like I do now.I just got $6000 on a debit card to help with my co_pays and deductible and July another $4000.I will have to talk to some one at the Support Group.I shouldn't worry now I have a year to figure it out.But I was reading if you get Medicare they can't help me cause I'll be on a government program.Just not fair we have to worry in our older age.Worked all my life and have a hard time getting help.I now pay $235 a month for highmark plus have $1200 deductibles and then $3700 out of my pocket before highmark pays 100% That's where the card comes in they help me with the $4900 I have to pay yearly.I am thankful I have Ins. or I would be up a creek without a paddle.Hope this doesn't confuse you.I just thought I couldn't wait to get to 65 and I would have it made I know I'll need a supplement.Well as my Mom used to say don't cross the bridge till you get there. Tell Riley Pebbles said hi.Poor Pebbles is constipated so I gave her some caster oil hope it works

[Kat]

Thank you for your tips Kat.  I'm a year away from medicare and just found out through a friend that she was advised by the U.S. governmental agent she spoke to that she should get a supplemental coverage plan on top of medicare for much better prescription, Dr. appointments, hospital stays and extended care payouts than medicare offers.  To rub salt in the wound the government began deducting $100 monthly from her social security check on her 65th birthday due to her last years salary which just barely exceeded (by a few dollars) the maximum amount allowed to not have to pay for medicare.  Very sad.  One positive note out of this,  the government now offers a six month 'magic window' for people to find supplemental insurance on their 65th birthday (3 months prior to 3 months after)  for a very important reason.  By a recently passed law Insurance companies are not allowed to ask about any pre-existing conditions that might increase your rates or allow them to not accept you because of them within that time frame.  This is a very important message to pass along because if you fail to get supplemental coverage then you'll never get a chance again not to have to supply insurance companies with pre-existing condition information.  Since psoriasis and psoriatic arthritis is treated as a pre-existing condition many insurance companies won't accept you or charge you much more because of your condition.  Please be warned those who have their 65th birthdays coming up suffering from psoriasis or psoriatic arthritis that do not yet have supplemental insurance coverage.   Nelson

Thanks Nelson!  With all the changes to our medical coverage here it's good to have all the information available.  I know Blue Cross used to have a good supplemental insurance to Medicare, not sure with all the changes if that's still true or not.  I did not know of the 6 month window, definitely good to know!  Yes, Medicare isn't free to everyone, thanks for adding that!  I think most people will have $100 deducted from their checks for Medicare but I don't know what the cut off is as far as who wouldn't have to pay.

KAT I was wondering what will happen when I get my Medicare next Feb.I am on disability now and I will have to be disabled for 18 months before Medicare will kick in for me.I will be 65 Feb 2016 and heard I won't be able to get help from the Enbrel Support like I do now.I just got $6000 on a debit card to help with my co_pays and deductible and July another $4000.I will have to talk to some one at the Support Group.I shouldn't worry now I have a year to figure it out.But I was reading if you get Medicare they can't help me cause I'll be on a government program.Just not fair we have to worry in our older age.Worked all my life and have a hard time getting help.I now pay $235 a month for highmark plus have $1200 deductibles and then $3700 out of my pocket before highmark pays 100% That's where the card comes in they help me with the $4900 I have to pay yearly.I am thankful I have Ins. or I would be up a creek without a paddle.Hope this doesn't confuse you.I just thought I couldn't wait to get to 65 and I would have it made I know I'll need a supplement.Well as my Mom used to say don't cross the bridge till you get there. Tell Riley Pebbles said hi.Poor Pebbles is constipated so I gave her some caster oil hope it works

Glenda, I'm not sure how the Enbrel Support works so no clue how Medicare affects that.  Here's some info regarding Medicare:

Part B premium.... Most people pay $104.90 each month.

Part B deductible.... $147 per year.

Part A premium.... Most people don't pay a monthly premium for Part A. If you buy Part A, you'll pay up to $407 each month.

Part A hospital inpatient deductible you pay:
    $1,260 deductible for each benefit period
    Days 1-60: $0 coinsurance for each benefit period
    Days 61-90: $315 coinsurance per day of each benefit period
    Days 91 and beyond: $630 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
    Beyond lifetime reserve days: all costs

Part C premium The Part C monthly premium varies by plan.

Part D premium The Part D monthly premium varies by plan (higher-income consumers may pay more).  Part D covers prescriptions,

Of course supplements are available from a variety of insurance companies so will vary greatly on price and coverage.

For prescriptions you need a Medicare Prescription Drug Plan (Part D), or getting a Medicare Advantage Plan (Part C) such as an HMO or PPO that offers Medicare prescription drug coverage.  Or of course there are plans available to purchase on your own.

Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.

I don't think I answered you really, just gave you some information.  As you say, you have a year to figure it out.  There are so many variables that you just can't say it will be "this way" or "that way".