LisaK
Frequent Contributor (1K+ posts)
Member # 41384
posted
I am trying to decide between insurance plans. can anyone help from a TBI perspective?
I know most LLMDs dont take insurance, but I am looking to maybe cover as much as possible...
It's been a while since I had any insurance, so it is all new again.
is higher deductible better or higher premium?
I don't really understand out of pocket maximums.
what does medically underwritten mean?
any info at all is appreciated! Thanks!
-------------------- Be thankful in all things- even difficult times and sickness and trials - because there is something GOOD to be seen Posts: 3558 | From Eastern USA | Registered: Jul 2013
| IP: Logged |
Keebler
Honored Contributor (25K+ posts)
Member # 12673
posted
- Talk to all your area lyme support groups first. -
Posts: 48021 | From Tree House | Registered: Jul 2007
| IP: Logged |
Check to see what your state offers in their exchanges, and yes, speak with your Lyme support group as well.
Prescription coverage and co-pays will be important to compare company to company, and plan to plan. Some insurance companies are just impossible to get them to pay for anything Lyme related, even if it is covered for non-lyme patients.
In RI we are lucky that all state approved plans must cover lyme Rx for as long as the Dr prescribes it. But that's the exception not the rule.
My company offered in the past years two levels of coverage comparable to silver and gold exchanges.
A couple of years ago I was planning to start IV Rocephin which is covered under medical vs Rx. I had a silver plan had to look at my deductibles and real monthly cost of IV and home nurse, vs the monthly premiums.
I ended up holding off the treatment until I could sign up for a more expensive Gold plan with lower deductible. I figured it would be easier to pay a small $500 deductible up front with increased monthly premium cost spead over the year than have $5000 or so deductable due in the first few months of treatment.
It turned out in my benefit since I was on IV for 16 months form Dec 2011 to April 2013.
The insurance companies have it figured out that they will get there money out of you either as a high deductible or a high monthly premium. This is one time we have a slight advantage knowing about how much we will be spending on treatment, vs someone who's not sick and hoping they don't need any costly treatment at all.
There is also out of pocket max for the year. Wading thru all this with a Lyme-brain is difficult.
Now that IV is done, I may drop my Gold plan and take risk with higher deductible next year.
TF
Frequent Contributor (5K+ posts)
Member # 14183
posted
Out of Pocket Maximum
Many insurance plans require you to pay a certain percentage of the cost of each prescription--say 20% or 30%. So, your out of pocket cost for each precription is that amount of money.
For an expensive drug like Mepron, your out of pocket cost could be hundreds of dollars.
Same with blood tests and other tests (x-rays, MRIs, etc.). Generally, you have to pay a certain percent of the cost. That is your out of pocket cost. The insurance company pays the rest of the cost.
For doctor visits, you usually pay a set cost, called a "co-pay." It could be $20, $30, etc. for each visit.
So, the insurance company keeps track of all of these costs you are paying as you use your insurance. There is a maximum that you may or may not reach in a year. If you happen to reach that maximum, then your insurance will not require you to pay the copays or other out of pocket costs anymore for the rest of the calendar year. You have reached the out of pocket maximum.
So, if you reach that dollar figure, everything is free to you--prescriptions are totally free, doctor visits, blood tests, etc. until Jan. 1 of the following year.
I reached that out of pocket maximum last year for the first time in my life. I believe it was $5,000 that I had paid out of pocket for myself in 2012. After that, for the rest of the year, everything was free to me--the insurance company paid it all. I believe that even applied to my husband, but not sure on that part.
I never reached the out of pocket maximum when I was treating lyme. I reached it last year because of some sinus surgery I had and lots and lots of other costs all related to a terrible sinus infection.
Anyway, that is the out of pocket maximum.
Posts: 9931 | From Maryland | Registered: Dec 2007
| IP: Logged |
LisaK
Frequent Contributor (1K+ posts)
Member # 41384
posted
I tried the calculator for exchanges. I don't qualify.
When I put my info in the affordable care page it said I "MAY be aligable for coverage or reduced coverage, but I won't know til Oct. 1st, but that is when my offer to get "real" insurance on my own- that offer expires last day of Sept!
-------------------- Be thankful in all things- even difficult times and sickness and trials - because there is something GOOD to be seen Posts: 3558 | From Eastern USA | Registered: Jul 2013
| IP: Logged |
LisaK
Frequent Contributor (1K+ posts)
Member # 41384
posted
I am pretty sure I don't qualify since my husbands work offers me insurance, right? doesn't that mean I am "eligable" through his work?
yeah, but for me to get through his work is gonna be $550/month just for me!!!
-------------------- Be thankful in all things- even difficult times and sickness and trials - because there is something GOOD to be seen Posts: 3558 | From Eastern USA | Registered: Jul 2013
| IP: Logged |
Razzle
Frequent Contributor (1K+ posts)
Member # 30398
posted
You might try contacting your state's Insurance Commissioner for help figuring out what you are eligible for under the ACA, given your family income, other options for insurance (through spouse's work), etc.
posted
I consulted R on this. A higher deductible will usually reduce the monthly premium. But to make the decision, look at how much the higher premium would be vs how much less you might pay in possible deductibles per year.
If you have a lot of doctors' visits, ER visits, prescriptions, tests--things that would be out-of-pocket deductibles to you--then it might be better to pay the higher premium for a lower deductible.
When you have TBIs, this is hard to work out in advance because you don't know how much of your LLMD's charges will be covered by your insurance.
Things to watch out for: 1. A much higher premium could cost more than the potential cost savings that you'd get with a lower deductible. 2. A high deductible might be a problem if it discourages you from getting medical treatment for something you might believe is "less serious."
This is hard to answer without the actual figures. If you spell out the exact amounts of the premium and the deductible (in a PM), we can give you a better idea.
Posts: 431 | From New England | Registered: Dec 2011
| IP: Logged |
posted
It's not necessarily the case that the policies offered to you by Sept 30 will be lower in price than those offered to you on Oct 1st. In theory, increased competition betw the insurance companies is supposed to make the price go down. In practice, it's uncertain, for now at least.
Posts: 431 | From New England | Registered: Dec 2011
| IP: Logged |
posted
Medical underwriting means that your new policy will be conditional on your not having major preexisting conditions. This discrimination will be against the law under the Affordable Care Act.
Posts: 431 | From New England | Registered: Dec 2011
| IP: Logged |
LisaK
Frequent Contributor (1K+ posts)
Member # 41384
posted
Anthro- I was told by insurance company that it will go up and only because they will now be forced to include psych, chronic illness, pre-diagnosed illnes, etc.....
that is why it is going up.
I got the plan that is $360/month- $500 deduct. $1500 out of pocket limit.
I racked my brain over it since we don't have the money to pay for it, but I am trusting in God that somehow it will work
my abx last month were $200 discount price! and it is really helping so I am anticipating more of that cost.
plus i need a GI dr. and other things checked out, so I hope it will pay off!
I go to my first LLMD today!!!!!!!!!!!!!!!
I am so freaked out and happy but crazy anxiety at same time. I hope hope hope I am not disappointed
-------------------- Be thankful in all things- even difficult times and sickness and trials - because there is something GOOD to be seen Posts: 3558 | From Eastern USA | Registered: Jul 2013
| IP: Logged |
LisaK
Frequent Contributor (1K+ posts)
Member # 41384
posted
luckily I have no pre existing condition. that is why I wanted to get in with insurance before I have any diagnosis of any kind.
-------------------- Be thankful in all things- even difficult times and sickness and trials - because there is something GOOD to be seen Posts: 3558 | From Eastern USA | Registered: Jul 2013
| IP: Logged |
The Lyme Disease Network is a non-profit organization funded by individual donations. If you would like to support the Network and the LymeNet system of Web services, please send your donations to:
The
Lyme Disease Network of New Jersey 907 Pebble Creek Court,
Pennington,
NJ08534USA http://www.lymenet.org/
UBBFriend: Email this page to someone!
Printer-friendly view of this topic