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Medical Costs and Choices

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I’m not a bad father.

Last spring, we noticed my son had a wandering eye. One of his eyes would just drift when he was looking at something. It was happening consistently, so we brought him to the eye doctor. After an exam, we found out that his eyes were 20/100. The doctor said that getting him classes may be enough to fix the wandering eye problem. The theory was that his eye was drifting because his eyes weren’t able to focus. Bringing the world into focus could have let his eyes train themselves to work right.

Nine months with glasses later, the problem hasn’t gone away, so we went back to the eye doctor.

He’s got alternating exotropia. His eyes aren’t working well together. One eye will focus, and the other will drift. So now we’re looking into vision therapists.

A friend went through something similar with his kid, so I asked him for the name of the doctor he used. He gave it to me and told me the clinic was the best in the business, and I would be paying for that. I asked about the cost and was handed the doctor’s spiel about how sad it is that parents focus more on the cost of care than getting the best possible care.

What a load of crap.

First of all, that’s a sales pitch. Of course the doctor is going to defend his prices. If his prices are exorbitant(I don’t have a basis for comparison) and he can’t defend them, people will go elsewhere. $3000 isn’t pocket change. That’s a significant chunk of change. Refusing to look at your options is irresponsible.

Second, price does not equal quality. There are a ton of things that are overpriced garbage. Not only do scam artists abound, but some legitimate things are are horribly overpriced at one location and reasonably priced at others. To stay on the vision theme, my $10 glasses are every bit as high quality as any $400 pair I’ve ever owned. The difference between generic and brand-name drugs? The label and the price. The FDA requires they be chemically identical to be sold. If you insist on the brand name because it’s “better”, you are flushing your money down the toilet. If you live by “you get what you pay for” you are guaranteed to get ripped off.

Third, balancing cost and treatment doesn’t mean I care less. Yes, I am killing my debt as fast as I can right now. Even when I was willing to use a credit card, I wouldn’t drop $3000 without considering my options. I have an entire family to consider, not one problem that my kid doesn’t even notice. Grr. I hate getting told–implicitly or otherwise–that I am a bad parent because I don’t choose to waste my money the way other people do. I’ll check out my options first, thank you.

Now, I will pay for the best when it is warranted. My wife wants Lasik and mentioned some sale some company was having. No. The guy sticking a laser and a scalpel in my eye will not be the lowest bidder. When I left the gene pool, I went to one of the top guys in the state for the procedure. When those things screw up, it’s permanent.

Vision therapy? Not so much. If it comes to surgery, we’ll go with the best. But it’s not there, yet. My kid is going to get a series of eye exercises, no matter where we go. Even if I go to some back alley vision therapist with a degree from a Nigeria U, what’s the worst case scenario? We may have to try someone else. Since I will be doing a bit more research than that, odds are better that my kid will get exactly the same therapy regimen for 1/4 of the cost. That’s the difference between a perfectly competent doctor and a perfectly competent doctor who convinced some trade magazine to write him up as the best in the business.

What do you think? Am I neglecting my kid by wanting to save some money for his braces, too?

Money Problems: Day 9 – Health Insurance

Finance

Today, I am continuing the series, Money Problems: 30 Days to Perfect Finances. The series will consist of 30 things you can do in one setting to perfect your finances. It’s not a system to magically make your debt disappear. Instead, it is a path to understanding where you are, where you want to be, and–most importantly–how to bridge the gap.

I’m not running the series in 30 consecutive days. That’s not my schedule. Also, I think that talking about the same thing for 30 days straight will bore both of us. Instead, it will run roughly once a week. To make sure you don’t miss a post, please take a moment to subscribe, either by email or rss.

On this, Day 9, we’re going to talk about health insurance.

The first thing to understand is that there is a difference between health care and health insurance. Health care is what the doctors do. Health insurance is when the insurance companies pay for it. Or don’t. They are not the same thing. I won’t be addressing who should get care or who should be paying for insurance. That’s political and I try to avoid that here.

I won’t spend much time discussing health care as a “right”. It’s not. If a right requires somebody to actively do something for you, it’s not a right. It can’t be. The logical conclusion of requiring somebody to provide you care gets to be a intellectual exercise to be completed elsewhere. That, too, is political.

What I will discuss are the components of a health insurance plan is the U.S. and what to watch out for when planning your insurance coverage.

Premium

This is the amount you pay for your health insurance. For people with employer-sponsored insurance, this is usually paid out of each paycheck, deducted pre-tax. For those with an individual plan, it’s almost always a monthly payment. There generally isn’t much you can do to lower this much. Most employers offer, at most, 2-3 options, ranging from a good plan for a high premium to “we’ll mail you leeches if we think you’re dying” for a much smaller price.

Copay

This is a flat fee paid out of pocket when you get medical care. Depending on your plan and the type of visit, this could be $10-50 or higher. For example, with a plan I participated in recently, the copay was $15 for an office visit, $25 for urgent care, and $100 for an emergency room visit. The office visit and urgent care visit were billed the same amount to the insurance company, so the price difference was entirely arbitrary. Currently, all health insurance plans are required to pay preventative care visits at 100%, meaning there is no copay.

Coinsurance

This is the payment split between the insurance company and the insured. 80/20 is a common split for plans with coinsurance. That means the insurance company will pay just 80% of the bill, until the insured has paid the entire out-of-pocket maximum. After that, the coverage is 100%.

Deductible

This is the amount that an insurance company won’t pay. It has to be covered by the insured before the insurance company does anything. For example, if you have an insurance plan with a $25 copay, 80/20 coinsurance and a $100 deductible, and paying for an office visit costing $600 would look something like this: $25 for the copay, followed by $75 to max out the copay, leaving $500 to be split 80/20 or $400 paid by the insurance company and $100 paid by the insured. That office visit would cost $200 out-of-pocket. The next identical visit would be cheaper because the deductible is annual and doesn’t get paid per incident. That one would cost $115 out of pocket.

HSA

Health Savings Account. For people with a high-deductible plan–that is, a plan with a deductible of at least $1200 in 2011–they are eligible to open an HSA. This is a savings account dedicated to paying medical expenses, excluding OTC medication. It can be used for vision, dental, or medical care. Payroll contributions are taken pre-tax, which makes it a more affordable way to afford major medical expenses. Unfortunately, there are annual contribution limits. Currently $3050 for an individual account and $6150 for a family account. HSAs do not expire, so you can contribute now, and save the money for medical expenses after retirement.

FSA

Flexible Spending Account. This is similar to an HSA, but the contributed funds evaporate at the end of the year. It’s “use it or you’re screwed” plan.

Individual Plans

If you’re not getting health insurance through your employer or another group, you are on an individual plan. These cost more because they A) don’t benefit from the economy of scale presented by getting 50 or 100 or 1000 people on the same plan, and B) you don’t have an employer subsidizing your premium.

Employer-Sponsored Plans

If your employer provides health insurance, you have an employer-sponsored plan. Possibly the fastest way to correct problems with the health insurance industry would be to make individual plan premiums tax-deductible, while eliminating that deduction for employers and letting insurance companies work across state lines. That would eliminate the mutated pseudo-market we have right now, and force the insurance companies to compete for your business. Honest competition is the most sure way to increase efficiency and service while reducing costs. It beats “one payer” or “socialized” care which add overhead to the process and hide the premiums in increased taxes.

Open Enrollment

Most employer-sponsored plans only allow you to make changes at a specific time of the year, unless you have a “life changing event”, like marriage, divorce, death, or children.

Explanation of Benefits

After you use your health insurance, the company will send an EOB, showing you what was billed, what they paid, and what you’ll be responsible for. It’s fascinating to see the difference between what gets billed by the doctor and what the insurance company is willing to pay, by contract. You should read this, to at least understand what you are consuming and how much is getting paid for you.

Maximum Dollar Limit

If your insured care cost more than your maximum dollar limit, or maximum annual limit, the insurance company stops paying. this was supposed to be going away under the Patient Protection and Affordable Care ~~Fraud~~ Act. Unfortunately, if an insurance company offers a crap plan, they have been allowed to apply for waivers based on the fact that they offer a crap plan. The deciding factor in whether the waiver is granted seems to be the amount of the political contributions the insurance company has made to the correct political entities, but maybe I’m just bitter.

Out-Of-Pocket Maximum

This is the most you will have to pay directly with coinsurance. After you pay this amount, the insurance company will cover 100% of expenses, subject to the maximum limit.

COBRA

The Consolidated Omnibus Budget Reconciliation Act of 1985 is, in short, an opportunity to continue your employer-sponsored health plan–minus the subsidy–after you have left the employer. It’s expensive, but it keeps you covered, and will eliminate issue with pre-existing conditions when you get a new plan.

Catastrophic Health Insurance

This is an extremely-high-deductible plan, typically $10,000 or more. For the people who can’t afford coverage, this is insurance-treated-as-insurance. It’s coverage when you absolutely need it, not when you feel a bit ill. $10,000 isn’t a bankruptcy-level bill, while $100,000 usually is. This plan prevent medical bankruptcy for a small monthly fee. For the people who got screwed by a PPAACFA waiver, it bridges the gap between a plan that’s useful for minor things and protection when something goes really wrong.

Things to Watch Out For When Applying For Health Insurance

Now that we’ve looked at the terms you need to understand, we’re going to talk about some things to check before deciding what coverage is right for you.

Individual, Individual + 1, Individual + Family

Do you need coverage for yourself, or yourself and your family? If you and your spouse are both working, make sure to run the math for every possible combination that will cover everyone. Is it cheaper to have one of you cover yourself and the kids, while the other just gets an individual plan?

Maximum annual coverage

It’s really easy to blow through a $3000 annual maximum. If you’ve got a low annual max, look into a supplemental catastrophic plan.

Primary and Secondary Coverage

For years, my wife paid for insurance that covered herself and the kids, while I covered myself. When we were expecting brat #3, I added her to my insurance plan, without having her cancel hers. When the bill came, my insurance plan covered the coinsurance and deductible, which saved us thousands of dollars when the baby was born.

Pre-Existing Conditions

If you’ve got a pre-existing condition, it can be difficult to get insurance if you don’t already have coverage. This makes sense. It prevents someone from corrupting the idea of insurance by waiting until something goes really wrong before getting a plan. Without this, all of the insurance companies would be bankrupt in a year. This is one of the biggest benefits of COBRA. It’s a short-term bridge plan that eliminates the idea of a pre-exisiting condition deadbeat. If you’ve got insurance, you can transfer to a different plan. If you don’t, you can’t.

Homework

Your homework today is to get a copy of the details of your health insurance and look up all of the above terms and situations. How well are you covered? Did anything surprise you?

Cutting Healthcare Costs

Finance

It’s not a secret that health care can be expensive. Many people pay two and three digit bills for their prescriptions. A visit to the doctor’s office can hurt the budget. Glasses cost hundreds of dollars? How can you cut this cost?

Drugs

If possible, go generic*. There is no difference between Trazorel and trazadone, aside from the cost. Wal-mart, Target, and many other stores offer common generic prescriptions for $4-5. When you are talking to your doctor, ask if there is an drug option that has an available generic. When you are talking to your pharmacist, ask if there is a generic alternative available.

Get the price match. The Cub Foods pharmacy near me matches the Target generic drug price, giving us $4 generics for the asking. This is often an unpublicized deal, so make sure you ask. If your pharmacy will not match nearby prices, consider going elsewhere.

See if there is a 90 day plan. Many insurance companies sponsor a 90 day prescription plan that gives you a 90 supply of drugs for the 60 costs as long as you are willing to accept the drugs by mail. For expensive prescriptions, this 33% discount can be a substantial savings.

Physician

Does your clinic offer online consultations with your doctor or nurses? Some clinics offer a chat or email option to talk to your doctor without requiring a visit that will add fees and copays to your expense sheet. Most clinics and hospitals have a free nurse line for basic questions, like “When is my baby‘s fever dangerous?” It’s a great chance to save some money. I know, from personal experience, that they won’t be shy if they feel you need to come in, but they generally won’t try to convince you to come in if aspirin will fix the problem.

Stay in-network. Check with your insurance company to make sure the doctor you want to see if in your network and therefore, available at the cheapest out-of-pocket price. If not, and you really want that doctor, ask your insurance company if they accept nominations for the network and ask your doctor if he’d be interested in being nominated.

Stay home for your cold. Don’t go to the doctor for every minor problem. The best remedy a doctor can give your for your cold will reduce it to a seven day malady. On the other hand, if you do nothing, it will go away in about a week. Why waste the money? This counts double for the emergency room and urgent care. Strep throat is not an emergency. Wait until morning and go to the clinic, paying the lower fees instead of the large ER costs. Make an appointment for a doctor visit, if possible. Urgent care is billed the same as a regular visit, but most insurance plans double or triple the copay for urgent care visits.

Cash Flow

A Health Savings Account(HSA) is a pre-tax account to save for qualifying medical expenses similar to a Flexible Savings Account(FSA). The main differences are that HSAs are only available for people with high-deductible insurance plans and do not have to be spent on medical expenses. Non-qualifying expenses move from pre-tax to post-tax, meaning you will be charged federal income tax for non-qualifying withdrawals. FSAs are “use it or lose it” plans. If you don’t use it, it will go away, usually at the end of the year. That makes December a great time to stock up on over-the-counter medicines and possibly replace your eyeglasses, as both of those are qualifying expenses. Find out if you have either option available. If you use either one, set aside a place to store every imaginable medical receipt, so you can be reimbursed. Make sure you understand the FSA-eligible expenses.

An Ounce of Prevention

Get routine checkups. The earlier you find a problem, the more options you have. This goes for everything from cancer screenings to blood tests. Get a physical every year and know what is happening with your body. We may be living in the future, but replacement parts are still hard to come by.

Maintain Your Health

It’s cheaper to be healthy. Eat right, exercise, quit smoking.

I enjoy a good meal. It’s one of my favorite things. I won’t cut rich foods out of my diet, so we reduced portions. Beyond the first few bites, the flavor isn’t nearly as enjoyable or even noticeable. There’s no more enjoyment for huge servings than small ones.

Get more exercise, even if it’s just a 2o minute walks twice a week parking on the far side of the parking lot, or taking the stairs instead of the elevator.

Vision

Go online. This one is worth a write-up all by itself. I have 6 pairs of prescription glasses–all varieties of frames and coatings–that have cost a grand total of about $150. There is no noticeable difference between my cheapies and the designer alternatives. While I work on the write-up, the best site to introduce you to the concept of online glasses is GlassyEyes. Reviews, coupons, and discount likes. They have step-by-step instructions on turning an intimidating idea into a simple and cheap solution to an expensive problem.

How do you save money on health care?

* There are no generics available on new drugs until the initial patent expires. This gives the pharmaceutical companies a change to recoup their research and development costs. Without this patent period, new private drug research would evaporate. Don’t hate the brand names, but don’t show undue loyalty.

Experience the Live Real Magic

Misc

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John Kerry’s Wife Hospitalized: Can You Afford Health Insurance?

Politicians

Secret message from Theresa Heinz Kerry (Photo credit: Mike Monteiro)

Even as a growing number of analysts are questioning the details of Obamacare, the sudden hospitalization of Teresa Heinz Kerry, the wife of former senator and current U.S. Secretary of State John Kerry, provides additional fodder to the ongoing healthcare debate.

Heinz, who is 74 years old, is the heir to the Heinz ketchup fortune. She is the widow of former Senator John Heinz, who was killed in 1991 in an aviation accident. Her marriage to Kerry in 1995 occurred when he was the senator from Massachusetts. Heinz was hospitalized on Sunday and is reported to be in critical condition after being flown to Massachusetts General Hospital in Boston.

Heinz was treated for breast cancer in December 2009 and went through two operations for lumpectomies. It is not known what specific health issues resulted in the current hospitalization. However, sources indicated that there was concern over the return of the cancer.

Regardless of the source of the current illness, it is taken for granted that Heinz will receive the very best of medical care, with cost being of no concern to treatments pursued. In the earlier process of treating her cancer, numerous doctors at the nation’s finest medical facilities were consulted. The issue of Heinz not having to worry about the costs of her care is the central theme of many who criticize our nation’s health care system.

For the millions of Americans who live daily without health insurance or any form of coverage, there is a constant concern over how they would deal with a medical emergency. These individuals know that they are one accident or serious illness away from devastating financial hardship. In fact, the single biggest reason for bankruptcy in the U.S. today is medical bills. According to the latest studies, the average hospital stay billed out at $15, 700, with an average daily cost of nearly $4,000.

These costs are onerous because so many people today find health insurance increasingly unaffordable. While the political debate over the current healthcare reform continues, there is one simple fact. That reality is that the annual cost of private health insurance, already out of the reach of many, has risen by as much as 50 percent in the last two years. Many plans for a family of four are now over $15,000 and it is predicted that a bronze plan under the implemented Obamacare will exceed $20,000 for that same family.

All of this brings us back to the hospitalization of Heinz. The reality we live in today means that many people diagnosed with cancer or other similar diseases have little hope of receiving the treatment or care that the wealthy can afford. Even with quality health care insurance, the co-pays and other costs create burdens that many cannot carry.

There are no simple or ready solutions to this situation. The morality of one patient dying because chemotherapy is too expensive while one with a large bank account survives is an issue that will see intensified debate in the coming months and years. Regardless of what caused the current hospitalization, Heinz is one of the lucky ones who will have superb medical care without financial considerations.

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