(and Medicare)
(last worked on: June 17th, 2024)
(You're at: https://57296.neocities.org/wellness.htm)

* "Medicare for all" --resonates well among our socially motivated political circles, but with some reservations by those of us who are already on Medicare. It's costly: $8856 per year for my wife and myself --including what we've (until recently) been paying for "medigap"/supplemental insurance.

* It's nearly all free if you qualify and means test for Medicaid, of course, but Medicaid, traps people into poverty, since any significant household economic progress results in forfeiture. (I'm relying on the account of a family friend with serious, chronic medical problems.)

* Our Medicare-Part B, plus our medigap coverage (November, 2018 --Plan C and Plan F respectively for us) came to $738/month, so I looked around for alternatives.

We could have saved about $100/month by dropping down to a Medigap Plan "G" (plus we'd then each pay the $183 Part B deductible each year for outpatient doctoring, so maybe we'd save $70/month).

* By taking the "Medicare Advantage" alternative, one's total out-of-pocket expenses get capped (at anywhere between $7800 to $12000 per year for the two of us --and that spells bankruptcy for most Americans), but one's Medicare Part A (hospital in-patient) costs are something like $350 to $450 per day (times 2 if both you and your spouse are hospitalized) for the first 5 days --or until you hit that cap --plus your premiums, and plus your outpatient medications.

5/17/2019 update: We did indeed go with a Medicare Advantage plan ("Moda" brand) and we're so far saving about $400 per month --minus maybe $20/month for appointment copays. Roughly speaking, our old Medigap plans guaranteed that we'd pay about $8000/year total for healthcare, while our new plans guaranty that we'll pay no more than about $10,000 (both figures including our "Part A" Medicare payments). We pay about $2000/year now with normal appointments and maintenance.

6/17/2024 update: After 5 years with Moda insurance and 15 years with my local clinic ("Waterfall Clinic"), and after half a year's correspondence about their contract lab billing me $290 for a routine blood panel --I've learned that Waterfall Clinic and my assigned PCP (primary care provider) --are both "out of network" and always have been --!! So: being a veteran, I've enrolled with the local VA clinic --being given a long delayed first PCP appointment (due to construction and a shortage of PCPs). (There are no VA benefits until after that first appointment.)

* Obviously, I've been shown up to be an idiot about healthcare, so here are some better informed opinions about what needs fixing --before we simply plunge into "Medicare for all".

4/13/2019 update: Bernie Sanders has made it clear that his "Medicare for all" would eliminate copays, mdicare gaps and the need for private insurance plans (unless you want a private hospital room, private nursing in attendance and such).

* The average hospital stay is 4 to 5 days.Medicare (Part-A and Part-B) alone requires a (you pay) $1316 deductible (year 2017) for hospital stays up to a 60 day stretch (very rare!) --but: if you're hospitalized again after a (hospital-free) period of 60 days, you have to pay that again. (That compares to a Medicare Advantage plan possibly billing 5 times $350 = $1750.) Then Part-A really gets stinky:

Days 61-90:   $329 a day
Days 91-150: $658 a day
Beyond 150 days: All costs

However: could one even survive 60 days of modern medicine?

3/27/2024 update: * After 15 years (and 16 PCPs at the clinic I've been going to) --and roughly annual blood panels, my health insurance refused to pay for my last labs, so the contract outfit doing the tests (Quest Diagnostics) billed me $290 --!-- blaming my last PCP for using inadequate diagnostic codes --and despite my insurance statements saying that I owed nothing to anyone. I appealed, finally getting notice that my appeal was dismissed, and getting rebilled ("Past Due"), this time to a discounted $130. That was after half a year and a stack of correspondence --so I just paid up. But then, a week later: back comes their check for $130 as a "write-off", and no further explanation.

* I'm a Navy veteran, so I applied to the nearby VA clinic with my DD-214 discharge paper, was accepted/"enrolled", and I'll see how that goes.

* I wish you good luck and good outcomes on your "wellness" journeys.

The State of Oregon is making an outstanding effort to extend health care to the poor, does its own prescription discount card which is open to everyone. Read about it in the Oregon guide book, obtained from the Senior Health Insurance Benefits Assistance (SHIBA) department. which helps us sort out the overwhelmingly many insurance offerings. (Costs/rates vary widely across the United States, within Oregon, and with time.)

You can download the current version of the SHIBA guide as a PDF from:

> https://healthcare.oregon.gov/shiba/Documents/or-medicare-guide.pdf

I found it to be much more helpful than the CMS/government guide, but even with this resource, choosing the right coverage reminds me of that Monty Python movie in which a poor schmuck keeps trying to make a better deal with the Devil.

* The Medicare Part B gap amounts to 20% of your (whatMedicare allows) outpatient billings and it has no out-of-pocket upper limit. That, along with the cost of medications, might bankrupt an old person of modest means --and it does: senior bankruptcies are way up (3x was it?).

* While full coverage (standardized plans "C" or "F", say) via a medigap supplemental insurance policy is expensive (perhaps $224/month for an 80 year-old), if it's within your monthly budget, at least you won't end up a charity case. (2019 update: Plans C and F are going to be denied to new applicants --and possibly priced out of reach for existing/grandfathered subscribers.)

* The price for a (privately administered) "Medicare Advantage" plan can look very attractive: maybe $24/month (plus the insurance company gets your Medicare Part B premium), but in my opinion, it's fraught with perils and "gotchas" in the form of co-pays, "co-insurance", big deductibles, "we won't pay because you forgot to get prior authorization" --and that might apply even to "in-network" care providers (read the fine print). (In Oregon, at least, it appears to be your primary care provider's responsibility and liability to get those pre-approvals, but find out for sure.)

* Also: I have to wonder: does your Medicare Advantage carrier have the same ability to simply deny (say) a $4000 hospital line item billing --and pay (say) $400 instead (thus: your 20% goes from $800 down to $80) --? (Would I even be seeing such statements, under a Medical Advantage plan?) (I'm about to find out.)

Again: with good medigap coverage (if you can afford it --and we can't), simply show them the card and get on with the help you need.

* Perhaps the best route is to pick a good medigap company when you're 65 years old --one that doesn't up your rates with advancing age, and stay with it. (Update: "community based", instead of "age based" medigap plans are pretty rare.)

* And here's Dr. David Belk's 2nd opinion --about the advisability of taking out a supplemental plan.



(from:  http://truecostofhealthcare.org/medicare-supplemental-insurance/  )

* I'm seriously considering his advice, but having determined I can get back on original Medicare at a later date, my wife and I are first going onto a "Medicare Advantage^" plan --one without drug coverage, for which the premiums are $24/month (for each of us).

^ Having back-and-forthed several times now with Medicare Advantage agents, it seems that they deliberately confuse privately run Medicare Advantage plans with government administered original Medicare --both in their literature and in conversations with clients/applicants.

* Perhaps what us common folks actually need is an affordable "B grade" system of medicine --one which avails you of whatever your doctor (or nurse practitioner) can fit into a physician's satchel and in his/her medical office.

When I was a boy, our family GP took care of anything short of internal surgery. He set fractures and applied casts, had his own Rube-Goldberg X-ray contraption, an all-purpose nurse, and was located up a narrow flight of stairs from our pharmacy (and soda fountain) --one stop shopping. He had no problem attending to my several childhood disorders: allergic rash, vacuous lost to the world day dreaming at home and in school, fall-to-the-ground shakes. Dr. Travis diagnosed "iron deficiency anemia" for my shakes and prescribed a supplemental syrup. That worked. They all just waited for me to grow out of my trances.

* Oregon's guide book contained a revelation for me: Medicare explicitly does not provide for an annual physical examination^. Presumably, you're supposed to come in (or be hauled in) with a pending medical problem. In looking at the benefits of the Pacific Source "Medicare Advantage" alternative, I again see no mention of an included, hands-on, nuts and bolts physical examination.

No doubt many of us walk around with diagnosable medical problems that we can jolly well live with, so perhaps our insurers would rather not encourage Docs to engage in fishing expeditions. My inference is that, on the average, early discovery and treatment --costs more than just letting stuff play out --until a condition becomes manifest.

I remember an old study showing that there was no morbidity/mortality rate difference between people given annual exams and those not. Perhaps that's largely still the case --at least for the run-of-the-mill health care that I can afford.

Apparently, and in lieu of physicals, Medicare subscribers are entitled to an annual "Wellness Visit". I at first had a hard copy of the 2014 Oregon guide book which stated in bold print that, during the Wellness Visit, your physician may "not" touch you^ or give you any kind of tests --nor should you or your doctor talk about any current medical problems or medications that you might be taking --!!

Out of this "visit", Medicare proposes that your doctor should then be able to come up with a "personalized plan to keep you healthy" ---arghhhh!

So aside from the financial exposure of only having Medicare, it would seem that you need to pay something out of pocket for an actual physical examination  --either directly or through some other insurance plan.

From everything I've read, not even top drawer "C" or "F" grade medigap insurance helps to get you a physical examination^, and the medigap terms are very explicit in that they cover only your portions of what Medicare normally covers --no "extras". (I'm not an expert, so verify all information I offer here.) The various (Medicare replacement) "Advantage" plans have their own holes and pitfalls, but I've read that some of them do include an annual hands-on physical exam (as distinct from a hands-off "wellness" interview).

^ However: that said, I have experienced occasional hands-on examination, perhaps in the exploration of specific symptoms/complaints. My wife and I are given blood panels several months apart, perhaps due to tracking specific conditions --and everything was covered by our Medicare + medigap plans.