U.S. Health Insurance Experience

[kellyrulez]

Some background info. I'm a foreign national, got my master's here in the States and will probably go on with a Ph.D. (provided I get accepted) next year or so. My health insurance company is in Europe; my treatment claims are handled through a U.S. affiliate of my insurance company. So far I'm pretty much covered 100%, no deductibles, no co-pays, and I hope it stays that way.

So, I watched MM's Sicko the other day and was quite appalled. No, I don't want to start a discussion about MM or the film, but I'd recommend seeing it, it's definitely his best film yet.

Anyways, I did some research about insurance, coverage etc. and what I found confirmed my concerns. For example, before I started grad school I compared my health insurance plan with the plans recommended by the university, one being Kaiser, the other some local HMO. Both were significantly more expensive than the health insurance plan from Europe while offering only half the coverage: No out-of-network treatments covered, 50% for imaging, $60 for doctor's visits, etc.

If I had one of those plans with TC, I'd already be in debt up to my eye balls. So here's my question to you guys: What's your experience with health insurance? What kind of insurance do you have? Were you denied insurance because of your cancer (history)? How much is your deductible/co-pay for things like surgery, chemo/RT, CT scans, medications, etc.

I'm very interested in your responses. Thanks.

[Fish]

There is significant variation between plans. I had several HMO's and now have BC/BS point of service, which is not an HMO, but does have "in network" affiliated doctors and facilities.

For maximum benefits I have to stay in network, however, in my area, I have never found anyone who is out of network. Out of network, I would pay 30% of the costs, with no negotiated reduction. In network, for procedures (blood work, scans, surgery, ets) I pay 10% of the negotiated cost after meeting a $250 aggregate deductible. My maximum out of pocket $3000/year, $6000 lifetime. My typical "copay" for a dr's visit is $15 or $20 dollars. For a CT scan of chest, abdomen, and pelvis, my ins co is billed ~$2500.00, the in network contract price is $800.00, my ins co. pays them $720.00 and I pay $80. Additionally, I do not have to get a referral to see a specialist. I also pay about 10% of the list price for prescription meds. Generics cost me about 5% of list price.

I have never had my company deny a claim or even question a claim. I once had to have emergency treatment (to clear gall stones from the bile duct) in the southwestern US, about 2500 miles from my home. The claim was processed and paid without problems. I consider myself VERY LUCKY, as I am aware of many horror stories regarding insurance companies.

My premium is $57 every two weeks, which is about 29% of the total premium, my employer pays the balance.

Dental and vision services are not included.

I once had the Kaiser HMO, personally, I would not choose them again.

I hope this info helps.

[Margaret]

My husband Boyce, works for United Health Care and staffs their cancer projects...how odd that he would wind up with cancer...anyway, we have United Health Care insurance.

When we got the plan, we had to pick which one we wanted. Of course the lowest coverage was the cheapest and the most coverage was the most expensive. We decided to pick the most expensive plan...we got lucky. We have always been healthy, knock on wood, and no one could have ever guessed that a healthy mid 30's guy would end up with cancer. But of course he did.

They covered a lot of the costs. We did have to come out of pocket for many of the really costly drugs like Kytril...we paid 100 dollars for that one, but they covered about 800 of it...so pretty fair trade. They also covered us to go to Sloan Kettering, which allowed us the best possible care. I have NO complaints about the coverage they provided. I think we pay about 200 a month for the 3 of us.

I have not seen Sicko yet...but we have many neighbors where we live that lived out of the country and they seem shocked at the health care system here. I am more afraid of Canada where it seems to take forever to see a doctor and then you get on a wait list to have things done. I hope the US never goes to a plan like that. Health care is costly, but worth every penny. I would have prob. told you a few years ago that I wanted the government involved with my health care...that is until someone I love actually got sick, and now I am thrilled that we got to pick when and where we went to the doctor. I believe that many of the choices we got to make saved my husband's life. I would hate to think that any of those choices would have been made for me or that my choices would have been limited in any way.

We had a friend, Johnny, who died of TC about 10 years ago. He had no health insurance at all. But I am not sure that is why he did not make it because there were plently of doctors that agreed to treat him...and treated him well...knowing he had no means to pay. I think he did not make it because they did not know as much 10 years ago and I see many flaws in his treatment course now, that I did not know then. But I did watch a young man with no coverage, get good care. I am not sure everyone gets that care, but I see ER rooms full of needy people that all see the doctor and I am sure many have no coverage. I know it sounds terrible, but the health care system seems too big to tackle. I cover my little family the best way I can and try and raise as many funds as possible for the cancer center we went to for people with no coverage. I guess in the end, that is all I feel I have control over.

Did not mean to say so much...sorry.

[Scott]

I'm sure there are problems with health insurance coverage and approvals, but I've been fortunate not to have any problems. I did prefer when I had HMO coverage, only a flat copay, and providers billed only the HMO. I can accept my current plan, which does make me more aware of health care costs. What I have trouble with is when people don't have access to prevention and treatment due to inability to pay.

[Already Bald]

We decided to pick the most expensive plan...we got lucky .

Funny thing Margaret- I picked the most expensive plan in open enrollment the year prior to my diagnoses as well.
I don't know why, but I remember telling my wife "I think we should go with the PPO, even though it will cost about $11,000 per year, before copays". Well, it turned out to be a great choice, we were both diagnosed with cancer that year, (she had a desmoid sarcoma tumor removed, and treated by RT while I was on chemo).
Because of that PPO I was able to go to Joel "The Rock Star Surgeon" Sheinfeld, no need for a referral, and only days from my call to his office.

We have guests from Denmark with us now, and we dicussed health care at dinner the other night. They have a socialized system, and as long as you are healthy it works great. But get sick, and need specialized treatments- and it can take months just for the first visit. Can you imagine?
I'll take poorer and healthier any day.

[Margaret]

Funny thing Margaret- I picked the most expensive plan in open enrollment the year prior to my diagnoses as well.
I don't know why, but I remember telling my wife "I think we should go with the PPO, even though it will cost about $11,000 per year, before copays". Well, it turned out to be a great choice, we were both diagnosed with cancer that year, (she had a desmoid sarcoma tumor removed, and treated by RT while I was on chemo).
Because of that PPO I was able to go to Joel "The Rock Star Surgeon" Sheinfeld, no need for a referral, and only days from my call to his office.

We have guests from Denmark with us now, and we dicussed health care at dinner the other night. They have a socialized system, and as long as you are healthy it works great. But get sick, and need specialized treatments- and it can take months just for the first visit. Can you imagine?
I'll take poorer and healthier any day.

Boyce and I say the same...that system works great while you are healthy...I would rather have it where I get more choices and faster treatment. Excellent point Joe

[Lori]

In response to the original question - we have very fortunate with our healthcare. We pay $20 an office visit and all our our CT Scans, etc, 3 rounds of EP, HDC with stem cell transplant and three surgeries have all been paid for. We also received $40 a night for our hotel stay in Indy so we could see the best docs in the world to fight Jon's disease. Our coverage is through the company I work for and costs about $300 a month.

[dadmo]

My wife is a teacher in NJ and our expenses were covered 100% once the $200 out of pocket was paid and of course the $10 co-pay for perscriptions.

[Fed]

So far, I have been extremely lucky for my coverage. I get my health insurance through my wife, and one of the perks of working for pharma is that you have access to great medical coverage. We have BC/BS PPO for my wife, kid, and I. My wife pays about $1K a year total for the coverage, and her company picks up the rest of the tab. All doc visits (GP, urologist, oncologist for me; pediatrician for my kid; endocrinologist, GP and OB/GYN for my wife) carry a $10 co-pay, but I haven't had to pay a single penny for the I/O, CT scans and reads, labs, second pathology read at Sloan, and X-rays. Since my diagnosis was done in the ER, the co-pay for an ER visit is $25. Interestingly, if I had picked the coverage from Dana-Farber, it would have cost me way more out of pocket (and this is where my docs are too!)

[Karen]

Well, we were happy as pigs in mud with out helathcare (Aetna) but just found out today our company (we both work for the same company, different locations) is changing to BC/BS and not a single one of our familiy's six doctors participate. I am major bummned because we've been with these docs forever and really love them, the group they are all in, the new state of the art one-stop-shopping facility, location and participating hospital. It''s odd because the medical group we use accepts what looks like every insurance under the sun but BC/BS.

So another lesson is once you settle in with a provider don't get too comfy, because it can change.

[Mom]

My son had Aetna HMO. They paid all but $250 deductible. He had CT scans, MRI's of abs, liver, brain. He was able to go to the doctors of his choice even though they were not part of the local network. He had in-patient chemo (3 weeks, 5 days each). He has had no problem with follow ups. The only thing that wasn't covered was IVF. It depends upon your health plan or if the state you live in mandates coverage. My husband had Personal Choice BX/BS product. He has never had a problem with health coverage but has had problems with TRT prescriptions. However, the problem ultimately turned into a blessing because they forced him to change to Androgel which has been the best TRT for him in 27 years. You are in a particular situation where there may be problems with a preexisting condition should you change to a US provider. We have a law in the US that provides portability but I am not sure if you would be covered under it.

[sldl1106]

Weighing in on the topic.... We have BC/BS of New Jersey, even though we live in NY. It covers almost 100% of Rob's treatment at Sloan. It is a PPO plan, we need referrals for nothing.

Also a tip from Rob's stepmother, who worked for an insurance company - anything not fully covered or denied, re-submit to them. We rushed my daughter to the ER last year twice in a month's time for respiratory distress. BC/BS didn't cover the second trip because "they did not deem it an emergency," based on the hospital's paperwork. I explained my case, we resubmitted the claim over the phone, came back fully covered. I've had to do it one other time since.

Quoting Robert -They don't accept it because the reimbursment they give doesn't even cover their cost of the procedures. If the test cost 100, they will pay 50 . So, Dr Groups are not accpeting them any more. They can't !

That's right! If you look at your EOBs you'd be appalled at the difference between what is billed and what they accept. Both amounts, actually, are appalling. My OB once told me he has told his children to become plumbers, not doctors, because what they bill their clients would be the actual amount they would receive.

Also, and I'm not thrilled to post this since I don't remember the exact source, but I saw on a news program recently that our country has the 37th best health care in the world. 37???

[kellyrulez]

Interesting replies. I will not comment on the discussion, though. From reading the relevant posts here and the research that I did over the past month or so it seems to me that the system and the plans are very inconsistent. Some people pay as little as $1000 a year and are almost covered 100%, others pay premium and have hefty co-pays and deductibles.

Again, I'm looking for personal experiences with health care providers. Please feel free to share your experiences with your HMO, etc.

[kellyrulez]

My son had Aetna HMO. They paid all but $250 deductible. He had CT scans, MRI's of abs, liver, brain. He was able to go to the doctors of his choice even though they were not part of the local network. He had in-patient chemo (3 weeks, 5 days each). He has had no problem with follow ups. The only thing that wasn't covered was IVF. It depends upon your health plan or if the state you live in mandates coverage. My husband had Personal Choice BX/BS product. He has never had a problem with health coverage but has had problems with TRT prescriptions. However, the problem ultimately turned into a blessing because they forced him to change to Androgel which has been the best TRT for him in 27 years. You are in a particular situation where there may be problems with a preexisting condition should you change to a US provider. We have a law in the US that provides portability but I am not sure if you would be covered under it.

Yea, that's a big point of concern for me. I've read about portability but I doubt this would apply to me.