Things To Know About Deductibles

Individual and Family, Medicare, Short Term, Supplemental

8 Things You Should Know About Deductibles

What is a deductible?

A deductible is the amount you pay for health care services each year before your health plan starts to pay. For example, if you have a $1,500 deductible, you pay the first $1,500 of the services you need.

Depending on your plan, you may also need to meet this in-network deductible before you pay for covered prescription drugs. This means you will pay the prescription’s full cost upfront until the deductible is met. Then you will pay your copay or coinsurance amount until you meet your yearly out-of-pocket maximum. But some plans do not have a deductible. And some types of medicines may be available at a lower cost (as little as $0), even if the deductible has not been met first.

What happens after I meet the deductible?

Once you’ve met your deductible, you usually pay only a copay and/or coinsurance for covered services. Coinsurance is when your plan pays a large percentage of the cost of care and you pay the rest. For example, if your coinsurance is 80/20, you’ll only pay 20 percent of the costs when you need care. Your health plan pays the rest.

Does the deductible reset each year?

Yes. Since your deductible resets each plan year, it’s a good idea to keep an eye on the figures. If you’ve met your deductible for the year or are close to meeting it, you may want to squeeze in some other tests or procedures before your plan year ends to lower your out-of-pocket costs.

Is a health insurance deductible different from other types of deductibles?

Unlike auto, renters or homeowner insurance where you don’t get services until you pay your deductible, many health plans cover the cost of some benefits before you meet the deductible. For example, your plan may cover the cost of annual physicals and many preventive health screenings before the deductible is met.

My plan information says I have a family deductible, too. What does that mean?

If your plan covers your family, there will probably be a deductible for each person and a separate family deductible. As soon as the family deductible is met, your plan starts paying at the coinsurance amount for everyone’s care. That’s the case even if some family members haven’t met their individual deductible.

With a family deductible, once you’ve met that one family deductible amount, no other individual deductibles are needed. After the family deductible is met, you’ll only pay your copay and/or coinsurance amount for services for each family member.

Some plans, like a health spending account (HSA) may only have a family deductible, so your member ID card will only list one deductible. Check your benefit details if you aren’t sure.

Do all health care services apply to my deductible until it’s met?

Not always. Some plans fully cover preventive services, which means you don’t pay anything at the time you get them. Because you don’t have an out-of-pocket charge, those services won’t count toward meeting your deductible.

If you receive care that isn’t covered by your health plan, it often won’t count toward your deductible. This might include such things as cosmetic procedures or seeing a provider who isn’t in your health plan’s network.

What are the pros and cons of a high or low deductible?

In most cases, the higher a plan’s deductible, the lower the monthly premium. If you’re willing to pay more when you need care, you can choose a higher deductible to reduce the amount you pay each month.

The lower a plan’s deductible, the higher the premium. You’ll pay more each month, but your plan will start sharing the costs sooner because you’ll reach your deductible faster.

Some people who don’t often need medical care would rather have a smaller premium and pay more up front for care as they go. But it can mean taking a chance that you might end up paying a big medical bill if you have an unexpected illness or injury.

Other people like knowing that when they need their insurance, they won’t have to come up with a large sum of money before their plan starts helping with the cost. They’d rather have a higher premium, but a lower deductible. It makes costs more predictable.

If I pay so much out of pocket before my insurance kicks in, why should I have coverage?

Health coverage can lower your costs even when you must pay out of pocket to meet your deductible. Insurance companies negotiate their rates with providers, and you’ll pay that discounted rate. Without that discount, people often pay twice as much — or more — for care.

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February 17, 2022

Shortage of Home HealthCare Aides Caused By Pandemic Leaves Many Without Help

Medicare, News

Pandemic-fueled shortages of home health aides strand patients without care

The elderly are finding it harder than ever to get paid help amid acute staff shortages at home health agencies. Several trends are fueling the shortages: Hospitals and other employers are hiring away home health workers with better pay and benefits. Many aides have fallen ill or been exposed to Covid-19 during the recent surge of omicron cases and must quarantine for a time. Staffers are also burned out after working during the pandemic in difficult, anxiety-provoking circumstances.

The implications for older adults are dire. Some seniors who are ready for discharge are waiting in hospitals or rehabilitation centers for several days before home care services can be arranged. Some are returning home with less help than would be optimal. Some are experiencing cutbacks in services. Some simply can’t find care.

Everyone is experiencing shortages, particularly around nursing and home health aides, and reporting that they’re unable to admit patients. We’re seeing increasing demand on adult protective services as a result of people with dementia not being able to get services. The stress on families trying to navigate care for their loved ones is unbelievable.

Ninety-three percent of Medicare-certified home health and hospice agencies and 98% of licensed agencies said they had refused referrals during the past year. Members say they’ve never seen anything like this in terms of the number of openings and the difficulty hiring.

Another agency that provides non-medical services is giving priority for care to people who are seriously compromised and live alone. People who can turn to family or friends are often getting fewer services. Most clients don’t have backup.

This is true of older adults with serious chronic illnesses and paltry financial resources who are socially isolated. Many agencies are focusing on patients being discharged from hospitals and rehab facilities. These patients, many of whom are recovering from Covid-19, have acute needs, and agencies are paid more for serving this population under complicated Medicare reimbursement formulas..

When paid home care or help from family or friends isn’t available, vulnerable older patients may be forced to go to nursing homes, even if they don’t want to. Many nursing homes don’t have enough staffers and can’t take new patients, so people are simply going without care.

Patients with terminal illnesses seeking hospice care are being caught up in these difficulties as well. Brody is running a research study with 25 hospices, and “every single one is having staffing challenges,” he said. Without enough nurses and aides to meet the demand for care, hospices are not admitting some patients or providing fewer visits, he noted.

Before the pandemic, hospice agencies could usually guarantee a certain number of hours of help after evaluating a patient. Now, they really are not able to guarantee anything on discharge.

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February 8, 2022

Medicare Seems To Be Confusing To Most Americans

Medicare

Poll shows Medicare for All is confusing to most Americans

A Kaiser Family Foundation poll found that majorities of those polled have mistaken views about the government-run program backed by Bernie Sanders during the 2020 primaries.

Around seven in 10 Americans think they would continue to pay deductibles and copays under Medicare for All when in fact they would not. 54% wrongly believe that individuals and employers would continue to pay premiums.

The same share think those who currently get health insurance through their jobs or buy it on their own would be able to keep their plans, when in fact the current proposals would essentially do away with private insurance altogether.

An aspect of Medicare for All that the vast majority of those polled understand very well is that some 78% say that taxes would increase for most people under such a plan.

Under Medicare for All, everyone would be enrolled in a government-run program that would provide comprehensive benefits with no premiums or out-of-pocket charges.

Implementing a Medicare for All-type system doesn’t rank as high when looking at health care topics. Some 28% of respondents want to hear how the candidates would lower the amount people pay for health care and another 18% want them to discuss increasing access to care.

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November 22, 2021

More than 80% of Seniors are Vaccinated, But That’s Not Enough

Medicare, News

More than 80% of Seniors are Vaccinated, But That’s Not Enough

The effort to vaccinate the nation’s over-65 population represents both a success story and a source of intense frustration. It’s the age group with the highest rate: 92 percent have gotten at least one shot and 82 percent are fully vaccinated. However, so many remain unprotected. With seniors at far higher risk for severe illness, hospitalization and death from Covid-19, there was to see their vaccination rate top 90 percent by now.

Nearly 10 million older people are without full immunization. That not only endangers them, but provides opportunities for the coronavirus to keep mutating in the bodies of those with weak immune systems. It could also complicate the planned distribution of third shots.

Last winter, when the vaccines became available, the older cohort got a head start. Seniors were among those who qualified to receive priority for appointments, and a federal program brought vaccine clinics directly to nursing homes.

Among 65- to 74-year-olds, 80 percent were fully vaccinated on July 1, rising to 84 percent by Sept. 1. Among those over 75, about 76 percent were fully vaccinated on July 1 and about 79 percent as of now.

But access isn’t the issue; in February, nurses and doctors started bringing vaccines to their doors. The political divide that has led many Americans to resist vaccination is smaller in the older population than in younger groups, but still exists. A study found that among those over 65, only three percent of Democrats said they would not get vaccinated in comparison to 13 percent of Republicans.

At the time when vaccines were unavailable but imminent, 13 percent of respondents said they probably would not get vaccinated, the survey found, citing primarily fear of side effects and mistrust of the government.

Vaccine mandates from employers and schools will not affect most older adults. Bridging this vaccination gap will take continuing efforts by federal and local health officials. Bringing vaccines to individual homes and neighborhood senior centers, providing transportation to pharmacies or clinics, revisiting nursing homes and including their staffs, enabling primary care doctors to offer vaccines in their offices.

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September 10, 2021

Proposed change to the “Birthday Rule”

ACA, Individual and Family, Medicare

Proposed Law Would End Health Insurance ‘Birthday Rule’ That Snags New Parents

For Charlie Kjelshus, “the birthday rule” meant that dad Mikkel’s plan ― with a high deductible and coinsurance obligation ― was deemed her primary coverage after her stay as a newborn in the neonatal intensive care unit. Mom Kayla’s more generous plan was considered secondary coverage. It left her parents with a huge bill.

When Kayla Kjelshus gave birth to her first child, the infant spent seven days in the neonatal intensive care unit, known as the NICU. This stressful medical experience was followed by an equally stressful financial one. Because of an obscure health insurance policy called the “birthday rule,” Kjelshus and her husband, Mikkel, were hit with an unexpected charge of more than $200,000 for the NICU stay.

Now, six months after Kaiser Health News and NPR published a story about the Kjelshus family’s experience, new parents may be spared this kind of financial uncertainty if lawmakers pass a bill that would give parents more control when it’s time to pick a health insurance policy for their child.

The new proposed law would eliminate the birthday rule. That rule dictates how insurance companies pick the primary insurer for a child when both parents have coverage: The parent whose birthday comes first in the calendar year covers the new baby with their plan first. For the Kjelshuses of Olathe, Kan., that meant the insurance held by Mikkel, whose birthday is two weeks before his wife’s, was primary, even though his policy was much less generous and based in a different state.

It’s an outdated policy,” Mikkel Kjelshus said. “Nowadays both parents typically have to work just to make ends meet.” Two jobs often means two offers of health insurance — and while double coverage should be a good thing, in practice, it can lead to a bureaucratic nightmare such as the one the Kjelshuses faced.

U.S. Rep. Sharice Davids, D-Kan., introduced Empowering Parents’ Healthcare Choices Act, a bill that would do away with the birthday rule and a “coordination of benefits policy” that trips up first-time parents when it’s time to sign up a new baby for insurance.

“When I heard about the Kjelshus family’s story, I knew there had to be a way to help,” Davids said. “Parents should have the power when it comes to their new baby’s health care coverage.”

For Charlie Kjelshus, the birthday rule meant her dad’s plan — with a $12,000 deductible, a high coinsurance obligation and a network focused in another state — was deemed her primary coverage. Her mom’s more generous plan was secondary. Confusion over the two plans caused a tangle of red tape for the family that took almost two years and national media attention to resolve.

This model regulation was set by the National Association of Insurance Commissioners and adopted by most states, including Kansas, said Lee Modesitt, director of public affairs with the Kansas Insurance Department. It is a somewhat arbitrary rule that could be fair if all jobs offered health plans with similar coverage. But for many families, one partner’s plan is much more generous.

“It feels awesome,” Mikkel Kjelshus said of the news that a change has been proposed. “We really didn’t want this to happen to anyone else.”

To be enacted, the bill would need to pass the House and Senate before receiving the president’s signature. Davids was elected to Congress in 2018, flipping a seat in Overland Park, Kan., that a Republican had held for a decade. She was reelected in 2020 and is the only Democrat in Kansas’ House delegation.

Ellie Turner, a spokesperson for the congresswoman, said Davids is talking with colleagues in the House to garner additional support.

“It’s becoming clear that the Kjelshus family is not alone in this experience,” Turner wrote in an email. “We are going to continue working to raise awareness and gain momentum for a birthday rule fix, because every family deserves a choice when it comes to their child’s health.”

As they await the arrival of their second child, this time around the Kjelshuses family have a better idea of how the health insurance will work. And, much like the first time, they feel prepared.

“We’ve got the crib. We’ve got the baby stuff. It’s a lot less stress this time around,” Mikkel Kjelshus said. “We kind of know what we’re doing.”

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was originally published on npr.org on July 27th, 2021.
Written by: Cara Anthony

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July 28, 2021

BCBS: Men’s Health: Do You Know the Signs of a Silent Heart Attack?

ACA, Health Resources, Individual and Family, Medicare

Think you know what you’d feel like if you were having a heart attack? Think again.

These types of heart attacks are described as “silent” because when they happen, their symptoms may not seem like a classic heart attack. There may be no extreme chest pain and pressure. No stabbing jaw, neck or arm pain. No overwhelming sudden shortness of breath, dizziness or sweating.

Symptoms can pass quickly and feel mild, but silent heart attacks damage your heart and can lead to life-threatening problems. Silent signs may include:

Fatigue or an ache or pain
Mild pain in the throat
Mild pain in the center of the chest

The symptoms can easily be confused with indigestion or general aches or pains, leading men to ignore them. But a silent myocardial infarction is just as dangerous as other heart attacks.

Let your doctor know if you think you may be having symptoms. You can decide together if you need to have testing or see a heart specialist.

What Can You Do?

Take it seriously. Heart disease is the leading cause of death in the U.S. The best ways to protect yourself are awareness and prevention.

Do what you can to lower your risk. The risk factors for silent heart attacks are the same as any other heart attack. They include smoking, being overweight and not exercising. Health conditions like high blood pressure and high cholesterol levels raise your risk, as does diabetes. Getting those health problems under control is important for your overall health and safety.

To lower your risk:

Know the signs of a heart attack.
Keep your weight, blood pressure and cholesterol in a healthy range.
Talk to your doctor about those numbers and ask if medication is needed.
Don’t smoke or use tobacco.
Limit alcohol use.
Try to exercise most days of the week.

Don’t skip preventive health care. Men tend to go to the doctor less often than women for annual checkups, says Johns Hopkins Medicine. That means they may not get important routine tests for cholesterol, blood pressure and blood sugar. Those tests help gauge heart health.

Skipping preventive exams and screenings also means men are less likely to find out if they have damage called myocardial scars from a silent heart attack. One study found that 80 percent of people who had myocardial scarring were not aware of it. And the study found that men were five times more likely to have myocardial scarring than women.

Don’t assume you’re too young to worry about it. Some men with a family history of early heart attacks can be at risk as early as their 30s or 40s. Learn your family history and talk to your doctor about it.

Ask for help. If you’re feeling depressed, don’t ignore it. Depression is linked to heart disease. Many men try to mask depression by self-medicating or other unhealthy behaviors rather than getting help. If you’ve consistently been feeling sad or hopeless for longer than a few weeks, talk to your doctor.

Manage stress. Stress can raise your blood pressure. Extreme stress can be a “trigger” for a heart attack. And some ways people cope with stress, like overeating, excessive drinking and smoking, are also bad for your heart. Better ways to address stress: working out or other active hobbies, listening to music, getting outdoors, and meditation.

Control diabetes. Having diabetes doubles your risk of heart disease, says U.S. National Library of Medicine. That’s because high blood sugar from diabetes can harm your blood vessels and the nerves that control your heart. It is vital to get tested for diabetes, and if you have it, to keep it under control.

Make time for sleep. Not getting enough sleep can also raise your risk for high blood pressure, obesity and diabetes. And all of those can increase your risk for a heart attack. Most adults need at least seven hours of sleep per night. If you regularly have sleep problems, talk to your doctor.

Take steps to protect your heart and health now. And if you ever think you might be having a heart attack, don’t hesitate. Call 911 right away.

This article was originally published on https://connect.bcbstx.com/ on May 3, 2021

Written by: BCBSTX Connect Team

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June 22, 2021