Open Season Roulette

~ snakesinthegrass2014
Source: Healthy Aging Show

It’s perfectly fitting this week that I find myself with a whopper of a cold.

The start of Open Season (sometimes called Open Enrollment) has begun for many Americans. This is the time when one needs to review his/her health insurance for the following year and make changes if needed.

For the last two days, I’ve been sneezing, coughing, blowing, and honking my way through cross-checking our current coverage against what will be different for 2020.

I’m an absolute vision of debonair right now, surrounded by containers of OTC cold medicine, tissue boxes, and a used grocery bag on the floor beside me, into which I am tossing said tissues. Each time I get up to go into the bathroom or kitchen, Gorgeous follows later wearing latex gloves and holding a container of Lysol Wipes. In each of our ways I suppose we’re both doing good deeds, although I suspect hers is slightly tilted more towards self-preservation.

Health insurance plans in the U.S. are required to follow a general uniform format to explain their summary of benefits and the coverage offered. This is a marked improvement from earlier years, when brochures from competing health plan providers all were starkly different from one another. I remember it taking the better part of an hour, often longer, to compare and make sure that everything I needed for coverage was included. Now, thankfully, it usually only takes me about 10-15 minutes to locate the pertinent areas I need to study.

The drill is pretty much what other people are (or should) be doing for the next four weeks or so:

  1. Review any changes in our current plan. Last year at this time, I discovered that we would be allowed slightly fewer chiropractor visits for 2019. It wasn’t a deal killer thankfully, but it was helpful to at least see the change displayed prominently and in plain language.
  2. Check and confirm prescription drug coverage. Nearly all the plans have an online search tool making this simple. Three years ago we discovered that a med Gorgeous took would cost at least 40% more on the plan we were then on. It turned out to be the catalyst for switching plans that year.
  3. Reconfirm that our doctors remain in the plan’s network of providers. This became our big snag this year, which I’ll get into below.

There are other things to check too: the monthly cost of the plan, yearly deductibles, co-pay and co-insurance costs, and the total amount the plan will pay for catastrophic care. I have yet to see a year in which any of these costs stayed the same from the previous year. It’s therefore pretty important to take the time and review everything. Last year our plan actually reduced co-pay costs for one particular coverage, which was a nice surprise.

The LA freeway system or the American healthcare system?
Source: Complex.com

If you’re reading this right now from, say, Canada, the UK, or Australia, yes, we too find the above routine to be a completely INSANE way to go about getting healthcare. And this is just the preparatory work: at some later point one has to actually navigate the system to see a doctor or <GASP!> a specialist.

Earlier this year a British citizen living here documented his experience about using our healthcare system. He found all the hoops one must jump through to be completely illogical. Coming from a country which has universal healthcare via a single-payer, I can only imagine the man’s utter frustration. The American system of healthcare is similar to going to a restaurant that charges extra for the use of a plate and silverware, while also requiring an advanced reservation for the napkin.

Even after ticking all the boxes ahead of time, there are still huge pot holes over which one must navigate to make sure everything is covered. The good folk at Kaiser Health News document those people who have faced unimaginable nightmares with coverage and billing in their Bill of the Month series. In most cases, these are people who believe they were following all the rules for their insurance plans. Caveat emptor.

Our challenge this year isn’t thankfully with our regular health insurance. We’ll continue to stay on the same Blue Cross plan we were on last year, though it will cost an additional 5% more. This time around, it’s with the optional dental coverage that has me double, triple, and quadruple-checking to make sure everything is tickety boo.

Source: The Graphics Fairy

Last June our dentist — whom some of you might recall enjoys the occasional religious tune played overhead while he works — notified us that effective immediately he was no longer participating in-network with our dental insurance provider. He was still happy to serve us, and would even file a claim with them on our behalf, albeit at an immediate out-of-network cost to us. This was disheartening mainly because our dental insurance pays, in the words of my tribe, bupkus for using a non-preferred provider.

I could understand his not wanting to work anymore with our insurance company. That’s a business decision; they probably paid him bupkus, and he was tired of getting a pitiful payment. But he made this monumental decision in the middle of the coverage year. Who does that?! Well, this dentist apparently.

We somehow got through the rest of year by delaying our second regular checkups and cleanings until next year. We could have just gone to another dentist, but we both like this guy in spite of his dubious music choices. When we return to him in January, I do plan on sharing my views about mid-year insurance changes and the effects they have on paying patients.

So along with blowing into Puff’s Plus and sipping hot lemon with honey mixtures, I’ve been doing a little comparative shopping for dental plans over the last few days. The new plan with MetLife does thankfully include our dentist in its network. It also costs 30% more over what we paid this year to the other insurance provider. Caveat emptor indeed.

For those of you who are in the midst of reviewing your own coverage, I wish you well and hope it goes well. For those who can’t be bothered, please at least go to your plan’s website and review any changes to next year’s benefits. And finally, for all you international folk reading this and shaking your heads, I’ll let Elaine Benes have the last word of supportive outrage:

Until next time (cough-cough)…

32 thoughts on “Open Season Roulette”

  1. We are in the middle of this too. We’ve been on a sup plan but are seriously looking at the Advantage (all in one) plans. As I gathered data (ours and theirs) I realized what a colossal waste of time this is. Yep we have to do it but seriously? It’s a challenge for me and I understand benefit structure. What do the dumb people do?

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    1. My sister made the switch from Original Medicare to an Advantage plan. I studied it along with her last year for probably four days, comparing all the supplemental plans, etc. It was exhausting, though I suppose an early education for me on what (hopefully) awaits me in a handful of years. But what about those who don’t have a relative or friend to help? I worry about them also.

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  2. Hi, Marty – None of this sounds fun. I greatly appreciate you sharing it. Although Canada does use a different health care system, it is not decision-free, nor completely cost-free. It also changes and requires regular reading of the fine print. Last week, The Widow Badass shared a new feature of Extended Coverage with the same insurance company that I use. I had not been advised of this new and cool feature. So I was grateful for WBA for sharing!
    Hope you are feeling better soon!

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    1. Hi, Donna. I’m grateful for your chipping in with some Canadian information. I had assumed/hoped there will be those from other countries who chose to do so.

      Healthcare is complicated. And as Kate was getting at earlier, what do those who aren’t sophisticated or savvy with electronic media or otherwise do to make an informed decision? The repercussions are potentially quite scary.

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  4. You really should put a disclaimer at the top – beer or coffee required to read this, and definitely don’t read before bed which is what I’m doing. 🙂 Yes, we’re involved in the same process, and it’s ghastly just like last year and dental never pays bupkis. I shouldn’t talk about dentists and their twice a year visits with X-rays and panoramic shots because I keep wondering why in the world we need to go twice a year at this age. Add to that we’ve been waiting for two weeks to get a referral to a specialist, and, yes, we repeatedly call. Enough or I’ll never go to sleep. Good luck with the choices and the cold. If you’re killing time, look up Cold Bee Gone. It is kind of a strange product, originated here in NH, and it works for us. I’m sure it doesn’t work for everyone, but when we start to get the pre-cold symptoms, we use it, and the cold doesn’t come through. Take care, feel better, and may we all survive the medical choices. 🙂

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    1. A disclaimer! I’ll consider that. 😏

      I’m with you on the twice a year mandate, though at this point I’ve gotten used to it and just grudgingly accept it. Sort of like oil changes every 3,000 miles miles? “Really? Oh, okay, whatever.” Gorgeous drives the dental insurance need here (with a requirement that we get the high option plan) because she’s had some adventurous issues in the last several years. So we tend to place a higher emphasis on it than most, I suppose. Needless to say I’ll have less money in my wallet next year.

      Re: Cold Bee Gone. Never heard of it, but I’m a sucker for all those homeopathic remedies, thank you!

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  5. Thank goodness for the British National Health Service. We’re in the middle of a General Election campaign, with the two main political parties competing with each other over who can promise more health spending. Latest score: Conservatives £149billion (+£28b on current budget), Labour £155billion (+£34b). These figures are for England only; Northern Ireland, Scotland and Wales have devolved health services, but their budgets are determined by how much is spent in England. Some fear that a Conservative government in a post-Brexit UK would allow US health providers access to the NHS in any future US-UK trade deal.

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    1. Good lord, you do NOT want U.S. health providers adding any of their alleged “value” over there. They are expert at limiting services and benefits in the name of profits only. I think it’s fascinating how the two major parties there are competing to see who will serve the needs better for healthcare. Here, the divide is over how much of the Medicare system can be turned over to the private sector to provide these services (the Medicare Advantage program is getting huge infusions from the current regime).

      Teddy Kennedy said his biggest regret was not accepting Richard Nixon’s offer to partner on a national healthcare program similar to the NHS back in the seventies. We’ve been floundering ever since with a patchwork system that benefits private concerns over the needs of the general public.

      Many thanks for adding to the discussion here, Spencer.

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  6. Yes. That’s about all I can think to add to this post. I dislike the healthcare game that I am forced to play, partially because it makes no sense, but mostly because it doesn’t have to be this way. Yet here I/we are starting to try to make the best choice, never sure that we do. Piffle, I say to the whole thing.

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  8. You make excellent points, Marty, hopefully helping others navigate this complicated system of benefits and changes.

    Reading the above comments I also saved your post for the morning plus coffee. I don’t want to miss any nuggets/gems.

    I agree with Donna’s comment how our plans and coverage still require decisions. Over the years career changes and raising a young family have resulted in a variety of medical/dental plans and benefits and even (almost) no benefits for a couple of years. An eye-opener. Yet, I am thankful I live here, despite liking my neighbours south of us.🙂

    Deb, Widow Badass recent post on Extended Coverage was very interesting, yet I believe a more rare and likely temporary feature. I appreciate her research and sharing of the information.

    I smiled (sheepishly) reading about Gorgeous following you with Lysol wipes. Self-preservation around here, too, thanks to a 1 1/2 year old who does not know coughing and sneezing etiquette. Unfortunately he does know about sharing his cold. I hope you feel better soon, Marty. 🙂

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    1. Going without benefits must have been scary for you all during those two years, Erica. I’m glad it was temporary at least. I will need to read Widow Badass’s post because it sounds interesting. The Canadian system has always seemed head-and-shoulders better over the piecemeal gridlock that we’re used to down here.

      Even as I’m recovering those wipes are still being heavily used here. I feel like a leper in my own home! 🙂

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  9. As always, the govnmt kicks its own when most vulnerable…I mean it only gets harder to navigate….Guess you can tell I’m a sickie, too…crabbiness is harder to control under such conditions – eh?
    Maybe when I get well, I’ll discover it was all a fever-dream?
    HA! At least there is still a modecum of humor amidst the crabbiness.
    Hope you’re feeling better, Marty.

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  10. Marty, the stuff I am learning from you is going to be priceless once my mother moves to the US – so huge thanks. My sister moved there with her (now ex) US Navy husband, so most of their insurances are service-related/provided. Trying to find out how things will work/apply for my mother have been difficult as my sister keeps finding something else she’d rather do and the clock is ticking. Sorry, sibling frustrations slipping out there! I’m just grateful that my sister finally became a US citizen last year as I’d been having to handle her UK passport renewals – remotely – every single time! 😉

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    1. Hi, Deb. Glad this is helpful, but honestly I suspect healthcare will be the biggest nightmare you’ll have in transitioning her. I know the NHS is fodder for much complaining (some deserved?), but it’s a veritable two-lane highway compared to the L.A. freeway interchanges I used to illustrate the mess that is the the U.S. system. Ours here is frighteningly disjointed until one reaches 65 and qualifies for Medicare. Though, even with that they’ve managed to make it a mess with the numerous and optional private “Advantage” plans that the current regime admits it would rather everyone use (some of them are admittedly good, but the regime’s intensions are suspect).

      If the idea is to eventually get your mother citizenship, then getting her on Medicare will eventually ease much of the confusion and headache. You’ll still need to at least pay attention to the Open Enrollment dance every year, but if she’s on Original Medicare, then you’ll only have the supplemental plans to review (I know I’m confusing you here with too much detail, sorry!).

      But prior to her becoming a citizen, or if that’s not even in the cards, then yeah, it’ll be a bit of a hill to climb to figure out how to get her covered with an insurance plan (i.e. PPO vs HMO).

      Of course, once she is covered and has a doctor she loves, then all will be great. We love the practice we visit. You will get to that place eventually, I promise! 🙂

      Feel free to reach out to me if you’d like. I’m a retired law librarian, so what could go wrong if I start giving healthcare advice? 🙂 No, but seriously I’m happy to offer up any nuggets of knowledge I might have.

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      1. Marty, I really do appreciate that for I’m beginning to realise just how big a mountain this is going to be to climb. She’s currently waiting to hear how the first part of her application has gone. Once we hear that she’s passed that bit, it then moves to the UK embassy in London to interview her. I’m waiting until we hear she’s on the second phase before I get properly motoring as, if she gets turned down, it’ll be a waste of time and energy.

        Our NHS is struggling at the moment as it’s horribly under-funded. The principle of free medical care for all is something that we don’t appreciate nearly as much as we should over here, instead it just takes a beating for its failings. Personally, I love it, having had top notch cancer care for absolutely not one single penny.

        But back to the original point, I’m not sure whether to wish my mother gets permission or gets turned down. There’ll be work to do either way, but I suspect any idea I had of handing her over to my sister is fading fast, so I’m truly grateful for your offer & will take you up on it when/if we get to that stage.

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  11. Your post here got me stressed all over again (but I’m grateful, really I am). My guy does all the work that you’re doing. (I even supply the tissue like your Gorgeous does. He doesn’t have a cold, but he ends up crying a bit over the entire process). It is a labyrinth of impossible dimension. We didn’t include the dental in our plan last year, but as my guy needs some work, we’ll have to see what we decide to do this year. I think I would change a dentist who decides mid-year to not include the insurance. That’s not user-friendly. This past year what made me the most stressed/angry was that a prescription my doctor and I believe is best for me was not covered by my insurance co in my drug coverage. So the doctor wrote letters/filled out forms to contest it. For two years. I got phone calls and talked for 1/2 hour increments explaining the need for the med. As did my doctor. FINALLLY a few months ago the insurance company accepted my prescription and said they’ll fulfill it. For $180 instead of $210. This is for 6 times a year! Why? Because it’s a ‘high end tier’ drug, which when covered, hardly gets covered. I was so mad that we’d put all that effort into a $30 change, never being told during the process that it was a “high tier’ drug. U R G H. Ah chool. Feel better!

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    1. Oh dear, Pam. That’s not quite one of the nightmare stories that the Kaiser Health News covers in their series on medical bills, but it certainly qualifies as a nightmare nonetheless. All of that work for two years for a savings of $30?!!!! That’s awful. I’m so sorry.

      Labyrinth is a great word to describe our system. None of it is transparent, and they purposely are misleading about rules and charges to give them all the wiggle room in the world. I used to think airlines were the most egregious liars of any industry (well, maybe they still are), but health insurance companies come close. I hope you guys can find a new plan for next year!

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  12. Isn’t your dentist’s change in insurance acceptance in the middle of the year a violation of his Hippocratic Oath? He really should have waited until November, like the rest of us, to make changes to in his insurance policies. As you point out, making sure my plan still includes my doctor is a major consideration. A few years ago, I was lucky to find a doctor that I really like, and would hate to lose him. I hope you are feeling better.

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    1. Well, if not a Hippocratic violation then certainly a thoughtless mistake anyway. He seems like a thoughtful and kind person, though, so I’m hoping I can get through to him about it in January and he’ll be more careful in the future. Obviously if he pulls a stunt like that again, then we’ll be forced to find another dentist. But we like both him and the practice, so I’m hoping this is a one-off issue. Yep, always do a quick review of your doctors to see if they remain in network, Joe. It’s a good habit.

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  13. If it’s any help in your future Medicare decision, I checked more than one “expert” who advised not to be taken in by all the “perqs” offered by Medicare Advantage Plan providers. And, since I believe you are already taking Social Security, I strongly recommend you start all additional Medicare related supplements i.e. Medigap and Part D, on the first day of the month of your birth, which is when the SSA will start deducting your Part B premiums, if I recall correctly, from your monthly SSI. I ended up with a gap of a month in my coverage between my husband’s former employer’s (COBRA) coverage even after we’d paid the premium for that month and were assured by his HR people that in that case we would continue to be covered before Medicare took over. They lied! So of course their insurer rejected the one claim that was submitted that month and now I have to decide if it’s worth it to go to battle w/them on that or just try to negotiate that one claim with the doc’s office.

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    1. It took me a few beats to remember this post — all the way from last November! Ancient history compared to all we’ve been through, and are continuing to experience! 🙂

      Many thanks for your helpful comments. I’m 60, so at the moment I am not drawing from Social Security yet, nor Medicare. I’ll wait till at least my FRA before starting Social Security (66 & 10 months), and it remains my hope that I can wait till 70 if I can. The open season I was writing about here was merely the general one in choosing a health plan to cover my wife and I for 2020. I am a retired federal worker, and was fortunate enough to take my health coverage into retirement, which is deducted from my monthly pension. Each November, I review the many plans that are offered for the following year, and either stick with what we have or make a change (last year we decided to stick with our current coverage, which is also what I assume we’ll do for next year too).

      Once I do start Social Security, I’ll continue to keep paying for the same coverage of my former employer, but it will become secondary to Medicare, and thus act as a “supplemental” coverage for prescription drugs and paying for that key 20% that Medicare doesn’t pay.

      I definitely agree with you that in general the Medicare Part C “Advantage” plans aren’t as robust as Part B “Original” coverage. However, my sister, a retired teacher, was fortunate to get on what appears to be one of the better Advantage plans; according to her number crunching, she has fared better under it than had she remained on Part B. I keep reminding her, though, that she needs to review it every year during open enrollment. One of these days I suspect she’ll have to go back on Part B because that policy will have changed. But for now, I must admit she does have what amounts to a veritable “Cadillac” of an Advantage plan.

      So sorry to read about the experience you had with the COBRA from your husband’s former plan. I bet it wasn’t so much that they lied, but they were just incompetent. Sadly, so many HR staff are ignorant of all the moving parts with Medicare.

      Many thanks for reading; stay safe!

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