The US Health Care system is a mess.  This blog attempts to help you understand how to navigate our patched together health care system, for those with serious health problems and expenses.  

Over 133 million Americans or about 40% of our population suffer from a Chronic Illness with about 81 million having multiple conditions. A chronic disease/illness as defined by the U.S. National Center for Health Statistics, is a disease lasting three months or unfortunately in many cases a lifetime.  Some typical chronic diseases include: Alzheimer’s, Dementia, Rheumatoid Arthritis; Cancer; COPD; Crohn’s Disease; Cystic Fibrosis; Diabetes; Heart Disease; HIV; Bipolar; Cyclothymiacs; Depression; Multiple Sclerosis, Parkinson’s; Pulmonary Disease; Cardiovascular Diseases, such as Heart Attacks and Strokes, Autoimmune Disease, such as Sarcoidosis; and unfortunately many more.  Today’s blog will give suggestions how to survive the financial impact. 

Below links discusses the importance of having short term and long-term disability. If you have a family member that need to consider the advantages of disability insurance you can share below links.

PART 1: DISABILITY INSURANCE IS OFTEN MORE IMPORTANT THAN LIFE INSURANCE 

DISABILITY INSURANCE IS OFTEN MORE IMPORTANT THAN LIFE INSURANCE {1 of 2 PARTS}

PART 2: DISABILITY INSURANCE RESTRICTIONS AND HOW MUCH $$$ INSURANCE IS NEEDED {CONTINUED FROM: PART 1: INSURANCE SHOULD BE NO MORE OF AN OPTION THAN EMPLOYMENT!}

PART 2: DISABILITY INSURANCE RESTRICTIONS AND HOW MUCH $$$ INSURANCE IS NEEDED {CONTINUED FROM: PART 1: INSURANCE SHOULD BE NO MORE OF AN OPTION THAN EMPLOYMENT!}

ECONOMIC IMPACT 

More than 75% of all health care costs are due to chronic conditions. By the year 2023, the impact to the US economy is estimated at $4.2 Trillion in treatment costs and lost economic output.

BUILDING A FINANCIAL PLAN 

Some suggestions for better controlling your health care cost:

1. Choose the best insurance plan you can afford
2. Lowering cost of medications
3. Ensure your medical procedure and doctor are covered by your insurance
4. Use an HSA or FSA for out-of-pocket medical expenses.
5. Create an emergency fund.
6. Stay organized and review medical bills for errors.
7. Set up a payment plan if needed.
8. Consider disability and life insurance.
9. Find easy ways to save money and earn more.

This week, I will discuss suggestions 1-3 and the next two blogs the remaining suggestions.

1. Choose The Best Insurance Plan

Every year my wife and I review our health insurance options.  It looks as confusing as above picture. But, it is important; when you have a chronic illness you choose the best insurance plan that meets both your health and financial needs.

Do a complete review what the various plans cover, the deductible and coinsurance, maximum out of pocket for the year; the cost of co-pays; prescriptions cost, etc. It is important to note any exclusions, limitations or exceptions to coverage.

Look at the frequency and type of treatment you received in the past. Note any trends that may influence the insurance plan you select.  Do you need numerous specialists?  Are there certain specialist highly recommended for your illness? If so make sure your selected plan covers those doctors. Etc. 

OVERVIEW OF TYPICAL TYPES OF INSURANCE HEALTH CARE PLANS

• Health Maintenance Organization (HMO):  Have lower monthly premiums and lower cost-sharing than plans with fewer network restrictions, but require a Primary Care Provider/Physician (PCP) referrals and will not pay for care out-of-network except in emergencies. Because of these requirements, many people prefer some of the below plans.  One benefit of an HMO, your PCP’s staff coordinates locates appropriate specialist and may assist with scheduling. 

• Preferred Provider Organization (PPO):  Have a network of physicians within their network, which they recommend and prefer you use.  But a PPO will pay for out-of-network care, however, typically you pay more out of pocket if you go out of network. PPO’s have fewer restrictions than most other plan types and tend to have higher monthly premiumsand sometimes require higher out of pocket cost-sharing versus an HMO.  PPOs have lost some of their popularity in recent years but are still offered by some companies employer-sponsored health plans.  PPOs have for the most part disappeared from the individual insurance market in some states. If you prefer to choose your own doctors, you will be happier with a PPO or EPO.

• Exclusive Provider Organization (EPO):  Have a network of providers they use exclusively. You must stick to providers on that list or the EPO will NOT pay.However, an EPO generally will not make you get a referral from a primary care physician in order to visit a specialist in their network. An EPO is similar to a PPO but without coverage for out-of-network care.An EPO may also help lower costs as long as you can find providers in network.  EPOs tend to be more effective in larger metro area, because of the wide selection of in network physicians.

• Point of Service (POS): Resemble HMOs but are less restrictive in that you are allowed, under certain circumstances, to get care out-of-network as you would with a PPO. POS plans require you to have a Personal Care Physician – PCP referral for all care whether it is in or out-of-network. POS and HMO plans may be better if you prefer your primary doctor choosing specialists for you. If you do choose a POS plan and go out of network, make sure to get the referral from your doctor ahead of time to reduce out-of-pocket costs.

SOME GOVERNMENT PROGRAMS 

Depending on your income and health situation, you might be eligible for assistance programs such as Medicaid, Children’s Health Insurance Program (CHIP), or government subsidies to help with the cost of insurance premiums.

Make sure that your insurance knows what you are dealing with – that your disease can be chronic and require more frequent treatments than once or twice a year.  If you are having trouble paying your bills do not wait for them to go 90 days late – talk to the financial advisors at the medical facility and see what they can do to help.  They may not have a perfect solution for your situation but you need to ask for assistance.

• PAYING FOR YOUR DRUGS

“Check out ‘Patient Assistance Programs’ under the medication in question. You will need to fill out forms and submit to the program. You can apply online through the drug manufacturer for patient assistance programs.

Google your manufacturer’s Patient Assistance Program to find any information on assistance offered. 

Example: AbbVie Inc. offers a discount on their autoimmune disease drug, Humira and other drugs. I pulled below from AbbVie’s web site.

“AbbVie offers below options:

If you have employer-provided insurance coverage or have purchased private insurance on your own…

• You may be eligible for a savings card that will reduce your
  out-of-pocket expenses for your prescribed AbbVie medicine. Restrictions apply.*

If you are uninsured or have limited insurance coverage…

• You may be eligible to receive prescribed medication at no cost from an AbbVie-supported Patient Assistance Program. Your eligibility is based on your insurance coverage, household income and out-of-pocket medical expenses.
   

If you are receiving coverage through Medicare…

• You may qualify for Extra Help from Medicare.   
• Independent nonprofit foundations may offer assistance depending on your disease.  
• You may also be eligible to receive prescribed medication at no cost from an AbbVie-supported Patient Assistance Program, based on your insurance coverage, household income, and out-of-pocket medical expenses.””

OTHER ASISTANCE PROGRAMS

Below link allows you to search for organizations by diagnosis. 

http://www.caringvoice.org/helpful-resources/

At the bottom of above link are a list of organizations that might help regardless of diagnosis. 

Other programs that can help with prescription coverage cost include:

• GoodRx — GoodRx is a search engine for drug costs to help you shop around, find coupons as well as find certain prescription assistance. Once you type in your medication, be sure to also filter by your insurance type and look for patient assistance programs.
• Partnership for Prescription Assistance— This free service connects you with prescription assistance programs you may be eligible for after you fill out some basic information about yourself. It guides you through the application. (The site also offers a free or low-cost clinic search engine.)
• Rx Outreach— This is a nonprofit pharmacy that ships certain medications at a lower cost to qualifying individuals based on income.
• RxAssist— This is simply a directory of patient assistance programs. You can search by the name of your drug.
• Coverage for All— The Foundation for Health Coverage Education runs this site meant to simplify the process of choosing affordable health coverage. After you answer a quick set of questions about your employment, income, health status, etc., the site provides a list of insurance options you may be eligible for.

 3. ENSURE YOUR MEDICAL PROCEDURE AND DOCTOR ARE COVERED BY YOUR INSURANCE

I have never dealt with an insurance company that wants to give out money.  Majority of US insurance firms are for profit.  How do they increase profit? DENY DENY DENY!  Just like majority of politicians! 

Before any expensive test or procedure always get the CPT code {“Current Procedural Terminology (CPT) is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations”.} from your doctor’s office so you can confirm with your insurance company that a service is covered. Get all confirmations in writing.

Make sure that both the hospital (or clinic) AND the doctor are in-network.  Often times the doctors performing certain procedures at an in network facility are NOT in your insurance carrier’s network. 

ADVICE FROM PEOPLE SUFFERING WITH CHRONIC ILLNESSES:  

“Share with your family and friends what you are going through. Set the expectations you will not be able to participate in as many family functions as the past, or maybe not able to give he type of store bought gifts as the past” 

Personally, the best gifts I receive are time with someone I care about and a heart felt letter from people I love. 

“Keep a log of ALL your doctor and ER visits treatments and drugs prescribed.The biggest challenge that I faced during this process was having to go back through two years of treatment and get all the doctors information, the dates I saw them, the tests they had me take, the medications they prescribed to me, and any information related to my treatment. My advice to anybody dealing with sarcoidosis now is to document all of these things as they happen. Then if you ever have to apply for SSDI, you already have all your information.”

CONCLUSION

Today we covered the below topics and provided two reference blogs on the need for short and long term disability insurance. 

1. To Choose the best insurance plan you can afford
2. Lowering cost of medications
3. Do your research so you know what to expect

For the next two blogs or more, I will continue this topic and cover:

1. Use an HSA or FSA for out-of-pocket medical expenses 
2. Create an emergency fund.
3. Stay organized and review medical bills for errors.
4. Set up a payment plan if needed.
5. Consider disability and life insurance.
6. Find easy ways to save money and earn more.

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DISCLAIMER

I am a proud nerd (my beautiful wife and daughter told me so) investment and finance blogger, with University Rutgers, MBA and Harvard University, Advanced Management education.  

I started my first business at ~13 years of age. I am a successful investor in equities and real estate and happy to share my personal finance and investment lessons learned with you.  I am NOThowever, a licensed financial advisor.  Please do not construe my suggestions on this blog, as recommendations for your personal situation.  For individual finance advice please seek your own licensed CPA or financial advisors.