Kaiser info, not for treatment but for backup basic, in case I get cancer etc

[Mouse girl]

Hello!

I am NOT looking to find treatment for my cfs/me through Kaiser. I have been sick for over 30 years, been there, done that, wasted time money and energy on getting better doing "everything".

I have SSDI, Medicare and supplimentry insurance and drug insurance. In the last year, with basically no medical care at all, except a few reg doc visits and normal scans (mammogram etc) and some out of pocket dental care, my medical costs were over $17,000 last year. I am 55. this is crazy and not going to be manable long term as every year my insurance costs go up fast and furious due to being 55.

So, this is my thought: maybe try Kaiser, so if I get cancer or heart attack or other basic stuff, it will be covered and taken care of, pay out of pocket, cash, for my rhuemo just so I have him for disability paperwork, jury duty etc if needed.

I am wondering, do I pay out of pocket for Kaiser each month on top of the Medicare payment of 175? I already have to pay $500 a year just to see my rhumo who gets cfs and fibro and is supportive for anything legal (meaning medicare, jury duty and other stuff that comes up).

and maybe I could get vision and hearing covered with some extra cost, to boot. My dad and my aunt had Kiaser and they loved it. I don't see docs in general, just see gyno and dermo for checkups and only see my rhumo several times a year to get meds that help me with some symptoms for sleep, pain etc and if I get sick and need anti biotics.

Anyone have any info? Again, not looking for treatment, I know there isn't any and for me, less has always been more treatment wise and i'm 30 years into this thing.

Just need to figure out more cost effective long term options. And I just need my rhumo for disability stuff if it comes up and my meds which I could probably pay out of pocket. So crazy this whole medical care in the US and I know I am one of the very lucky ones that I have what I have.

 

[Mouse girl]

Kaiser, anyone?????

Do you have to pay extra from the Medicare amount they take out of your check or does it cover Kaiser care?

looking for a sustainable medical plan, so I don't lose my home or all my assets if I get cancer or in car wreck etc and maybe out of pocket for doc who helps with disability paperwork and jury duty etc.

I hate that the modern cfs/me community doesn't have any helpful info on things patients need for survival, like docs who will help with disability paperwork, etc. Local docs is what patients need, just to survive. We all know there is no treatment, we all just need to survive. I can't imagine the hellscape it is to get sick now a days without local support groups that had such great info, support and commuinity. Even the old cfids assoc of America had so much helpful info, helped patients and lobbied, rather than foolish "protests" or endless small scale meaningless studies.

Social media really ruined things and ended forward movement.

 

[Judee]

@Mary had some very good info on Medicare and Supplemental plans last year in one of the threads. I don't remember her talking about Kaiser though. That seems like an awful lot to be having to pay if you're on disability.

I hope she or someone else will have some suggestions.

 

[Mary]

@Mouse girl - how did you end up with $17,000 in medical bills if you had almost no care? Adding up your monthly Medicare premium and the monthly cost of your supplemental plan and drug plan should not be even close to $17,000.

How much is your supplemental plan?

Kaiser is a Medicare Advantage plan - it's an HMO. To find out how much a Kaiser plan will cost you, go to Medicare.gov and click on Health & Drug plans at the top of the page. I'm guessing there is more than one Kaiser plan available in your area and you can find all that out at that link.

If you go with Kaiser, you will no longer have a supplemental insurance plan. You're only able to have a supplemental insurance plan if you have straight Medicare and not an HMO plan. If you have straight Medicare, a supplemental plan is optional - it's not required. And this can get a little more complicated - not everyone is eligible for a supplemental straight Medicare plan, and for this I'd let an agent explain it to you.

It can help to work with an agent - it won't cost you anything. They can explain all the ins and outs and costs of the various plans. I had a good experience with United Medicare Advisors. https://unitedmedicareadvisors.com

One last thing - Medicare Advantage plans are notorious for requiring pre-authorization for various procedures. They're cheap and make up for it by making it difficult to obtain care when you most need it. I don't know how Kaiser rates in this area. With straight Medicare, I've never had anyone question anything I've had done. But I do have that 20% copay which is covered by the supplemental plan I have.

 

[Mouse girl]

yeah! Thank you guys !!!! finally, someone, some two in fact (hehe) had some info! Oh yes, it's super easy to have $17,000 with basically no medical care. the insurance alone is a lot! and I had dental care this year and of course, I have no dental care, I'm not a senator! lol

Yes, I have medicare ppo with supplimental insurance and pharmacy insurance. All the insurance about $8000, pap smear not covered, of course, can't remember without looking at notes if I had some other small payments for copays or tiny tests. RX out of pocket (since the deductable is so high) was around $1000. Then I did need extra dental work this year as my mouth got extra dry from anti depressants I took for a bit to help me climb out of a pretty hard core mental breakdown from just the worst kinds of betrayal during losses and huge traumatic event. I did find a good therapist, who was down to earth, believed in facts, science and common sense, so that was $3000.

Just think if I got even a minor cancer or minor heart attack or got in a car accident. I can't even imagine the costs! And I don't want to risk losing all my assets by not having the secondary insurance.

Kaiser is an HMO, yes, but they do offer two different plans, one if you are in the Medicare advantage HMO and one if you have the better Medicare ppo and they have choices within each. I didn't go the Medicare advantage since it's an HMO and I had seen issues with it. I mean, people have issues with everything especially medical care, even with excellent medical care, I've seen people complain about lighting and seating being too hard in waiting rooms! Kaiser was known as the Cadaliac of HMOs, not sure if that is true, but it was the best by far of the HMO arena before. I do worry about the whole.....I have cfs/me thing and I would be tagged as being "crazy" for the first time in medicine and have that ruin getting good care for other things that could come up as your records are transfered to other docs. having tranfered records is great in general, you don't have to waste all your time, with more paperwork and explaining things over and over and over but it's the damn cfs thing. I believe even if you had doc there who gets it, they don't do paperwork if you have a review or get jury duty, but not sure if that is true. I just worry, would I be able to transfer back? would I get a real answer to that question from anyone and will that answer change in the future? the medical insurance stuff randomly changes all the time. medicare used to cover pap smears but stopped for me.

I know my dad and aunt liked Kiaser. And I know you can change plans during the change period each year, I just wonder if you really can go back after having Kieser. I have a friend who had Keiser with real CFS and he changed to Medicare ppo just to try my doc as he has some other really tricky stuff going on that sadly, no one seems to have anything to treat with or can't find out what is going on. But I don't know if he went back to Kaiser.

Some years back, right after my dad died and my brothers tried to get everything my dad left me, I had all these tests come back wrong. it was a nightmare trying to find all these different specialists, see who took Medicare, see if I could get in to see them within time, have all these procedures done and such was really stressful on top of researching outcomes for all the different cancers they were looking for etc. But that all calmed down after all the horrific stress calmed down. And luckily, my body was just a wreck and falling apart but no cancer and such. Every week, I was searching madly on my own, having no idea if these strangers on the internet would be any good at all. I know one was a referral but that was it. My cfs/firo doc only knows concierge docs who only take all cash. At Kaiser, it would all be in house and set up easily.

My secondary insurance is going up to $500 a month in June and it will only keep going up, same with the RX insurance, so I don't see how this could be sustainable unless I marry someone with tenure or DGA insurance, lol. I"m only 55 and my SSDI is less than welfare pays and I live in So Cal. So, I need my assets to live on as I plan to live as long as as healthy as possible, and I hate wasting money.

and I know I am lucky to be in this position. I'm just so new to all of this and have no one to get advice from or who has experience. There is a reason why people who have emotional support and people who love them do much better in life, we are not wired to be completely alone in the world. But, I'm still here! and don't need anit depressants anymore, got off other meds too and have gotten out a wee bit. Saw some whales yesterday at the beach! Saw bunnies, a squirrel, seagulls, seals and whales! Surrounded by all these yellow wild flowers on a hill overlooking the water. what a magical place Malibu is, I sure miss it and hope to be there more. Wish you all could have seen it too, well, that is....if you like that kind of thing. For others, it might be a completely different thing that would be lovely for you and I wish you more of what makes you heart soar.

 

[Mary]

I have medicare ppo with supplimental insurance

Medicare PPO is a Medicare Advantage plan. https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf

What "supplemental insurance" do you have with your PPO? There are no Medicare supplemental plans for PPOs or Medicare Advantage plans. I really urge you to work with an agent on this. I gave you a link above you could use. They can answer all your questions.

If you had straight Medicare - not a PPO or HMO and no insurance company involved - then you can buy a supplemental insurance plan to pay the 20% copay which is due with straight Medicare. But even for that, $500 is a ton of money. Talk to an agent.

 

[Mary]

I'm still here! and don't need anit depressants anymore, got off other meds too and have gotten out a wee bit. Saw some whales yesterday at the beach! Saw bunnies, a squirrel, seagulls, seals and whales! Surrounded by all these yellow wild flowers on a hill overlooking the water. what a magical place Malibu is, I sure miss it and hope to be there more. Wish you all could have seen it too, well, that is....if you like that kind of thing.

That really sounds lovely, especially the whales! I'm really glad you got to see them! Years ago I went on a whale watching trip to the Channel Islands (out of Oxnard) only we saw no whales. My sons were 4 or 5 then, and both got sick as dogs on the way over too - I felt so bad, like I was torturing them, though they perked up quickly when we got to dry land.

I used to live in the Antelope Valley and if we were very fortunate, in the spring the hills would appear to be on fire with poppy blooms - but everything had to be just right for this to happen - enough rain, good temps etc. So those yellow wild flowers you saw might have been poppies . . .

 

[Mouse girl]

Hi Mary! Thanks for writing back.

Sorry you didn't get to see whales. I've seen them quite a few times from the shores of Malibu, they come up that way each year. And in this one beach section, I have even seen a mama and her baby very close to shore. They are known to camp there for a bit while the babies are young so they can get a bit bigger for the migration up. I forget which kind of whale they are. I have seen some little whales whale watching one time when I was in school. But other times, whale watching, just got sick but always saw dolphins. I even swam out to dolphins in Malibu and had some swim under me, it was so exciting and a tiny bit scary just to see a huge shark shaped animal below you! I mean, I wasn't scared, I was so happy and excited but i pulled my legs up out of the water while on the boogy board just out of some instinct and natural fear seeing shark shaped below me. Magical.

Yes, I have used an insurance agent. The supplimental insurance I have is for the top 20%. It is through AARP and is much cheaper than any other supplimental insurance for the PPO medicare. Insurance is crazy expensive when you don't have help from an employer. I am 55, I think it was about half the cost when I first got it after my father died when I was 49. The insurance agents do a review every year and make reports showing me the costs, out of pocket and all that stuff. I also live outside LA so I'm sure it's more expensive than in other states where cost of living is cheaper but I don't know. So, this is why I am wondering about Kaiser. I just wonder if need be, I could switch back to PPO and all that. I mean, I know technically, you can, but I know with so many legal issues in life, the law vs reality is vastly different. I have found that out very harshly since my dad died and all the laws that should protect trusts and wills and just being lied to by sooo many professionals that stood to gain financially even though they have fuduciary duties etc. Even health insurance specialists don't even know all the ins and outs of health insurance in the US because it is so complicated and changes constantly. This is why I hate the the cfs/me communities have been destroyed by social media and younger generations, you can't get local and solid info that you could get before from the patient community that you met in person or talked to on the phone.

Whoosh, got a bit too cocky and did too much so paying for it but that's how it goes. But, I'm so glad I can do more overall compared to just last year really.

Oh, yes, they aren't poppies. they are something called Coreopsis, they are much larger, big bushy like yellow daisy looking flowers. I LOVE poppies though. I grew up in LA and have always loved poppies. Very pretty especially where I was, but they even line PCH right now. lovely.

I had to look up Antelop valley, even though I know the name, there are just sooo many places in So Cal, I forget them all. Yes, now I know. lots of neat terraign up there. lots of cool filming locations. and I know peeps who have gone up there to see the wild flowers. sounds amazing to see hills and hills of poppies!

 

[Azen]

@Mouse girl

Sorry for resurrecting an old thread, but I wanted to ask you Mouse girl, have you ever looked into getting onto 250% Working Disabled Medi-Cal (also called Medicaid). Most CA people on SSDI qualify for it, but often only if they file strange unintuitive paperwork. It doesn't actually require you work in any meaningful sense. It has expanded eligibility as of a couple years ago, so this might be a new option for you that wasn't available previously. It used to disqualify you if you had significant assets, but now assets don't matter.

If you have both Medicare and Medi-Cal, that usually gives you way better insurance coverage and then zeroes out basically all medical bills. The 175 stops being deducted from your SSDI check. Kaiser has great Medi/Medi plans, though I'm not sure if they're available in all CA counties or just some. You can get referred to Kaiser's ME/CFS Consultative Service, which I'm pretty confident in being able to prescribe basic medications and give you some documentation. There's lots of other non-Kaiser options too though that take Medi/Medi.

If you're married or if you have substantial income that is not from work and not from some sort of disability payment, you might not qualify in some cases.

This has more info about it:

https://canhr.org/aged-disabled-medi-cal-program/

If you can't understand the above resource, this legal aid organization is known for helping clients apply for it:

https://cahealthadvocates.org/about-us/contact/

Anyway I'm on SSDI and this type of Medicaid and it's great, much better than Medicare + a paid supplement.

 

[Mouse girl]

Man, they really changed things up. I don't work at all though. I used to have medi/medi before my dad died which was so great. I was so lucky when I had to go to the ER and still had it then. So many docs don't even take Medicare here now or take any insurance and want cash only or concierge patients. I have to pay a fee each year to be a patient of his plus visits that is the only doc I know in all of LA who knows what cfs is or takes patients with it. So worried what I will do when he stops working as he is old. Really need to find a husband with some good insurance, lol. Wish I could meet someone who was a good man and cared etc. Has anyone ever found that?

 

[Mouse girl]

@Azen thanks for sharing this though. this might help someone else out. they change things up and if you don't know someone who knows, you never hear of things. This is why I so miss having a community of people with cfs/me and fibro. Man, things were so much better then. Much more humane and sane.

 

[Azen]

Man, they really changed things up. I don't work at all though. I used to have medi/medi before my dad died which was so great. I was so lucky when I had to go to the ER and still had it then. So many docs don't even take Medicare here now or take any insurance and want cash only or concierge patients. I have to pay a fee each year to be a patient of his plus visits that is the only doc I know in all of LA who knows what cfs is or takes patients with it. So worried what I will do when he stops working as he is old. Really need to find a husband with some good insurance, lol. Wish I could meet someone who was a good man and cared etc. Has anyone ever found that?

CA basically changed the definition of "working" to be as easily accessible as possible, in an attempt to increase Medi-Cal eligibility. I claimed I made one "wellness phonecall" a month to my family member, who pays me 5 dollars a month. This meets the criteria. You just need to submit a contract or a receipt. Recycling cans once a month is another common type of "work" for this program. Please consider it! If you like, I can send you a digital copy of the wellness phonecall contract I wrote up, which was accepted by my Medi-Cal office workers.

There's other aspects of the eligibility criteria. Sometimes you can just get approved after only submitting proof of work, sometimes other aspects will disqualify you and would have to be troubleshooted, maybe with the help of CA Health Advocates.

 

[Mouse girl]

Thanks. I doubt I qualify and I'm not struggling to get by financially but i'm curious about it if you would be so kind to send me a private message of the info you mentioned, I am curious to find out about this. I know a friend did get medi medi even though he didn't qualify before due to the 2000 asset disqualifier of the past and receiving any help from family etc. He really could use the extra help and I'm very pleased he has it.