Guest Blog by Maureen T.

​On a cold February morning of 1982 my life changed forever.   I was 8 years old and my father was about to go on a business trip.  He told my mom that he didn’t feel like I was looking well.   My mom took me to the doctor and didn’t see anything obviously wrong with me and we left the office. We put on our coats and hats and started to walk out the door.  That’s when the nurse came running after us – my blood sugar results came back and they were off the charts.

Though I was displaying so many of the symptoms of Juvenile Diabetes such as thirst, weight loss and blurry vision - they were subtle at that point because the disease was caught within weeks of onset. The next week was filled with visits to specialists, education classes, and an overhaul on what the rest of my life will look like.  

I remember my mom sitting on the hallway floor with the phone receiver outstretched from the kitchen crying and telling my dad I now had an autoimmune disease whose origins were a mystery.  I was now a juvenile diabetic (referred now as Type 1 Diabetes).  My pancreas had stopped producing any insulin and that I would have a lifetime of insulin injections to stay alive.  A lifetime.

I did my best to live as normal life as possible.  As with many autoimmune diseases I did develop others as well.  I struggled a lot but I did all the things kids do – I did well in school, I participated in school plays, I went to prom, I attended college. 

It was after college that life with chronic illnesses became difficult.  Prior to the Affordable Care Act (ACA) (passed in 2010 and implemented in 2014), adult kids on their parents plan would be kicked off as soon as they left school.  I truly believe the entire trajectory of my life would have been different if I could have stayed on my parents insurance until I was 26 years old.  I could have found the right career; I could have had the time to find the right business to work in.  Instead it was a desperate scramble to find any job that provided full benefit insurance to someone with a pre-existing condition.

Every decision I had to make as an adult revolved around health insurance. This was a constant stressor of getting to a job that provided any insurance, staying at jobs that were terrible to keep insurance, going without insurance when I had to move states.  A Type 1 diabetic was UNINSURABLE before the ACA. If I was offered any kind of insurance my pre-existing conditions wouldn’t be covered or I would be denied coverage or only be offered a subpar plan at an exorbitant premium rate, with an unattainable deductible and no prescription coverage for the very medications that keep me alive.

Since the ACA, I’ve been able to keep my wonderful job in small business because I can buy an ACA plan on the Marketplace that cannot discriminate against me. A job where I can really help people, a job I’m good at, and a job with my many, many health challenges I can still be a productive contributing worker in society.  Since the ACA I’ve had access to comprehensive medical care and with a disease like Type 1 diabetes - better access and diligent care on an ongoing basis are the keys to being healthy. 

The complications from decades and decades of diabetic wear and tear are overwhelming, expensive, and can be deadly.  The more I’m able to take care of myself now, after almost 40 years of this disease, the better I’m prepared to avoid terrible outcomes like kidney failure or blindness.  When you have a disease that will be with you for the rest of your life - health insurance isn’t about having something in case something bad happens.  Health insurance is assurance in keeping bad things at bay.

The ACA is not without deep flaws and personal sacrifices.  I see it only as a first in a long needed step in being a country that resembles other first world countries.  Premiums have risen year to year with huge jumps, nothing has been done to stop the runaway train of prescription drug prices, and in order to see any real, affordable premiums, deductibles or co-insurance the yearly salary has a very low cap.  Also, Wisconsin chose not to expand its Medicaid coverage as other states have, so there’s a larger chasm between Medicaid coverage and where tax subsidies begin to take effect. Combining incomes with a marriage can put someone with a chronic illness into a position where taking care of oneself is not affordable, because they may no longer qualify for subsidies or with the higher income bracket you see higher premiums and huge deductibles.

Despite all this I'm so grateful for the ACA.  I’m grateful I had a choice. An unpreventable, childhood illness shouldn't have had the roadblocks that it has.  I can only hope now we can take this as our springboard to true healthcare reform so that all citizens in the county can be their best most productive selves.
 

Next year, plans sold on the Healthcare.gov Marketplace will be permitted to increase their “Out-of-Pocket” maximums to $7,900. What does that mean for you?

Out-of-pocket maximums are the amount set by a health plan that says, provided all medical costs are “in-network”, that once you pay that amount then the insurer will pay 100% of all in-network medical bills moving forward that calendar year. This can be a huge relief to someone facing catastrophically high medical bills, but uncomfortable for someone seeing only moderate number of bills
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Basically, most insurers require you to cover a “deductible”, where you pay 100% of medical costs up to that amount. After that, your plan will usually require either co-pays (fixed dollar amount payments) or coinsurance (a percentage of the incurred cost) depending on the service you receive, up until you hit that out-of-pocket maximum. Insurers can sometimes have separate out of pocket maximums for medical bills and for prescription drugs.

So what has changed? Next year (2019) plans will be permitted to increase their maximums up to $7,900 per person ($15,800 for a family plan), up from $7,350 in this year. That $550 difference is on top of changes in premiums and deductibles.

What can you do? To keep health costs down, we recommend the following:

1. Make sure you are going to an “in network” provider. Deductibles and Out-of-Pocket maximums can be even higher if you go to a provider outside of your insurer's list of who is preferred. Be sure to check! Doctors often don't know if the lab they recommend or the referral they suggest are in your plan's network or not. Most insurance companies will have a website feature or number to call to confirm.
2. Keep in mind what your expected medical costs next year might be when buying a plan. If you think you'll only have moderate expenses, less than the out of pocket max, you might want to consider a plan that features more co-pays (it will likely cost you less per procedure). But if you expect a lot of expensive medical visits next year, a plan with high coinsurance may have lower premiums and once you hit that out-of-pocket max the insurer will generally cover 100% of remaining in-network bills.
3. If a bill is wrong, challenge it! If you get a surprise bill saying it is out-of-network when you confirmed it wasn’t, call your insurance company or hospital billing department. Ask for clarification of the bill. Were you billed for a specialist but never saw one? Is your patient info correct? Were you billed twice for the same service? With a large deductible and/or out-of-pocket maximum, these bills will likely increase how much you must pay. Challenging bills is not always straightforward or easy, but doing so can save you on medical bills.

​Out-of-pocket costs can be a major crimp in your budget, especially when it is unexpected. Wisconsin Health Insurance Advocate LLC can be there to help you with these important health decision. WIHIA provides no-cost health insurance enrollment support for individuals and small groups, and we can also help you interpret (and possibly challenge) medical bills. Contact us here or call 414-797-3408!

Why use a broker? You're a savvy consumer and don't need help navigating the marketplace, right? Think again! A recently published research study confirms what I've been saying for years: getting help with your health insurance from a broker saves even the most insurance-savvy consumer time and money. The study shows that consumers who navigated the marketplace on their own did no better than random chance sampling in choosing a plan that would save them money, whereas individuals who got help were far more likely to choose the plan in their best interest. Best of all, our help is no cost. Open Enrollment is November 1-December 15 and we can help anyone in Wisconsin (call/text 414-797-3408 to schedule an appointment). 
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According to the study, "Consumers left to their own devices seem to make large errors when choosing health insurance, suggesting that they will select options that are not cost-efficient and they seem to be unaware of their failure" (http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0081521). 

Brokers know these plans in an out. We have contracts with the companies and have to attend company-specific training every year. Navigators and certified application counselors don't. And best of all, as brokers of record we can help solve problems including billing issues year round. Free assisters can't do that. Brokers also have a back-door portal and we can do applications over the phone in less than half the time it takes to do it on your own or with a navigator. 

Try us out and see the difference. We guarantee you will be more than satisfied.