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When: Monday, October 30th
Sessions: 10am and 2:30pm
Address: 1220 116th Ave NE, Suite 200 Free Parking: in front of building or the level marked 1220 only

We'll cover Social Security and Medicare eligibility - including how and when to enroll, the different parts of Medicare: A, B, C & D, and general information about Medicare Advantage, Medicare Supplement (aka Medigap), stand alone prescription drug plans and more.

This is an educational event. A licensed sales representative will be present with information only; there will be no sales activity. The Centers for Medicare & Medicaid Services (CMS) has neither reviewed nor endorsed this information.

"For accommodations of persons with special needs at meetings, call (206) 569-5415. Light snacks will be provided. Space is limited. RSVP (optional): please call or text (206) 569-5415 or email:  loy@sudergroup.com or erin@sudergroup.com

One of the most frequent questions I get about Medicare is “Do I need to sign up for Medicare when I turn 65 if I have employer group coverage?” And the answer is: It depends….

It depends on the size of the employer group and some other factors:
• Your cost for the coverage (including premium contribution and out of pocket expenses for deductibles, copays and your annual out of pocket maximum)
• If the employer plan benefits meet your needs (benefits, provider network)

NOTE: If your employer group is less than 20 employees, you should sign up for Medicare Part A and Part B when you are first eligible or face a lifetime late enrollment penalty. Your Initial Enrollment Period is a seven month window:

• 3 months prior to your 65th birthday,
• your birthday month and
• 3 months after your birthday month

With employer groups of less than 20 full time employees, Medicare is the primary payer and your employer group coverage pays secondary based on the benefit plan.

If your employer group is more than 20 employees, and offers medical and prescription drug coverage that is at least as good as Medicare (aka "creditable coverage"), you may not need to sign up for Medicare Part B right away. However, it's important to review the benefits and cost of your employer plan compared to the benefits and cost of Medicare plus a Supplement and drug plan or Medicare Advantage plan. In many cases, people save money by enrolling with Medicare.

There are several options for Medicare Advantage and Medicare Supplement plans available, and the key is determining which one will offer you the best coverage based on your healthcare needs, your lifestyle and your budget.

Medicare agents must be licensed in the state they sell products and must complete an annual certification and insurance company specific product training each year to assure they are qualified to help beneficiaries in making good choices. If you need assistance with your Medicare decisions, please contact me at 206-569-5415 or by email at suderloy@gmail.com. I am a licensed and certified health insurance agent in WA State and represent multiple health insurance companies. I can help you with your decision and enrollment for the plan that best meets your needs.

"Insurance companies are denying more claims than before and for unusual reasons. Appeals are taking longer and the process is becoming increasingly complex.,, claims that once might have been paid immediately are instead quickly denied "  More at KFF Health News ➜

A Comment by MFish

Your avatar
MFish • 05/30/2023 at 03:18PM • Like 2 Profile

Unconsciousable. Insurers need to find a way to pay claims within the terms of the respective policies. Lean toward paying not nitpicking to deny.

"When a stubborn pain in Nick van Terheyden’s bones would not subside, his doctor had a hunch what was wrong. Without enough vitamin D in the blood, the body will pull that vital nutrient from the bones. Left untreated, a vitamin D deficiency can lead to osteoporosis. A blood test in the fall of 2021 confirmed the doctor’s diagnosis, and van Terheyden expected his company’s insurance plan, managed by Cigna, to cover the cost of the bloodwork. Instead, Cigna sent van Terheyden a letter explaining that it would not pay for the $350 test because it was not “medically necessary.”. ... Read more at ProPublica

"The insurance industry and Republicans are using the debt ceiling fight and President Biden’s vows not to cut Medicare to fend off changes to private Medicare Advantage plans, which are popular among the public but have faced criticism about their costs to the government."  More at Roll Call ➜

Many of the patients left in the lurch have life-threatening digestive disorders that render them unable to eat or drink. They depend on parenteral nutrition, or PN — in which amino acids, sugars, fats, vitamins, and electrolytes are pumped, in most cases, through a specialized catheter directly into a large vein near the heart..... Read full article at KHN

"Caitlin Wells Salerno knew that some mammals — like the golden-mantled ground squirrels she studies in the Rocky Mountains — invest an insane amount of resources in their young. That didn’t prepare her for the resources the conservation biologist would owe after the birth of her second son." Read more 

The Annual Enrollment Period is the time to review your current Medicare Health Insurance to make sure you are on the plan that has the best coverage for you. I represent six insurance companies and they each have a variety of options available, many that include new benefits for 2022. If you have not reviewed your current plan to assure it is meeting your needs, now is the time to do that. I have been in the health insurance industry for many years and I would be happy to answer your questions and /or help you evaluate your health insurance needs to make sure you are enrolled with a plan that makes the most sense for you. Please call Loy Suderman at 206-569-5415 to get the help you need.

The bill-signing ceremony, took place at the Truman Library in honor of former President Harry S. Truman, who had first proposed national health insurance in 1945. The former President was enrolled as Medicare’s first beneficiary and received the first Medicare card.
For 50 years, these programs have been protecting the health and well-being of millions of American families, saving lives, and improving the economic security of the nation.

AURORA, Colo. — Fatumo Osman, a 65-year-old Somali refugee who speaks limited English, was in a bind. She made too much money at a meal prep service job so she no longer qualified for Medicaid. But knee pain kept her from working, so her income had dropped. She could reapply for Medicaid, get her knee fixed and return to work, at which point she’d lose that safety-net health coverage. Her first step was getting a note from a doctor so she wouldn’t lose her job.

So, Osman came to Mango House, a clinic in this eastern suburb of Denver that caters primarily to refugees and turns no one away, regardless of their ability to pay. Dr. P.J. Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. reject as too low.

The clinic is just one part of a broader refugee ecosystem that Parmar has built. Mango House provides food and clothing assistance, after-school programs, English classes, legal help — and Parmar even leads a Boy Scout troop there. He leases space to nine stores and six restaurants, all owned and run by refugees. Mango House hosts a dozen religious groups, plus community meetings, weddings and other celebrations. When Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he can easily grab one of his tenants.

“This is what I call a medical home,” Parmar said.

Although it’s not part of the formal U.S. refugee resettlement program, Mango House is in many ways emblematic of refugee health care in the U.S. It’s a less-than-lucrative field of medicine that often relies on individual physicians willing to eke out a living caring for an underserved and under-resourced population.

Parmar finds creative ways, often flouting norms or skirting rules, to fit his patients’ needs. As a result, Mango House looks nothing like the rest of the U.S. health care system and, at times, draws the ire of the medical establishment.

“How do you deliver the quality of care necessary, and that they deserve, while still keeping the lights on? It’s a struggle for sure,” said Jim Sutton, executive director of the Society of Refugee Healthcare Providers. “It’s these heroes, these champions out there, these cowboys that are taking this on.”

Osman brought her son, Jabarti Yussef, 33, to interpret for her. They have been coming to Mango House for 10 years and said that Parmar opens doors for them when they have trouble accessing care.

“If we ask for an appointment to get Medicaid, P.J. makes the call,” Yussef said. “If we call, we’re on hold for an hour, and then it hangs up. If we go to the ER, it’s a three-hour wait. Here, the majority of people walk in and sit for 30 minutes. It’s good for the community.”

As for Osman’s knee pain, Yussef asked Parmar, could they pay cash to get an MRI at the hospital?

“I can almost guarantee it’s arthritis,” Parmar replied. “You could do an X-ray. That will cost $100. An MRI will cost $500. And if it shows a bigger problem, what are you going to do? It will cost you $100,000.”

Parmar said he would connect them with someone who could help Osman enroll in Medicaid but that it’s an imperfect solution. “Most orthopedists don’t take Medicaid,” Parmar said. Older immigrants need to have worked the equivalent of 10 years in the U.S. to qualify for Medicare.

Medicaid, which covers low-income people, generally pays primary health care providers a third less than Medicare, which covers seniors and the disabled. And both pay even less than commercial insurance plans. Some doctors paint Medicaid patients as more difficult and less likely to follow instructions, show up on time or speak English.

Parmar said he realized back in medical school that few doctors were motivated to treat Medicaid patients. If he limited his practice to just Medicaid, he said dryly, he’d have guaranteed customers and no competition.

So how does he survive on Medicaid rates? By keeping his overhead low. There are no appointments, so no costs for a receptionist or scheduling software.

He said his patients often like that they can drop in anytime and be seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in their native countries.

Because he takes only Medicaid, he knows how to bill the program and doesn’t have to hire billing specialists to deal with 10 insurance companies.

It’s also more cost-efficient for the health system. Many of his patients would otherwise go to the emergency room, sometimes avoiding care altogether until their problems get much worse and more expensive to fix.

“Really none of our innovations are new or unique; we just put them together in a unique way to help low-income folks, while making money,” Parmar said. “And then, instead of taking that money home, I put it back into the refugee community.”

The son of Indian immigrants, Parmar, 46, was born in Canada but grew up in Chicago and moved to Colorado after college in 1999, where he did his medical training at the University of Colorado School of Medicine. He opened Mango House 10 years ago, buying a building and renting out space to refugees to cover the cost. Two years ago, he expanded into a vacant J.C. Penney building across the street.

“There’s a good three-, four-year dip in the red here, intentionally, as we move from there to here,” Parmar said. “But that red is going to go away soon.”

The covid pandemic has helped shore up his finances, as federal incentives and payment increases boosted revenue and allowed him to pay down his debt faster.

Parmar must navigate a host of obstacles while working to overcome financial and language barriers. A Muslim Somali woman needs dental care but is uncomfortable seeing a male dentist. A Nepalese woman needs a prescription refill, but she lives in Denver and so has been assigned by Medicaid to the safety-net hospital, Denver Health. Parmar won’t get paid but sees her anyway. Another patient brings paperwork showing he’s being sued by a local health system for a year-old emergency room bill he has no way to pay. A Nepalese man with psoriasis doesn’t want creams or ointments; good medicine, he believes, comes through a needle.

“A lot of this is, basically, geriatrics,” Parmar said. “You have to add 20 years to get their age in refugee years.”

When one patient turns away momentarily, Parmar discreetly throws away her bottle of meloxicam, a strong anti-inflammatory he said she shouldn’t be taking because of her kidney problems. He began stocking over-the-counter medications after realizing his patients got overwhelmed amid 200 varieties of cough and cold medicines at the drugstore. Some couldn’t find what he told them to get, even after he printed flyers showing pictures of the products.

Parmar’s creative solutions, however, often rub many in health care the wrong way. Some balk at his use of family members or others as informal interpreters. Best practices call for the use of trained interpreters who understand medicine and patient privacy rules. But billing for interpretation isn’t possible, so hospitals and clinics must pay interpreters themselves. And that’s beyond the capabilities of most refugee clinics, unless they’re affiliated with a larger health system that can absorb those costs.

“It’s a good thing to have the standards, but it’s another thing altogether to implement them,” said Dr. Pat Walker, an expert on refugee health at the University of Minnesota.

When Mango House began providing covid vaccines, residents of more affluent areas of town started showing up. Parmar tried to limit vaccinations only to those patients living in the immediate area, checking ZIP codes on their IDs. The state stepped in to say he could neither require IDs nor turn away any patients, regardless of his refugee-focused mission.

During a recent lull at the clinic, Parmar took stock of that day’s inventory of patients. Six were assigned to Denver Health, one patient’s Medicaid coverage had expired, and two had high-deductible commercial plans. Chances are he wouldn’t get paid for seeing any of them. Of the 25 patients he had seen that day, 14 had Medicaid coverage that Parmar could bill.

“We see the rest of them anyway,” he said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Kyunghee Lee’s right hand hurts all the time.

She spent decades running a family dry cleaning store outside Cleveland after emigrating from South Korea 40 years ago. She still freelances as a seamstress, although work has slowed amid the covid-19 pandemic.

While Lee likes to treat her arthritis with home remedies, each year the pain in the knuckles of her right middle finger and ring finger increases until they hurt too much to touch. So about once a year she goes to see a rheumatologist, who administers a pain-relieving injection of a steroid in the joints of those fingers.

Her cost for each round of injections has been roughly $30 the past few years. And everything is easier, and less painful for a bit, after each steroid treatment.

So, in late summer she masked up and went in for her usual shots. She noticed her doctor’s office had moved up a floor in the medical building, but everything else seemed just the same as before — same injections, same doctor.

Then the bill came.

The Patient: Kyunghee Lee, a 72-year-old retiree with UnitedHealthcare AARP Medicare Advantage Walgreens insurance who lives in Mentor, Ohio

Medical Service: Steroid injections into arthritic finger joints

Service Provider: University Hospitals Mentor Health Center, part of the University Hospitals health system in northeastern Ohio

Total bill: $1,394, including a $1,262 facility fee listed as “operating room services.” The balance included a clinic charge and a pharmacy charge. Lee’s portion of the bill was $354.68.

What Gives: Lee owed more than 10 times what she had paid for the same procedure done before by the same physician, Dr. Elisabeth Roter.

Lee said it was the “same talking, same injection — same time.”

Lee and her family were outraged by the sudden price hike, considering she had gotten the same shots for the far lower price multiple times in the years before. Her daughter, Esther, said this was a substantial bill for her mother on her Social Security-supplemented income.

“This is a senior citizen for whom English is not her first language. She doesn’t have the resources to fight this,” Esther Lee said.

What had changed was how the hospital system classified the appointment for billing. Between 2019 and 2020, the hospital system “moved our infusion clinic from an office-based practice to a hospital-based setting,” University Hospitals spokesperson George Stamatis said in an emailed statement.

That was a change in definition for billing. The injection was given in the same medical office building, which is not a hospital. Lee did not need or get an infusion, which requires the insertion of an IV and some time spent allowing the medicine to flow into a vein.

Nonetheless, that change allowed the hospital system to bill what’s called a “facility fee,” laid out on Lee’s bill as “operating room services.” The increasingly controversial charge — basically a room rental fee — comes without warning, as hospitals are not required to inform patients of it ahead of time.

Hospitals say they charge the fee to cover their overhead for providing 24/7 care, when needed. Stamatis also noted the cost of additional regulatory requirements and services “that help drive quality improvement and assurance, but do increase costs.”

But facility fees are one reason hospital prices are rising faster than physician prices, according to a 2019 research article in Health Affairs.

“Facility fees are designed by hospitals in particular to grab more revenue from the weakest party in health care: namely, the individual patient,” said Alan Sager, a professor of health policy and management at the Boston University School of Public Health.

Lee’s insurance had changed to a Medicare Advantage plan in 2020. The overall cost for the appointment was nearly three times what it was in 2017 — before insurance even got involved.

The National Academy for State Health Policy has drafted model legislation for states to clamp down on the practice, which appears to have worsened, Executive Director Trish Riley said, as more private practices have been bought by hospitals and facility fees are tacked onto their charges.

“It’s the same physician office it was,” she said. “Operating in exactly the same way, doing exactly the same services — but the hospital chooses to attach a facility fee to it.”

New York, Oregon and Massachusetts are pursuing legislation to curtail this practice, she said. Connecticut has a facility fee transparency law on the books, and Ohio, where Lee lives, is considering legislation that would prohibit facility fees for telehealth services.

But Riley noted it’s difficult to fight powerful hospital lobbyists in a pandemic political climate, where hospitals are considered heroic.

The Centers for Medicare & Medicaid Services has attempted to curtail facility fees by introducing a site-neutral payment policy. The American Hospital Association sued over the move and plans to take the case to the Supreme Court.

Resolution: Lee’s daughter, Esther Lee, was furious with the hospital over the fee. Her mom, who is fiercely independent, finally brought her the bill after trying for weeks to get the billing office to change it.

“This is wrong,” Esther Lee said. “Even if it was a lot of money for services properly rendered, then of course she would pay it. But that’s not the case here.”

When Lee called her doctor’s office to complain, they told her to talk to the billing department of the hospital. So Lee, with Esther’s help, repeatedly called the billing department and filed a complaint with Medicare.

“I don’t want to lose my credit,” Kyunghee Lee said. “I always paid on time.”

But after receiving a “final notice” in February, and then being threatened with being sent to collections, the Lee family gave up the fight. Esther Lee paid the bill for her mother. But she’s worried her mom will delay getting the shots now, putting up with the pain longer, as she knows they are more expensive.

The Takeaway: When planning an outpatient procedure like an injection or biopsy, call ahead to ask if it will happen in a place that’s considered a “hospital setting” — even if you think you understand the office’s billing practices. Ask outright if there will be a facility fee — and how much — even if there’s not been one before. If it’s an elective procedure, you can search for a cheaper provider.

One easy place to scout for more affordable care is the office of a doctor whose practice has not been bought by a hospital. It is the hospital, not your longtime doctor, that is adding the fee, said Marni Jameson Carey, executive director of the Association of Independent Doctors.

“This is one of the terrible fallouts of consolidation,” Carey said.

Sources:

Stephanie O’Neill contributed to the audio version of this story.

Bill of the Month is a crowdsourced investigation by KHN 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!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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