Monday, April 13, 2009

Medicare or BCBSNC? : gee, which one should I choose?

What a hoot. Or a screech. That's the sound of their tires veering off the road paved w/ the millions of $$$$$$$$$ of NC citizens who have no reimburseable (via BCBSNC Advanta Plans: $750/ month my healthy 3 member family pays for BCBSNC) access to :

1. screening colonoscopy
2. mammogram
3. mental health parity

I dunno: what a tough decision: Medicare or BCBSNC?

Here is what Medicare pays for re: those 3 important items which would affect many people over 50.


SCREENING COLONOSCOPY, recommended by the American Cancer Society, beginning at age 50. Price of screening colonoscopies in Asheville two years ago was $1200; not inclusive of any necessary biopsies:

"If the flexible sigmoidoscopy or colonoscopy is done in a hospital outpatient department or ambulatory surgical center, you pay 25% of the Medicare-approved amount. "

So that means that the Medicare insured would pay .25 X 1200 = $200

Here is what BCBSNC pays for re: screening colonoscopy (bear in mind the lovely state law requiring colorectal screening which impacts not a whit on the non-availability of screening colonoscopies in western NC):

"Colonoscopy is a covered benefit for Blue Cross and Blue Shield of North Carolina (BCBSNC) members. Below is a summary of the standard benefit for colonoscopy screening.
• The out-of-pocket cost of a colonoscopy done in an office based colonoscopy center is a member’s specialty co-payment for Blue Care, Blue Options and Blue Advantage members.
• Colon cancer screening is an enhanced preventive benefit for Blue Options HSA members. Screening must take place in an office location to meet the Blue Options HSA preventive benefits.
• Members can have a colonoscopy in a hospital or ambulatory care center, subject to deductible and coinsurance. Colonoscopy screening in a office based colonoscopy center can lead to significant out-of-pocket cost savings for members. .."

If you go to the website, and type in 'gastroenterology, you'll turn up dozens of physicians, most of them at the same dozen or two practices (looks like more that way) but the only one that does the REIMBURSEABLE office based screening colonoscopy is in Boone, NC, two plus hours away from major metropolis Asheville w/ 100,000 people.

And WHY do gastroenterologists mostly do only clinic based colonoscopies? Because people need anesthesia. Why do they need anesthesia? Because they might squirm w/ discomfort during a colonoscopy. And what happens if they squirm? They might get their bowel punctured. And what happens if you get your bowel punctured? You're DEAD.

Screening mammograms:

What do we get re: Medicare:

"Medicare pays for screening mammograms once every 12 months for women age 40 and over. Eligibility is based on the date of your last screening mammogram. You do not need a doctor’s order to get a screening mammogram. The Medicare Part B deductible will not be applied to a screening mammogram. However, you will be responsible for the 20% coinsurance. "

OK, so mammos cost a couple of hundred $$; 20% co insurance would be $20.


Funny how difficult it is to turn up information at the BCBSNC website. :

The answer is this: under the Advanta plans, which are those that families have who pay for their health insurance, specifically, the Advanta plans, you have to meet your yearly deductible before BCBSNC will pay for your mammogram. For my healthy 3 member family, w/ $750/ month, the reimburseable for EACH MEMBER is $2500.

Mental health?

I can answer this one as I am a medicare psychologist:

90806: 45-50 min therapy: medicare pays approx $60; usually there is wrap around to other insurance policies such as Medicaid or AARP, etc, in order to make the co pay; otherwise, the patient pays the co pay. Usual fee is $100-150/ session.

96152, Health & Behavior CPT codes e.g., 96152: therapy associated w/ medical issues which includes correspondence and wrap around to physicians: approx $25/ 15 minutes up to 7 units/ session. I commonly see people for 1.5 hours so that would be approx $150.00.


Remember NC Mental health Parity big brouhaha? didn't touch BCBSNC Advanta members. They simply continued w/ what they were doing as per my policy announcement which indicated that therapy would continue to be paid at 50%.

Only if you were 'fully insured' would you be able to get to mental health parity rates:

"Effective July 1, 2008, or upon a group's subsequent renewal date, the Mental Health Parity Act changes the way that fully-insured groups and MEWAs (multiple employer welfare arrangements under ERISA), can administer benefits for the treatment of mental health conditions."

Are there 96152 codes reimburseable per BCBSNC?

dunno: can't find any information using any normal means of obtaining info as per their websites. I assume no. Humana does not cover 96152 but only 90806 at the ridiculous rate of $55/ session.

I can't wait to see BCBSNC go away.

So, sorry, WSJ (Wall Street Journal): making the government look like the bad guys in this case simply won't work.

What they said:

"....Congress will finish the job with regulatory changes. Under the aegis of a level playing field, all private plans will be forced to offer benefit packages similar to those in the public option. They will also be required to accept all comers, regardless of pre-existing conditions, and also be forced to offer similar rates to all enrollees, ending the ability to manage risk through underwriting. Any private plan will essentially become a public utility where government decides what products it must offer and how much it can charge. ..."

Oh, boo hoo hoo.

1 comment:

HappyWithBlues said...
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