Emergency Room Sticker Shock

[kenobi_65]

@Coriolanus

Her fear was that Medicare would take her home away if she owned a house. The thing about that is, if you go into a Medicare home they are just waiting for you to die.

This would have all been about Medicaid, not Medicare. Allow me to explain.

Medicare covers inpatient (hospital) and outpatient (doctor) care for senior citizens, but doesn’t cover ongoing residence in an assisted-living or skilled-nursing facility. Medicare will cover short-term residence in such a facility for rehabilitation (e.g., recovering from a surgery or a stroke), but that’s it; Medicare won’t cover the cost of living in a facility for an indefinite amount of time.

If you are in need of such 24/7 residential care, Medicaid (yes, the same program which provides health insurance for poor Americans) will cover the cost of a facility, but only if you are effectively already broke.

So, elderly people who are in need of that kind of care have to either (a) spend down their assets* until such time as they can no longer pay for residential care themselves, at which point Medicaid will pay for it, (b) look at other options (i.e., having a family member live with them and act as a caregiver, part-time professional caregiver care, etc.), or (c) have been fortunate enough, sufficiently foresightful, and wealthy enough to have purchased a “long-term care” insurance policy when one was younger.

Just giving all of your money to your family, to render yourself broke in order to qualify for Medicaid, doesn’t always work; Medicaid can look back something like 5 years to see if you did that.

And, yes, the nursing facilities which accept large numbers of Medicaid patients are often not the best ones.

Due to this, it’s entirely possible for the same person to be on both Medicare (which is paying for heir hospital and doctor bills) and Medicaid (which is paying for their nursing-home care) at the same time.

*- AIUI, they can’t force you to sell your house if your spouse doesn’t need that level of care, and is living in the home, but that’s one of the relatively few exceptions.

[robby]

My issue with emergency medical sticker shock was with ambulance fees and balance billing, which I recounted here:

What are "Adjustments" to my medical bill?

Yes, it’s called “balance billing” and is prohibited in some circumstance, but allowed in others. It is generally allowed if you seek non-emergency care at an out of network facility. Your insurance may cover some of that cost, and you will be responsible for the rest. If you go to an in-network facility, but receive out-of-network care; or in the event of an emergency, you cannot be billed for the balance. Your insurance will pay the contracted rate (at an in-network place) or a “reasonable …

Fortunately my insurance covered the out-of-state ER itself, and there was no balance billing there even though they were out of network.

[Coriolanus]

@kenobi_65

Allow me to explain.

Thank you.

In hindsight, at least, my mother’s trepidation about losing her home to the Feds or NY were unfounded. Yet 25 years ago, I couldn’t put into words, “This is your house. Sell ift and find a nice condo nearby. Do not do this “living deed” or whatever, as there were already fractures between myself and my oldest brother -vs- my psycho middle brother over the DNR for my father a decade prior. It was perhaps a noble thought, yet like King Lear it ends in tragedy.

Try and tell your mom, “You are never going to live in a Medicaid home.” when she’s 72. I am holding a mystical sphere: You’ll live to 100 and the Queen won’t write you a card because you’re Irish and she’ll be gone.

[Dinsdale]

The terms Medicare and Medicaid are quite similar and can be confusing. Used to be to me. What I decided upon was that Medicaid has a long-A sound, like in the word state. So Medicaid is a state program, Medicare federal.

And, as kenobi has explained, the state program - Medicaid - is more generally available to all, based on indigence alone. Whereas the federal program - Medicare - has eligibility requirements.

Hope that helps you somewhat - at least in terms of using the correct terms.

[kenobi_65]

@Dinsdale

The terms Medicare and Medicaid are quite similar and can be confusing. Used to be to me. What I decided upon was that Medicaid has a long-A sound, like in the word state. So Medicaid is a state program, Medicare federal.

Generally true, but it should be noted that Medicaid is actually a joint Federal-state program. The Feds provide a lot of the funding for Medicaid and set out a lot of the eligibility and administrative rules, but give each state a significant amount of leeway as to how they administer their own state-level programs, and whether or no they cover anything beyond the basics (as you noted upthread).

So, if one is on Medicaid, one is receiving benefits from your state’s Medicaid program, not directly from the Federal government; conversely, if one is on “original” Medicare, one is receiving those benefits from the Feds. (If one also buys a supplemental Medicare or Medicare Advantage plan, you’re buying that from a private insurer, but the core of your Medicare coverage is still Federal.)

Generally speaking, “red” states tend to have skimpy Medicaid programs, while “blue” states tend to have more robust programs.

[chela]

When i was on vacation the power went out at the airbnb in the middle of the night and someone in the house smacked their head on a door and slipped on an area rug and konked their head again.

Lumps and black eyes appeared. Thought they should get checked out the next day. Went to a walkin clinic, was told they didnt accept their insurance but quoted 1k for a CT scan. Instead they went to an ER that did take their insurance where 7k later got the all is well with the noggin. Insurance got it down to 5500

Next time, stay out of the ER.

[psychobunny]

My story is that I went to urgent care but they refused to treat me because my oxygen level was low. They wanted to transport me by ambulance to the nearest hospital. I didn’t want that hospital so I signed out against medical advice and drove to my preferred hospital. They tried to get me to pay the $300 ER fee but I asked them to bill me. Eventually I was admitted. I paid the $50 UC fee and the copays for the overnight admission but I guarantee that if I had paid the ER fee I would have had to fight with the insurance company to get a refund. I probably would have had to provide hospital records to prove that I had been admitted.

[Lumpy]

I live five minutes from a hospital but it’s not the one that’s in-network for me; that one is twenty or twenty-five minutes away. I’ve imagined having to decide if I could make the drive if a crisis came up, or at least instructing the EMS crew to drive me to the right hospital.

[Spiderman]

In general, EMS is going to take you to the closest appropriate facility. If something happens to you while in their care longer than necessary they are liable & could potentially lose their (individual) certification for not providing appropriate care. This does not include bypassing the local ER to take you to a somewhere like trauma center or dedicated stroke center if the nature of your reason for being in an ambulance dictates that longer ride to a more appropriate facility.