Every January, my husband Tosan and I brace ourselves for the impact of the 'January reset' on our family's finances. As parents of a child with complex medical needs, we're no strangers to the avalanche of medical bills that come with insurance deductibles and out-of-pocket maximums starting anew. Our latest episode offers an intimate conversation where we peel back the curtain on the financial challenges that families like ours face, diving into the intricacies of insurance policies in Texas, and the relentless vigilance it takes to ensure our daughter's healthcare needs are met.
Join us for a heart-to-heart about the proactive financial strategies we've put in place, like leveraging Health Savings Accounts and planning for a multi-year safety net. As we exchange stories and strategies, Tosan and I reveal how we've navigated the stormy seas of healthcare costs and even seeking healthcare grants and exchanges when money was tight. We aim to empower and offer solace by sharing our journey, reinforcing the importance of resilience and the strength found in taking it one day at a time.
https://notyourmamasautism.com/
https://www.instagram.com/notyourmamasautism/
https://www.facebook.com/NotYourMamasAutism/
Every January, my husband Tosan and I brace ourselves for the impact of the 'January reset' on our family's finances. As parents of a child with complex medical needs, we're no strangers to the avalanche of medical bills that come with insurance deductibles and out-of-pocket maximums starting anew. Our latest episode offers an intimate conversation where we peel back the curtain on the financial challenges that families like ours face, diving into the intricacies of insurance policies in Texas, and the relentless vigilance it takes to ensure our daughter's healthcare needs are met.
Join us for a heart-to-heart about the proactive financial strategies we've put in place, like leveraging Health Savings Accounts and planning for a multi-year safety net. As we exchange stories and strategies, Tosan and I reveal how we've navigated the stormy seas of healthcare costs and even seeking healthcare grants and exchanges when money was tight. We aim to empower and offer solace by sharing our journey, reinforcing the importance of resilience and the strength found in taking it one day at a time.
https://notyourmamasautism.com/
https://www.instagram.com/notyourmamasautism/
https://www.facebook.com/NotYourMamasAutism/
Welcome to season six of the Not Your Mama's Autism Podcast, a podcast about neurodivergence told both through the eyes of our family, the Olleys, and through the lens of the greater global neurodivergence community. I'm Lola Dada-Olley. We hope you enjoy this episode we have lined up for you. So, with that in mind, let's get started. In this episode, I'm here with my husband, Tosan. Tosan, say hi, and we are here today to talk about a topic that too many families in the US are familiar with and that is going back and forth with insurance companies. So, for a bit of level setting, let's explain.
Lola :Every January, the clock resets. Now what do we mean by that? We mean that, starting January 1st, families are charged medical costs until they meet their deductible. A healthcare deductible is the amount of money a person or family has to pay in out-of-pocket expenses before their health insurance carrier has to start contributing to these costs Every year. As a family, because of the amount of healthcare services we utilize, we tend to meet our deductible amount within the first month of the year, I dare to say within the first couple of weeks. So keep that in mind. Tosan, for some more level setting, do you want to tell our audience about what an out-of-pocket max is. For those who may not know, sure.
Tosan :I think one thing you said about too many families being familiar. That may actually not be quite right. I think in all of families in our position so let me qualify that.
Tosan :So too many families in our position. Yes, the neurotypical or the normal family interaction with insurance is January 1st rolls over and nobody really thinks about it until somewhere in April or May little junior hurts his knee and gets a scrape and you go and you have some kind of a copay if you have a flat fee for certain tax visits and what have you, and you may only have to think about the copay for most families for the whole year because you know you don't quote me 90% of families don't ever have to think about coinsurance, which is what you pay or the percentage you pay after you each are deductible. But, like you said, we're so very familiar with those terms we almost don't even really think of the copay because we pay so quickly that we get to deductible coinsurance out of pocket, max conversations. Why? Frankly, because of a narrow depending on the insurance within the first two, three weeks of the year, particularly in Texas, which we will touch a little bit. But to give folks who are not quite as familiar with the terms, a deductible is the amount you have to pay either as an individual A baby girl has a room deductible, then the family has their own deductible to hit and the deductible is the amount you get to get to before your insurance comes in alongside you to bear some of the expenses of your medical costs.
Tosan :It usually varies anywhere from 70% the insurance takes 70% of the costs to some extra nice. Insurance will take like 90% to 95% and you share the costs and that percentage until you hit the next threshold, which is on the out-of-pocket max, either as an individual or as a family. So baby girl has her own individual out-of-pocket max which if she hits it when the first second of the year, then her health care is essentially free for the rest of the year, whereas the rest of the family still has to catch up to get to the family deductible and the family out-of-pocket max which, now that a lot is not in as much therapy as she used, to the family deductible we hit it later. But before I remember a time lots of long ago we hit both family and individual in a month.
Lola :We had a lot of public data, tough civilians out-of-pocket acts and real quickly what we say that we hit it, it means usually within 30 days of when we hit it. We are expected to come up with the payment for thousands of dollars.
Tosan :But actually I should make it a little bit worse and this is the differentiation with Texas versus the other states we've been in in most other states, either because there's better protection, I feel like, or there's a better assumption that the preauthorization for therapy is almost a formality and to the inter-explan preauthorization is a hurdle that insurance puts in front of the providers where they have to essentially bet and approve that the services are quote medically necessary, which feels a little bit redundant and a little bit absurd, given that we have a child who is intellectually disabled and the autism spectrum and her speech, the liaison. She doesn't show up every year and go. I still have autism, that is what it is. But insurance makes you essentially re-vet and reassess her like she's a new case and been submitted in other states. Preauthorization feels like it's a bit more formality and the therapy providers essentially hold their bill in anticipation of the preauthorization will go through and when that happens they now submit all of their claims and then you're in the expectation of pain.
Tosan :The deductible and the out-of-pocket match or whatever it really be, almost comes at once. But that is usually a night, 21 days, 30 days after therapy has started. For the year X is a different beast X is essentially requires at least that there are people who have had it when you've been a part of it in Texas require you to put a card on file where you get charged like you have no insurance until the pre- authorization is approved and there's some media claims and they will after the fact refund you if you were paid. So, like Lola said, our families a lot of times in our situation are out of pocket. In the first week of the year that was in anticipation of perhaps a refund, which is weird.
Lola :That took some getting used to.
Tosan :I call it the Texas Disability Tax, what I call it. I'm just like maybe that I'll stop doing business here.
Lola :It's different than some other places and like, for instance, these past couple of weeks, were always on guard because there's a partial monitoring of the bills that are accumulating very quickly, along with monitoring the insurance provider, as well as monitoring the provider to make sure that they're in proper communication with the insurance carrier, because what can easily happen is the provider will just keep charging, charging, charging, charging, charging. So this time of year, just like you, turn into part time, if not full time, insurance specialists.
Tosan :My second career when I retired could be insurance consultant, personal home office insurance consultant. But yeah, you very quickly learn the case manager from an insurance perspective on your own baby girl's case being very quickly established. Early communication ensure that from the therapy side that all of the information that the insurance company needs is submitted. We have less privilege that we have on the therapy side a BCBA.
Lola :Or a certified behavior analyst. She's our case manager for our daughter's ABA applied behavioral analysis therapy. She's our case manager. She keeps those trains running on time.
Tosan :I just want to give and she is one of the best to work with, so she's on point. But we've had situations where that's not the case, where so you're essentially managing two fronts to ensure that the therapy provider is submitting exactly what they're supposed to be submitting, and your constant communication it was spending three hours a week on the form of insurance companies, probably no more about bidding costs than I should Just ensuring that, again, book parties are marching towards the desired outcome, which is the care of our child. So, yeah, it's the first. The happy new year fades very quickly and it's early ink, fortunately. I mean a career where the first week or so is still kind of everybody's coming off of the holiday, coming down from the holiday. I, you know budgets already set and we know that. You know FP &A work is all the code ready to be stored.
Tosan :So I can divert attention to the, not to the on-front but understanding the yeah, you know, with the fact that we have insurance, we are fairly well versed of the nuances and the maze, the Byzantine maze that is health insurance, and especially in Texas, you know, somebody should have to think, oh, what are the people doing?
Lola :Yeah, it's a really can be. It can be very frustrating and we've had past seasons where, you know, we just didn't have the funds to even pay for that initial deductible or pay for that initial out-of-pocket max, and we've been very fortunate enough to get help from secret grants, because this money kind of pops up very quickly and this is clearly not just a nice tab but it's essential for our family to run and it's. There have been past seasons where it was difficult to make these payments, or in a much better season now, and we're grateful to God for that. But we're also very aware that there are a lot of families that, especially depending on where you live, there's this middle ground where you can't qualify for Medicaid because you make too much, but then you don't have enough to pay these massive amounts up front.
Lola :So and there are families that are struggling with that and it's, you see how different your life is sometimes from other families. I remember some family friends there. I think their kid ended up in the ER and that was the first time ever in their family that they'd hit their out-of-pocket max and you would have thought like their whole world was shattered. And I realized was like. This happens to us every single year, every single year. 10 years, 10 years, 10 years, 10 years. And we laugh about this and we've had previous podcast episodes about financial planning. But when I say that this is a line item, this is for sure a line item.
Tosan :Yeah, and the way we've been able to the financial planning comments, the way we've been able to address that is, you know, like Christmas, we know this is going to show up right, it's on the calendar every year.
Tosan :So, depending on what kind of insurance that whatever company we are with is offering, you use a combination of the modular HCA's healthcare accounts or you use, if you have the high deductible plan that gives you the HSA's that allow you carry over funds, that becomes essentially a parking mechanism.
Tosan :No, you're essentially investing for this event, you know, and once this is all paid up and you have the other pocket max fully met the rest of the 11 months of the year because, like I said, everything gets, it's in January. So the 11 months is getting ready Well, next January and, if we do it well enough, getting ready for next January with a little bit of cushion, because you want to get to some kind of cumulative effect where maybe in two, three years time, if out of pocket max don't drastically change, we'll get to a January where it's like we have enough in there for the next, you know, two years or three years or whenever you want. You know, out of our head, maxes fluctuates and, of course, if you're investing, you're subject to the Williams like capricious is over on.
Tosan :There's something that's not rich Is what I've been told it's. It's. It's an interesting, but it also gives us also a mindset for how we set up financial planning specifically for my health care perspective. Or baby girl post 26, which One hour is the, at least from what the church restricting is the cliff age where she drops off. What we since learned, given how hard I know, says there might be the possibility I believe it's in the law now that you could stay on on the parents, uh, parents, and show us and you know why I have a long that she needs to himself.
Lola :And then we have to roll that up to me, up to you.
Tosan :That's something on our Research agenda.
Lola :Yeah, yeah, we have to definitely research that further, but friends have told us so it's definitely something we need to run down more and better understand as we all age, because these health care costs are not going to go away. But we have to Figure out how best to fit it into our overall budget. And the health care accounts are one thing. Uh, just life choices we've made. Um, not upgrading our home, just very frankly. There's just certain things in life we've made decisions about because we know that Our medical costs are going to be more likely to be a lifetime than just over a season, and that's just what we have to do. That's just what we have to do to care for our children the way we need to.
Tosan :Yeah, so looking margin right, and that's our One of our themes, well, the bifurcating part of our agency creating margin physically, financially and spiritually, um, maritably emotionally. So you don't want to leave close to the edge as much as you can, you don't want to leave as far with the edge as possible, because the kids you know, wherever you're caring for, is relying on you for that extra buffer and they will. When they reach for that buffer, if it's not there it's, it starts a spin cycle. Um, that is difficult to recall, for whatever that you know, um, that line is physical, emotion, academic and what have you. So let's say it's enjoy that. If you hear the background, that's baby girl.
Lola :Baby girl telling us we should be all done. I don't know if you're so, maybe that's her, that's our cute to wrap up, because she's telling us she's trying to get in and she's saying all done, all done. So I think it's to wrap up.
Tosan :But what's your families? Um, hang in there, absolutely Hang in there. You know, if you survive, yeah, the pocket max cliff this year, build some more resilience. Next year will come again. You know, to those who don't have insurance, yeah, there's a lot of information out there on grants. You know we were at the situation one time we didn't have insurance coverage for being girl items through, you know, research and folks helping us out from a research perspective, that we were able to get certain insurance coverage from the healthcare exchange and that's different. Now that it was one way person, we're smooth side, as robust as it was in 2015. I'm ready to get, I know a lot of providers don't accept so very conscious of the challenges and in some way this is a conversation where we talk about margin or insurance privileged folks. Yeah, for that to better work. So we put one step, one leg in front of the other and tell we hit the other bucket max, we crack like a bottle of wine.
Tosan :Celebrate like it's a personal super bowl yeah so because we should always hit it before the Super Bowl, so exactly, so it's pretty appropriate.
Lola :It's pretty appropriate, because once that out of max hits, then yes, then it's for then all other medical services for the remainder of the year.
Fela:You know are free.
Lola :So well, I should put all covered medical success, that part, that part. So we will put in the show notes a link to grant program for people that use you H C United Healthcare, just to have that as an example of the type of grants that are out there and like to say I said, just hang in there. There's a reason why my motto, if you follow this podcast, social media it is constantly one day at a time and that that's why we've developed this mindset over time. It's just build resilience over time, because this world is not designed for families like our. So hope is the audacity of seeking light in the darkness, and that's what our family does, our best every day.
Tosan :Absolutely. One day at a time, one moment at a time, one step at a time.
Lola :And the words of our daughter as we wrap up this podcast. All done. Be well.
Fela:The Not Your Mama's Autism Podcast is written and produced by my mom, Lola, Dada- Olley, and is occasionally produced by me, Fela Olley. My dad and sister also contribute sometimes. Big thanks to Anna Lee Ackermann for her audio and video editing support. Until next time, everyone, see you soon.