Feature Image - Tooth Extracted
Caption – We are not certain
how Buster’s tooth decayed so far as to need an extraction. One of the reason we have regular exams is
for Prevention and Early Intervention.
Requirements
|
|
|
|
|
Reqirement
|
Specification
|
|
|
|
|
|
|
Author
|
Keith “Buster” Torkelson MS
|
|
|
Editor & Third Person
|
Avey C Asus
|
|
|
Consumer
|
Keith “Buster” Torkelson
|
|
|
Publication Date
|
March 11, 2022 (F)
|
|
|
Title
|
Brand New Day Affordable
Healthcare
|
|
|
Routes
|
Blog
Written Complaint
|
|
|
Wishes
|
2020 No out-of-pocket for
healthcare
|
|
|
|
|
|
Last Reviewed: 20220306-SUN:
Full Title
Affordable Healthcare Glitch
– Brand New Day insurance associated out-of-pocket expenses 2021
Abstract
– Executive Summary
This
report pertains to a consumer of healthcare.
The consumer is a male, Scandinvian, age 62 named Keith “Buster”
Torkelson. We here at Mentalation
Solutions Group (MSG) represent Buster’s interests. The overarching theme of this report is
affordable healthcare. Buster lives in
Orange County California and helps out and lives in a home for Dying Old Men
(DOMs). Buster has been with his current
health care insurer Brand New Day (BND) since 2012. Buster’s insurance is more formally Universal
Care Brand New Day. For 2021 Medicare
awarded BND 3.5 Stars for BND’s overall plan.
5.0 (Medicare) Stars is Superior.
For 2021 Buster reached an all-time-high for out-of-pocket healthcare
expenses. His dental out-of-pocket alone
exceeded $150.00 per month. For service
year 2021, Buster’s BND mediated dental plan was Liberty Dental. Now he is making the transition to BND Delta
Dental for service year 2022. In this
report we address the nature of some of Buster’s 2021 losses as well as
expectations for 2022. His primary
losses occurred with medically necessary dental work and dermatology. We begin by addressing something that did work
well during 2021. Buster’s overall drug
coverage was very good. Brand New Day’s
drug coverage was augmented with a subsidy called “Extra Help”. For 2022 we hope to find something like Extra
Help to reduce Buster’s losses associated with necessary dentalcare.
Figure – Different Angle
Tooth #18
Affordable Prescriptions
Buster Yearly BND Drug Plan
Report
Year-to-date totals
01/01/2021 through 12/31/2021
|
|
|
|
|
|
Responsible Party
|
Year to Date
|
Note
|
|
|
|
|
|
|
|
Plan paid
|
227.68
|
BND Drug Plan
|
|
|
You paid
|
16.90
|
This is awesome
|
|
|
Other payments
|
446.04
|
Extra Help
|
|
|
|
|
|
|
|
Total drug costs
|
690.62
|
|
|
|
-
|
|
|
|
Lasts Reviewed: 20220311-F:
Entities of Interest –
Retroactive Scoring primarily centered about 2021
Overall Insurance Provider =
Brand New Day
Centered about Affordable
Dental Care
Prior Extractions
Metadata >
11_Health_Dental_22013101_STR
Accounting Centered about 2021 Tooth Extraction
Consumer = Keith “Buster” Torkelson
Extraction History
Prevention
& Early Intervention
With
this document we are intervening early to prevent for service year 2022 anything
but a covered root canal and crown.
Previously Keith “Buster” Torkelson’s general dentists have been able to
determine level of care based upon basic x-rays and an exam.
The
2021 Case of Escalation
Late
in 2021 Buster was diagnosed with a molar (Tooth #18) that needed a crown and
potentially a Root Canal (RC). The RC
became problematic and Buster was given Tooth #18 x-ray and a referral to an
Endodontist. Basically the endodontist
bilked Buster for $200.00 the cost of a Full Mouth Image (FMI). Being an Endodontist he should have been able
to make his determination using the original x-ray. Below we have included Buster’s image of the
unnecessary Full Mouth Image (FMI). The
Endodontist said he could not treat Buster’s tooth. Buster was provided no good reason for the
$200.00 FMI. By this stage Buster was in
crisis due to the miserable and sleep depriving Pain.
Figure
- Image of Tooth Extracted
X-ray
created at Primary Dentist office. Caption:
This was what Buster provided the Endodontist to whom he was referred. The x-ray cost was no out-of-pocket. Usual and customary is the x-ray is enough to
make determinations about treatment.
Notion: We recommend in the near future that our Primary Dentist invest
in colorizing software to help improve x-rays by contrasting healthy areas from
areas of concern.
Image – Full mouth by Endodontist
- Potentially Unnecessary
Keith “Buster” Torkelson is just
over sixty (60) years old. He has had
dental work performed regularly since he was a kid in the 1960s. X-rays were all his dentists needed in order
to make a treatment plan. On October 22,
2021 (F) at Noon Buster linked with Dr. Farshad Seyedein [SPELLED] the Endodontist
with which he was referred. The only
thing Dr. Seyedein did well was recommend Aleve for Buster’s excruciating
Pain. If we had not had to pay $200.00
for (unnecessary) full mouth scan we would say the Full Mouth Image (FMI) is
nice to add to Buster’s dental record. We
feel that the Endodontist could make his decisions using only the Tooth #18
X-ray provided by Buster’s general dentist.
Thus it is very likely that the FMI was unnecessary. Dr. Seyedein said he could not treat Buster.
|
|
|
Farshad Seyedein (Correct Spelling from receipt)
|
|
Metadata >
Dental_Farshad_Seyedein_Endodontist_22021202_Profile
Nature of Compliant – Extraction
Stage
Overall for 2021 we have mixed
emotions with Brand New Day (BND) Buster’s health insurance provider. We address BND’s performance in a separate
report. Here, when it comes to
affordable healthcare we focus on BND’s dental coverage. Basically, for 2021 there was no adequate
dental coverage. This came to light with
Buster’s Tooth #18 problem that escalated into an extraction. We paid $1295.00 out-of-pocket to the
provider to which Buster was referred by his BND associated Primary
Dentist. For us here at Mentalation
Solutions Group (MSG) the fees for Buster’s extraction were unreasonable. We discuss the oral surgeon performing the
procedures at Dental Associates of Huntington Beach in a separate report. Below we itemized the steps and costs for
Buster’s Tooth #18 extraction. Just for
fun we here at MSG tried to approximate the costs per hour. No wonder Liberty Dental BND’s dental plan would
not cover the Oral Surgeon’s fees.
Liberty Dental probably determined that the extraction process as it is constitutes
a rip-off.
Specialist – Oral Surgeon
Dental Associates of Huntington Beach
DBA – A Kid’s Dentist
Service Window – 20211108
Service – Uncomplicated Extraction
Costs of Living
Later on we outline some of Keith
“Buster” Torkelson’s budget. His rent
keeps increasing. The small annual
increase with his SSDI check far from keeps pace with the Cost of Living (COL). The stimulus check was helpful in 2021 yet it
didn’t help his standard of living unless you count its’ application for pain
remediation. We checked and Buster does
not meet the federal criteria for poverty.
Sad to think of how many individuals and families have is worse than
Buster. We do not know when and how much
that Buster received in stimulus money because his older sister is his
payee. Yet we do know that the majority
of Buster's 2021 stimulus monies were applied to pay for his dental
out-of-pocket.
BND Overall
Buster has been with Brand New
Day since 2012. He is one of their
better performers as reported by his BND associated doctors. BND as a product line is has been and is
deteriorating. In 2021 BND provided some
offset yet none enough to help Buster with his dental out-of-pocket or
Dermatology co-pays. Now in 2022 the BND
offsets are failing. Both BND’s healthy
food benefit and rewards program are problematic. Their clubhouse is non-existent. Very few of the helpers are dealing with
those in their caseloads face-to-face (F2F).
We just tested their Over-the-counter (OTC) benefit. As of March 8, 2022 (TU) our order is in the
mail. We received our OTC order March 9, 2022.
BND is most likely giving out bus free passes. Buster would like a gas stipend card to the
tune of $50.00 per month as a reward for his staying healthy. Buster uses his car for his BND associated
appointments.
Older Adult – On Fixed Income - Subsidies
Monthly Resource Management
Monthly Disability (SSDI) Check after insurance deduction approximately
$1500
Figure – 2021 for Whole Year
Medication Coverage
Keith “Buster” Torkelson
Older Adult – On Fixed Income
Monthly Resource Management & Budget
Monthly Disability (SSDI) Check after insurance deduction approximately
$1500
Money Matters
Buster’s representative payee
reports a monthly income for 2022 of $1550.00.
She tries to save a bit each month for unexpected expenses. Typically she saves around $600.00 per. Buster’s cost of living has increase faster
that his income. Buster and his payee
pride themselves for not being in debt for 2021. It was the stimulus check that pulled through
for us in 2021. If not for the stimulus
monies Buster would not be in good standing with either his Dermatologist,
General Dentist, Endodontist or Oral Surgeon.
What do we do when we cannot pay?
If it were not for gifts Buster’s Quality of Life would suffer.
Dermatology Costs – 2021
If it were not for the excessive the
out-of-pocket costs Buster suffered over dental work we would overlook the
co-pays he paid for his dermatology work.
We have included a table outlining some of the surgical work done by his
Brand New Day (BND) associated Dermatologist.
The procedure that his Dermatologist has performed on numerous occasions
is called MOHS. MOHS = “Frederic E.
Mohs, is microscopically controlled surgery used to treat common types of skin
cancer”. Up until 2021 there was no
out-of-pocket for Buster’s MOHS surgeries.
Another annoyance in 2021 was that for first time Buster was billed
after leaving his Dermatologists office the day of the procedure. Shelling out approximately $170.00
out-of-pocket (co-pays) for MOHS is a good deal and reasonable share. Yet, when added to the dental losses it did
add insult to injury. There is a chance
that Buster may need MOHS in 2022.
Metadata >
11_Dermatology_TQN_22021702_STR
Most Recent MOHS Procedure Date: 2021_0928 @730am
|
2021_1122-M
|
Statement Date
Co-pay Invoice
|
Lip MOHS
$139.48
Paid in person
|
|
2021_1211-SA
|
Statement date
Co-pay Invoice
|
Lip Biopsy
$33.37
Paid in person
|
Dermatology
Now that we have complained
enough about Buster’s affordable dental care let us address his out-of-pocket
about Dermatology. Our records indicate
that Buster linked with his Brand New Day (BND) associated Dermatologist in
2013. Until 2021 all care including
surgeries where fully covered. We were
really happy with both the Dermatologist and BND in the context of
Dermatology. Aside: We also have
accolades for Buster’s BND mediated eye care.
With BND’s Dermatology group it was usual and customary to work out
costs and payments in advance. Including
Buster’s MOHS surgeries it was also usual that suffers no out-of-pocket
burdens. In 2021 Buster had a Squamous
Cell Carcinoma in his lower lip removed by MOHS. For the first since 2013 Buster was
billed. In addition for the first time
since 2013 Buster received by US mail two bills after the fact. We are forced to pay all medical bills to
retain any and all BND associated practitioners.
Dermatology - MOHS Summary
Buster’s Healthcare Expectations for 2022
Denials – Featuring Liberty
Dental Plan
During 2021 Brand New Day (BND)
was Buster’s primary health insurance.
They went with Liberty Dental for their dental plan. In the last quarter of 2021 Buster received
at least three (3) denials of payment from Liberty. Denials are another way to say we offer very
low quality insurance. Up until fall
quarter of 2021 we here at Mentalation Solutions Group (MSG) believed that if a
service order was approved it meant the insurance was picking up the majority
if not all the cost. When it came to The
Extraction Fiasco (TEF) Buster was approved by Liberty Dental for both the
Endodontist and the Oral Surgeon. When
it came back for Liberty to pick up their share Buster was denied any help with
either the Endodontist or the Oral Surgeon.
Why in the world would Liberty have to approve of something to which
they contributed nothing? With respect
to Buster during 2021 Liberty Dental Plan failed to perform. We would not recommend Liberty Dental for our
friends or family. Remember, approval
does not indicate coverage. It would
nice if BND could make things right by refunding Buster for his dental to the
tune of at least $1295.00. Once again we
applied Buster’s one time stimulus monies to balance Buster’s 2021 dental
accounts.
Affordable Health Care - Dental
For this service year Brand New
Day (BND) swapped out Liberty Dental replacing it with Delta Dental. Delta Dental insured Buster for service year
2020. We are not happy with either Liberty
or Delta Dental. We have a benefit
schedule for Delta Dental that was issued to us before 2020. Delta Dental insures no better than
Liberty. Back in 2017 Delta Dental had
good coverage. For quite some time CalOptima
has been trying to get Buster to move over.
Yet, it looks like CalOptima’s dental plan is Delta Dental. We might ask our BND insurance broker for
help getting affordable dental care.
Later on we compare BND with CalOptima’s OneCare as measured by Medicare
(CMS).
Complaints and Complaint Forms
Nature of Compliant - Focus on Affordable Dental
Keith “Buster” Torkelson signed
on with Universal Care Brand New Day (BND) back in 2012. BND is Buster’s health insurer for both
physical and behavioral healthcare. For
the most part his health insurance has been affordable. We would like to than BND for their help with
Buster’s cataract surgery and his retinal re-attachment. Then in 2021 he incurred some unexpected and
unusual costs about his Dermatological and Dental needs. If it were not for the 2021 stimulus monies
he would not have been able to afford his treatments from these specialists that
were deemed medically necessary. Buster’s
representative payee indicates that we are running short on money. We do not expect any more stimulus
monies. Without money we cannot guarantee
keeping promises in our BND service agreement about following doctors’ orders. This especially holds true with respect to Buster’s
dental work. Dental alone last year
generated co-payments greater than $1500.00.
For Buster fifteen hundred dollars ($1500.00) was not affordable. Plus when other people got to do something
cool with their stimulus monies Buster lost his in out-of-pocket medical
expenses.
Resource Revisited – Brand New Day (BND) Cash off-sets
Annoyance - Health Foods Status
for February 2022
For the month of January 2022 the
usual $30.00 per month Health Foods subsidy from BND was deposited per their
promise on Buster’s charge card. There
was no deposit for February 2022. The
dropped Food Subsidy is just one more little annoyance this year.
CalOptima Rewards
Ever since we signed on with
Brand New Day as our health insurer in 2012 CalOptima has mailed Keith “Buster”
Torkelson materials as if he were insured with them. A few years back we asked our BND insurance
broker about CalOptima. He said ignore
them. CalOptima made good on their
promise for cash gifts about getting vaccinated.
CalOptima – Cash Subsidy with No Extra Effort
“…we are automatically processing you gift card(s)”
Figure – Message from CalOptima
CalOptima Rewards
For Buster we find it a priority to
get going on some insurance alternatives for 2022. CalOptima does things to stay on our
RADAR. An example of CalOptima working
behind the scenes they awarded Buster a total of $50.00 for his two initial
COVID vaccines. Buster did not have to
do anything other than get vaccinated.
When we were younger during the 1960s and 1970s when we could not afford
dental we went to a local dental “college”.
We still have yet to find this resource in the 2020s.
Shop Around
Ever since Buster settled for
complete disability back in 2006 when he agreed to be LPS conserved he has
shopped for medical insurance. At first
he was covered as an indigent with the Orange County Health Care Agency. After about one year the OCHCA graduated him
as a success. Buster knew nothing about
shopping for health insurance yet HICAP pulled through and helped him narrow
down the options. Initially he had
HealthNet and then Kaiser. Since 2012
Buster has had Universal Care Brand New Day.
Plan Comparisons
We have been tracking the way
Medicare rates health plans for years now.
For each plan that Medicare oversees they more often than not offer up their
CMS Stars scores. Buster has been with
his health plan, Brand New Day (BND), since 2012. During his tenure BND’s overall CMS Stars
score has moved from 3.0 Stars to 3.5 Stars.
In 2019 Medicare gave CalOptima OneCare 4.0 CMS Stars. With each’s' Stars report CMS offers a
breakdown including overall rating, health plan services and drug plan
services. We have already addressed
Buster drug plan. So now that Buster is
shopping around we think it prudent that CMS breaks out the dental plan. For 2021 we give BND’s dental plan, Liberty,
0.5 Star Equivalents. As things stand
for service year 2022 for which BND has chosen Delta Dental we expect no better
than 0.5 Star Equivalents even in the face of our advocacy work here and
elsewhere.
FYI – Brand New Day 2021
https://bndhmo.com/BrandNewDay/media/Enrollments/H0838_Part_D_Star_Rating_2021_template_1_english_10142020133314910.pdf
OneCare 2019 Medicare Star
Ratings – CalOptima
https://www.caloptima.org/~/media/Files/CalOptimaOrg/508/Members/OneCare/2019/2018-10_OneCareStarRating2019_E_508.ashx
FYI - 2021 Star Ratings - Brand New Day
Sample CMS Medicare Stars Report
https://bndhmo.com/BrandNewDay/media/Enrollments/H0838_Part_D_Star_Rating_2021_template_1_english_10142020133314910.pdf
Medically Necessary
Below we include a page on “Medi-Cal
Adult Dental Benefits”. Under the
section” “You have these services now” is listed “other medically necessary
dental services”. We feel that when a
dentist prescribes a treatment such as an extraction that those prescriptions
indicate Medical Necessity. Buster is
“Medi-Medi”. He should have affordable
dental care. Going back to Buster’s he
extraction fiasco: Buster was in such incredible pain that it was aggravating some
of his other medical conditions.
Additionally, the pain made it impossible to sleep a couple of
nights. For Buster not getting sleep
historically is associated with serious health complications. He considered calling
“911” and going to the ER a couple of times.
Exhibit - Medi-Cal
Other medically necessary services
Exhibit - Welcome Letter from Delta Dental
Dated: 12/29/2021
Delta Dental Fee Schedule
Metadata >
Legacy Annoyance
Back in 2017-2018 Brand New Day
went with Delta Dental. We had cause to
reference Delta’s benefits and copayments schedule while writing a report back
in 2017. It took over two (2) months for
Delta Dental to deliver on our need. In
2021 Liberty Dental when asked over the phone quickly delivered their
schedule. Now we are faced negotiating with
the not new and improved. Again, back in
2017 Buster was covered by Delta Dental.
He had an extraction and Delta covered a sufficient portion of the fees. In 2020 Buster had Delta Dental and almost no
dental fees were covered by Delta.
During 2020 Delta’s customer service was terrible. Via customer service it took way too long to
get their Schedule A of benefits and copayments. Now in 2022 Buster has called Delta’s
customer service three times to get his facility reverted back to his 2021
dental office. He was on hold each time
for ½ hour and hung up each time.
Looking back at our 2020 Delta fee (benefits and copayments) schedule it
looks like Buster’s dental in 2022 will be unaffordable.
Figure – Delta Dental Benefits 2018
Affordable Health Care – Page
As of 2022 it looks like Keith
“Buster” Torkelson’s health care premium is waved. Years ago Buster was fortunately enough to
qualify for SSDI. For 2022 Buster
expects a monthly check of just about $1500.00.
About Buster's income: At $15.00 per hour that would equate to 100 hours
of work or 25 hours working per week. Adjusted
for full-time or 160 hours per month = $1500.00 DIV 160 $9.375 per hour. At $10.00 nobody living in Orange County
California could afford health care with out-of-pocket expenses.
FYI - Understanding Obamacare
Subsidies and Eligibility (eHealth)
https://www.ehealthinsurance.com/resources/affordable-care-act/aca-obamacare-subsidies
Everything to Know About
Obamacare (ACA) Subsidies
By Davalon Updated on January 21,
2022
What is the definition of
affordable health care?
“Individual coverage: For an
individual, coverage is considered “affordable” if the cost of the individual's
coverage does not exceed 8 percent* of the individual's household income.
Individuals are exempt from the individual penalty if coverage is unaffordable.”
Obamacare Calculation - Subsidy
Eligibility (8% = 0.08)
Payment and Co-payment
Last year 2021 was one of Buster’s worst years with
out-of-pocket expenses on healthcare.
Buster’s monthly SSDI check is approximately $1500.00. This $1500.00 per month is Buster’s household
income. This makes his yearly income
around $18000.00. As with most people
the majority of Buster’s income is spend on unaffordable rent. In general when talking about affordable
healthcare they are talking about the premium rather than services. The Obama Calculation indicates that Buster’s
monthly premium for healthcare should be $124.26 or less. Buster’s monthly healthcare premium is less
than $124.26. Therefore his healthcare
might be considered affordable. Again, due
to out-of-pocket expenses such as co-pays Buster’s healthcare was not
affordable in 2021. If nothing is done
to address Buster’s concern we predict healthcare will be problematic for 2022.
Shopping for Better Coverage
Up First CalOptima
Keith “Buster” Torkelson signed
on with his primary insurer Universal Care Brand New Day (BND) back in
2012. During that time he has been
solicited by CalOptima to move over. In
2021 CalOptima gave Buster two $25.00 gifts for completing his COVID
vaccines. His insurance agent says to
stay away from CalOptima. For 2022
Buster’s dental plan with BND is Delta Dental.
Delta Dental has a specific plan for BND they call BND Delta
Dental. We check and it looks like
CalOptima goes with Delta Dental. Yet,
CalOptima Delta Dental may be superior to BND Delta Dental. On various documents such as referrals
generated by the BND associated primary care clinic they list CalOptima as the
secondary insurer.
FYI - HealthCare.gov
Get 2022 health coverage
https://www.healthcare.gov/
Official site of Affordable Care
Act
It turns out for most most of Buster’s
healthcare during 2021 that it was affordable.
For example Buster’s routine monthly lab work, monthly medication and
periodic eye care were affordable. For
2021 both his Dermatology and Dental were not affordable. On behalf of Buster as well as others we commit
to investigating some alternate plans and pricing. This may require contacting “Rick” Buster’s Brand
New Day (BND) insurance broker. There is
a chance that his BND broker is retired.
FYI - Get Coverage page: https://www.healthcare.gov/get-coverage : For service year 2022 and down the line we hope to
save money on health costs. Actually we
have to save money else we may have to pick and choose from the list of
medically necessary procedures and services as prescribed by Buster’s doctors
and dentists.
FYI: https://www.coveredca.com/
Poverty – Cost of Orange County
As of December 2021 the Orange
County Health Care Agency (OCHCA) has a new Deputy Director. Her name is Veronica Kelley. She oversees OCHCA Behavioral Health
Services. Last month (February 2022)
“Ronnie” as she prefers to be called stated in a Zoom meeting that living in
Orange County is Exorbitant. Buster
lives in Orange County and only has enough money each month to meet his basic and
necessary needs. Even though he feels impoverished
he does not appear to be in poverty. We
found that the Federal Poverty Level (FPL) for is around $12,880 per year for
an individual. We found that figure for
2021 on the ASPE website below.
For those interested in the study of poverty…
FYI - 2021 Poverty Guidelines | ASPE - HHS.gov
https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references/2021-poverty-guidelines
FYI - HHS Poverty Guidelines for 2021
The 2021 poverty guidelines are in effect as of January 13,
2021
Federal Register Notice, February 1, 2021 - Full text
https://www.federalregister.gov/documents/2021/02/01/2021-01969/annual-update-of-the-hhs-poverty-guidelines
Summary
Our primary concern for 2022 is
affordable dental care. Keith “Buster”
Torkelson’s routine yearly dental exam is coming up. With the new (old) dental plan, Liberty
Dental, we hope for little or no out-of-pocket expenses. If there is going to be a copay or overt
charge we should be informed up front. In
other words we strongly recommend no billings after the fact. We would prefer any problems with Buster’s teeth
caught in the routine examination. We
are going to shop around for both: Better overall insurance to replace Brand
New Day targeting affordable dental. If
need be we would prefer securing something like “Extra Help”. Remember Buster as well and many other older
adults live on a fixed income. For the
most part Buster spends all of his monthly “Check” on the necessities of life
such as rent and food. Buster used
stimulus monies to pay for his healthcare in 2021. Buster cannot afford his health care as he
did in 2021.
