Wait did they not mail you the sticker before? PA has since at least like 2014. Your sticker is so much better though, ours suuuuucks

It differs by county bc we are a commonwealth so everything differs by county but my county uses this:

https://www.pmconline.org/sites/default/files/styles/full/public/2019-11/I voted sticker 2_0.jpg

suuuuucks

The problem is proprietary systems that are mandatory to interface with. I have chrome installed for these stupid bullshit situations and as a result it’s constantly so far out of date that I just end up having to reinstall it the once or twice a year I am forced to use it.

Government interfaces are the one I run into the most. I recently had to log into nppes, the us government database for updating information attached to the national provider identifier number for healthcare practitioners. Super important thing, literally necessary to bill every single insurance in America and to join basically any practice. Locked out of the site unless you use edge or chrome. Like scripting on the page that makes the page blanked out for any other browser (including older versions)

Similarly I just had to pay the local tax bill in my county and their website had the same deal although they also supported safari. The website is blocked out with Firefox and brave. Could get past that but the website still didn’t work right even trying all 3 of their “supported browsers” on 2 different computers and a vm. lmao except I still have to figure out how to pay my taxes

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You don’t

You have lived with diffuse boundaries for some time and are now reaping the penalties. You can and should proceed with care and grace as you implement boundaries and define roles to move to where you want to be but it is absolutely foolish to think that it will not be at least a little hurtful to your pseudo partner.

they will implement their boundaries in response to changes you are proposing; you have to respect these. If they chose to leave and tell you to fuck off then you have learned a valuable lesson in why you shouldn’t let boundaries be so diffuse for so long through so many changing contexts.

It’s not realistic (usually) to expect you to know everything you need and want from a relationship up front but when contexts change you need to clarify what is and is not okay. If you’re okay with keeping it casual after things don’t work out that’s fine but make sure they’re aware. If they suddenly have to move in consider the boundaries of the situation again: are they still cool with keeping it casual? Are they now that you share a bed? Are they now that you’ve purchased a bed together?

If you’re the one that wants it casual and wants the door open for new relationships it’s your responsibility to make sure your partner is aware of where you stand. One could say your friend/partner is foolish for assuming you’ve changed where you stand, and they’d have a valid point, but one could also say that you’ve been very misleading here. Boundaries need to be enforced and they need to be occasionally reviewed as contexts change, otherwise they fade away

Would be more impactful if it gave a sample size for the posts. An account that made one repost as its only post is 100% but imo not as convincing as one that made 12 and also has 100%.

Depends on the program. Diploma mills for graduate degrees absolutely exist but many are extremely competitive.

Clicker training is just paired stimulus to provide an easier and cheaper mode of reinforcement, training a behavior is separate

like you do the clicker training by associating a noise (or whatever) consistently with a positive stimulus. what stimuli you use to prepare depends on the learner as different stimuli have different potency depending on the learners preferences. eg you can say a blanket “I’ll use food” for your dog and for some dogs this is fine. mine certainly seems to be food indiscriminate with no serious preference and very few refused items. But even with that I still need to take care not to use the non preferred (he spits out lettuce and celery. otherwise literally anything gets him salivating)

but then to change a behavior you’re still relying on operant conditioning which would be something like upon exhibiting the desired behavior provide access to reinforcement consistently and then fade it out as the behavior strengthens. Operant conditioning is much more complex than this of course but this is a pretty standard jumping off point.

That said there are pros and cons to clicker training humans. This is something that is practiced and even has some evidence behind it. The clicker solves a lot of potential reinforcement issues: it’s far easier to deliver immediately (which matters a lot). But I worry about the potency loss translating a strong reinforcer to a clicker. If you pair it with a food you really love or something it will potentially be effective but never as effective as the food itself.

This is still potentially worthwhile as food reinforcers are often problematic (increasing caloric intake, often food reinforcers for people aren’t healthy options, promoting unhealthy eating habits) and reducing it to a click eliminates those issues. But if the behavior you’re trying to create is particularly difficult or aversive the reduction may mean the potency is no longer high enough to motivate.

Often this can be countered by making the behavior less complex and working up to it (eg instead of learning a complex task in its entirety breaking it down into more manageable chunks). In practice this may look like just initiating the task at first and providing reinforcement, then as comfort increases raising the bar for reinforcement. Eg I need to keep my room clean but I hate cleaning so to start out I provide reinforcement for just picking up one item/small area. But then when I do that consistently I raise the bar and now I have to pick up 2 areas. Etc. or you could approach as a tolerance thing, I start by cleaning for only 3 minutes and reinforcing, then 5, 7, 10, etc. numbers are arbitrary and depend on the learner. Approach depends on the learner too, the toleration approach makes more sense for most people but if you do a bad job cleaning and need to develop the skill of cleaning thoroughly the first can make more sense. Then reinforcement is not time based but quality based, Eg did you clean the area sufficiently even if it took you 8 minutes. Drawbacks and positives for every approach

And of course there’s the issue of delivering your own reinforcement. If you control access what’s to stop you from just taking the thing even though the behavior wasn’t exhibited. These strategies typically work better with external control of r+, but some people do have the self discipline to do it alone.

There’s a LOT more to conditioning and reinforcement but I’m getting bored of this lmao. Also you may notice I didn’t describe anything about punishment. That is intentional because it is generally at a much higher risk of creating adverse effects and some studies suggest it is not nearly as effective as reinforcement based strategies wrt general population (and some specialized populations)

I worked homeless outreach in a rural area. My job was to connect people to housing, assist with obtaining government benefits, and mental health services if necessary. They would spend the day at local hot spots, well trafficked convenience stores in the morning, well trafficked stores like the local grocery store for most of the rest of the day. A lot of them would hang out in the stores as long as possible to escape the heat/cold and many would also hit up strangers for money at these spots

They were often very hesitant or completely unwilling to share where they actually slept. Even though I worked for a nonprofit a lot of them saw me as a government employee and even the ones who didn’t still were very hesitant to trust me or any of my coworkers with that info. I’m pretty sure they were scared that I would call the cops or something. Some slept in wooded areas, some slept behind stores, some couch surfed, etc from the ones who did share and who I found (part of my job was being the point of contact for police and other emergency services who found people staying outside in dangerous weather and getting them emergency housing).

Even though it was probably like 2013 or so that I did this job the absolute cheapest room that would rent to the homeless was $700/mo. There were cheaper rooms around but they tended to require big deposits and would often refuse to rent to someone that didn’t already have a permanent address. I’m pretty sure that’s illegal but they would get around it usually by being vague and ghosting. “Oh so sorry someone else got the room”, stuff like that, and you’d see it was still available for 3 more months. I can’t even imagine what the rent is like now

Super depressing job. It’s very difficult to escape that cycle once you’re in it. It radicalized me a lot to work with people who were literally left on the street in a town with hundreds of vacant apartments. By our estimate there were maybe 20-40 homeless people in said town at any given point

There’s evidence that trigger warnings actually worsen anxiety and are counterproductive

The way to treat anxiety is to face the source of anxiety to try and change your relationship and reaction. The best way to do this is via controlled access that exposes one to the trigger gradually in a context that has no risk of harm (eg a media depiction, discussing the concept, building up to discussing the source of trauma that led to the phobic response if applicable)

Trigger warnings enable active avoidance. This sensitizes one to the aversive stimuli and makes the phobic response stronger. As a result when one encounters the stimulus (eg a friend, family, celebrity etc commits suicide, suffers an eating disorder, etc) your resilience to the trigger is now even lower and the response is more likely to be more significant than it was before.

That said education on access to resources like 988 or other warm lines can lower suicide rates, maybe. Research is more mixed here because it’s difficult to prove causation

The important takeaway from this is that “supplements” have 0 oversight. The CBD, probiotics, vitamin d, etc that you buy could just be capsules of vegetable oil that does nothing at all. Or they could be asbestos and cyanide for all you know (that probably would lead to an investigation though). There’s also no safety regarding packing and handling, so it might literally be a guy with unwashed hands who just picked his butt loading your gelcaps in a dirty bathroom that someone just took a massive shit in. No one checks and verifies any of this and that’s why shills and hucksters jump onto this shit, it’s a completely unregulated market where can cut corners everywhere and say whatever you want as long as you include *not intended to treat any diseases and not evaluated by the fda

A $1200 thing you buy on instagram that sends “good waves” to your brain? Supplement. The cbd you buy at the gas station? Supplement. Doterra oils? Supplement. No regulation, no oversight, just robbing people based on their desperation to fix chronic pain and mental illness

Then if you’ve met your deductible the big question is if you have a coinsurance after the deductible is met and an out of pocket maximum.

If your coinsurance is 60% or 80% or whatever, you won’t be responsible for the full bill but only that percentage of it.

If you have no coinsurance (a no charge after deductible plan) the service should be covered 100%

If you have coinsurance you should have an out of pocket max, which once hit should end the coinsurance and make services covered 100%. OOP max is typically quite a bit higher than deductible, sometimes 5-7x as much, but not always. It’s plan specific.

If your employer pays 50% that is an arrangement they have worked out and the specifics will be tied to your companies contract. This could mean they would pay 50% of any bill (unlikely as this is not a fixed cost they can plan for. Maybe if you’re like a ceo or some shit) or it could mean that up to your deductible they’ll pay 50%.

Also keep in mind even if you’re in a “covered 100%” scenario there are some instances in which you would still get billed:

Differential vs contracted rates - if the hospital charges $5000 for your procedure but your insurance only pays $4600 the hospital can sometimes bill you for the difference. This is not always the case; some contracts require the servicer (doctor) to accept the contracted rates and not charge more. Most common reason you’d get a bill in the above 100% scenarios and also the reason the math might not work out in coinsurance scenarios. Eg in the above surgery example your bill would probably be $1320. It should be 920 as that is 20% of the $4600 paid, or even $1000 as that is 20% of the 5k billed, but you pay the 920 as 20% of what your insurance paid plus the $400 difference, so $1320

Out of network providers - these can often have a separate deductible and sometimes in hospitals a provider can be out of network even though the hospital itself is in network

Non covered services - if the procedure involves a service that isn’t covered (uncommon)

Billing errors: if a bill looks wrong contest it and if your insurance isn’t reimbursing providers properly complain to them. Sometimes a medical office gets your info wrong and assumes your deductible or coinsurance is active when it shouldn’t be. Sometimes your insurance makes similar mistakes.

one of the most frustrating aspects of being a therapist in america in the past 10 years is the hand waving of the ethics involved in the financial renumeration of our relationship with those we serve

I would say a significant stressor for the overwhelming majority of the clients I have is financial woes. And because the system is backwards, those with high paying jobs well into their career tend to have the fancy PPO plans with no deductible where seeing me (or anyone) is only $10 despite the fact that they could much more easily afford a 5-10k deductible. Meanwhile the people who are making 20-50k a year on the other end of the spectrum almost always have those high deductible plans with sometimes massive deductibles and rarely have employer funded hsa.

I’m not an idiot, I run my own practice and I do the books for it. I can do the math to figure out how much take home pay someone has with those salaries. I can also conceptualize the cost of housing, food, phone, transportation, etc because I am also paying these things. So when I meet someone here and their appointments are $140 per meeting I am in a tough spot. I am asking them to take on a burden of $560 per month (assuming weekly sessions). That’s immense. And if the deductible is 5k, 7.5k, 10k, it will take ages to meet especially if they’re younger and not really making contact with many other medical providers.

I am contractually obligated to charge what your insurance pays me in these instances. If your insurance pays me $140 for the hour I have to charge you that until you hit the deductible. I could be dropped from the network if I modify this for you and get caught.

I can ask you to skip using your insurance and charge a lower out of pocket rate but this is complex. For one, many therapists can’t adjust their rate much lower. I have flexibility here because my practice is entirely telehealth so my overheads are much lower. But if you see them in an office? They are paying about 40-50% of that just in rent most places.

Additionally even with telehealth I have to be careful with adjusting rates. Insurance only pays me for specific timed and coded sessions. If you and I have a phone call for 25 minutes? Not covered. If you ask me to collaborate with your psychiatrist and I talk to them for 40 minutes? Not covered. The time I spend dealing with billing and this system, which works out to an average of 20-30 minutes per session? Not covered. So the 25% of my week doing billing shit and the overtime hours doing phone check ins, case collabs, etc. has to be covered by that.

This is why many therapists give fee schedules and charge you for all of these things. If you want paperwork from them it’s $1 a page, phone calls are $75/hr, etc. I can make it work without this because I’m not paying for office space but if I was I would need to do this to keep myself afloat.

This is also part of why many, many therapists simply don’t take insurance anymore. Just pay me the $140 directly. I can collect it via square or whatever and your billing is done. I no longer spend 5-10 hours a week on billing nonsense like fighting retracted payments, finding out why claims were denied, etc. You can submit receipts for out of network reimbursement and you deal with them.

I understand why my peers do what they do. But ethically it’s a mess. I signed up to help people and what I have become is a gigantic cash sink that puts a tremendous amount of pressure on the people I serve and is counterproductive to our work.

At the same time I deserve a fair salary for my work and this is the only way to get it. And if I protest the system by leaving it because it’s so broken then the end result is that there’s 1 less mental health provider who takes insurance. If I stop taking insurance altogether I alienate a ton of people with high need who can’t afford to pay out of pocket forever and/or don’t know how to navigate out of network reimbursement.

I cannot tell you how many times I do a screening call with someone and they say “this sounds like what I need”, they tentatively schedule, and then once I run their insurance and give them the actual numbers of what treatment will cost they simply ghost. It is a system that actively deters people from seeking assistance because it is so cost prohibitive

And the insurance lobby has its fingers so deep into the framework of america that this will simply never be fixed. It will only be changed. Look at Kamala Harris’ proposed Medicare for all: it still allows private plans. That will be a movement in the right direction because it will end the idea of someone being “uninsured”, which is great, but it will also create a two lane system in which many practitioners will do whatever they can to avoid taking basic Medicare patients in favor of the commercial plans. Commercial plans, at least in my area, simply pay more. Significantly more. Like $80/hr vs $140/hr. And in the end I will have the same problems because the unnecessarily complex private insurance system will still exist and be very powerful. I will just have one more insurer to add to the web of complexity. But no politician will ever remove the private health insurance industry. To do so would alleviate so much spending waste, so many wasted administrative dollars and man hours, but it would also result in layoffs of hundreds of thousands, if not millions, of americans whose jobs rely on processing the complex bullshit of this system

Speed or mallrats depending on what kind of vibe you’re going for

edit: upon reflection I will change my Sandra bullock movie to “the net”. Terrible, but strong 90s vibes

your scenario is either worded incorrectly or very atypical (which is very possible, there are a lot of different insurance plans in the us

typically high deductible plans work in a way of “meet your deductible and then we cover x% after that”

eg I am a therapist, I bill your insurance $100 for an hour session. You have a $1000 deductible with 80% coinsurance.

Our first 10 sessions will cost you $100 out of pocket, which goes to me directly. I submit billing for these sessions but get no reimbursement from the insurer because you have already paid the full amount. However, my submission of billing indicates to the insurer that you paid $100 for a medical service on whatever date for whatever diagnosis.

After the $1000 deductible is met your insurance splits the bill with you 80/20. Now you pay me $20 per meeting and when I submit the billing the insurance (hopefully) pays the other $80 to give me the $100 per meeting I am owed.

This of course assumes no other medical spending goes on for the duration, otherwise you would hit your deductible faster. If you saw me 3x and then had a surgery that cost $5,000, you’d pay $700 for the surgery to settle your deductible plus an additional $860 (20% of the remaining $4300) and then sessions would be $20 under the 20% coinsurance.

You should also have an out of pocket max, this is kind of similar to a deductible but it is different. This is a tally of your total spending and once you hit it your coinsurance usually drops and you pay nothing.

Also important point is that deductibles reset every plan year. This should have been made abundantly clear to you but I still encounter many who do not know this

Additionally your insurance may have certain services covered that don’t cost you anything or where the deductible doesn’t apply (eg you’d only pay 20% even if it’s the first appointment of the year). Typically this is preventative care, things like physicals and vaccinations

That is the most typical. But like I said it there are many plans and variations. It’s possible you have a plan that prior to meeting the deductible you pay 50% of billing and then have a 0% coinsurance. This would be really great insurance.

It’s also possible that you have a benefits package from your employer that is basically paying 50% of your deductible in a roundabout way. this is far more commonly done by the employer funding an hsa/fsa account which would be a payment card that you use on medical spending and not the insurer. However, I have encountered plans where the hsa and insurance were rolled together and joint companies, where the hsa would pay all or part of billing prior to deductible on the patients behalf

Using the same examples above you’d pay me $50 until you met your deductible, then nothing once the deductible is met. If you had a $1000 deductible, saw me twice, then had the 5k surgery you’d pay me $100 and $900 for the surgery. If you have one of the situations where the employer is covering 50% of the deductible it would be the same but the surgery would be $400 because ultimately you’re only paying $500 of the $1000 deductible and your employer is covering the other half. This is not a situation I’ve ever encountered

Another important point is that deductible status is dependent on your providers doing timely billing and your insurance processing said billing in a timely manner as well. This does not always happen. As a result you may meet your deductible but my billing verification shows that is not the case. The examples I used above were clean and easy but it’s never that simple. Most people have a deductible around $2500 (and many 2-4x this) and see several different healthcare services.

I submit my billing at the end of each day but some places are sloppy and will take weeks to submit. This can lead to situations where you are charged money because I was under the impression you had a deductible but you should not have been. Eventually the insurer will pay me once things sort out. If I am good at record keeping (I am great at it for this reason) I will catch the double payment and send you a refund. This is why it is important for you to keep track of deductibles and medical spending. Not all offices are managed well. I’ve personally had money stolen from me (because this is literally fraud, to not refund the double payment) and I don’t believe it was ever intentional, just offices with shitty management. Let your providers know if you’ve met your deductible. I will always hold off on charging you if you tell me this, submit billing, and see what the insurance reimburses. If they reimburse me in full then you were right. If they don’t I send you a bill and if that is incorrect you need to call your insurance to complain

You should be able to track deductible and out of pocket spending on your insurances consumer portal (eg go to Aetna.com or whatever and click “for subscribers” and make an account, if you haven’t already). This should also give you an explanation of plan details.

Most importantly you should be able to call the office of the place (or billing dept if it’s a larger health network) doing the procedure to have their office manager check what you will be expected to pay for the procedure both at time of service and expected cost total. This takes only a minute but be forewarned it is essentially an estimate and not a guarantee. Billing can change last minute depending on how the procedure goes (eg added complexity allowing them to add another cpt code for something)

There’s a lot more to it than this unfortunately. Some plans have tiered deductibles, sometimes a staff member in a hospital isn’t personally enrolled and then are considered “out of network”, which is a whole other thing, sometimes you are still responsible for a certain services that the provider requires but the insurance refuses to pay. That last point especially: every time you establish with a medical office or get a procedure you sign something that says you are financially responsible for services not covered by insurance (I guarantee this, every time). So if you get bloodwork with like 30 tests and 2 aren’t covered even if you’ve met your out of pocket max and have the best insurance in the world you’re getting a bill (and potentially a hefty one, some blood tests are extremely expensive)

Sorry this is very long and complex but that is kind of how insurance is? To boil it down to a “eli5” 2-3 sentence explanation would either require your specific plan information in much more detail or to overgeneralize and potentially mislead you.

You’re both wrong for speaking in absolutes. It could be pica but it’s impossible to fully assess such a situation based on a literal sentence description, you would need to know the context, frequency of behavior, occurrence with other items (eg is it solely soil). It could be soil eaten out of desperation to alleviate symptoms related to iron deficiency but again, impossible to know from a single sentence but a child eating soil would be grounds to evaluate for pica unless the child was specifically instructed or something (eg folk medicine)

brought to you by someone who spent 5 years doing neurodevelopmental evals of autism and intellectual disability in children, where pica came up a decent amount of the time (especially for the kids with ID)

There’s a theory that says this is the case (I can’t remember the name) but if it was accurate it’s probably been thoroughly destroyed by the modern diet which is laden with foods that push reward cravings (like excessive carbohydrates)

A cheap beginner bass guitar. I was like man will I play bass even? I’m a drummer mainly but I also play a decent amount of piano bc my main drum things are drum set and marimba and I played synth for 1 season in drum corp. I got a bass because I wanted to actually try playing bass parts for songs instead of clicking them in. It does sound better (well, eventually it did) but it’s just really fun to play. Like I had also bought a $100 used guitar and I just find playing that a chore. I can play a few songs but I’m a permanent beginner and have no real interest in growing. The bass though? I play that like an hour a day and it’s actually cutting into my drum and piano time

This exists, kind of

There’s bonded connections in several senses

Bonded ports but this doesn’t increase throughput in the way you’re thinking. eg if I bond 2 1 gigabit Ethernet ports I can’t connect at 2 gigabits, I can connect 2 users at up to one gigabit each (or several users totaling 2 gigabits but no 1 user at more than 1 gigabit)

bonding routers can take two internet connections and combine them, which is closer to what you are probably imagining. They combine throughput, eg a 100mbit connection and a 100mbit connection become a 200mbit connection although realistically it’s not that perfect and you have to get the right services for it, not just any connection will work, it’s a rabbit hole and generally much slower and worse latency than if you just got a traditional connection. Think people using starlink and 5g internet in rural settings

There’s also something called speedify, which is software that claims to do the above in software alone, bonds two connections to combine throughput. Never tried it, reviews are mixed. Some say it works, some say it’s spotty, some say you only get the speed of the one connection, etc.

heating built in. They make the kind that have mixing but as you said the hot water is contingent on your homes supply. In my house that’s like 90-120 seconds and that is a lot of time and wasted water for bidet usage. Plus I have a vanity instead of a pedestal sink so running the hot water line would’ve meant I had to cut a hole in the vanity and get a pretty long line.

this one was a decent bit more expensive but circumvents those issues. It also adds some features like a heated seated, a blow dryer to dry you when you’re done, and nozzle adjustment to make sure you get the right spot. Downside of this is that it needs electricity but I was much more comfortable running a new gfi outlet to the toilet than I was tapping the hot water line of the sink and cutting the vanity (or running a more permanent hot water line). Outside of the outlet the install is simple, install the mount the same way would any toilet seat, slide the seat into the mount (the seat can pop out of the mount with a button so you can clean it easier, which is nice), turn the water off and drain the lines, install a t adapter, reconnect the lines to tank and seat, turn on water, check for leaks, plug into power, done

It’s definitely some bougie shit but I don’t care, I love it. I got an open box and saved about $225 (mine is a toto washlet, I paid about $275). I’ve had it for about 5 years and it’s been perfect, reviews suggest they’re bulletproof and I plan to use it basically forever. there are more brands now though that are significantly cheaper with the same exact features though but not as clear as to whether they will last as long. toto is built super solid but I don’t know if it’s worth the price premium over some of the chinese brands that have popped up on ebay and amazon

bidet with warm water hookup. the toilet seat kind, I don’t have the space for a whole extra thing