The Underbelly of Healthcare Reform
I’ve said it before and I’ll say it again – the devil’s in the details. That statement particularly (and painfully) applies to January of 2014 – the year the healthcare system in this country has, apparently, imploded, collapsing in on itself from the weight of red tape, poor communication, too many cooks and too little information. We’re buried under a heap of complexity that, I’m not afraid to admit, I find terrifying.
I’m going to share what I’ve learned in the last few weeks (months) in the hope that it will help someone else navigate this mine field of beaurocracy and avoid blowing their own foot off the way I did.
I’m one of those people that had an insurance plan that was not supported by Obamacare because it didn’t provide the full amount of coverage required under the law. That’s because I’m self-employed and I (previously) purchased my insurance through a broker. The plan was fairly comprehensive, but it had a very high deductible ($9000 for the year), but after that deductible was met, just about everything was covered (well, after we hit a $10,000 out of pocket maximum). Even so, 10K is a bargain when you’re facing a major health issue like Ana had – cancer and transplants mark the top of the list of “complex medical conditions.”
I could have continued on with a very similar plan in 2014, but it would’ve cost me twice as much for my monthly premium (an increase of $500 to $1047) and the deductible would’ve been $10,000 and the out of pocket maximum would’ve been $12,700. I was told by my broker that this increase was due to the new benefits required by Obamacare which necessitated the increased premiums.
So, if I’d stuck with my comparable plan with CDPHP, my annual cost for health insurance would have jumped from $16,000 in 2013 to $25,000. This is not through the Exchange, by the way, it wouldve been through my broker. So, after picking my eyeballs up off the floor, I logged into the exchange and signed the girls up for Child Health Plus – the NY State subsidized health insurance plan that many of you are probably familiar with. If you’re not familiar with it – basically, anyone in NY with kids can sign up for this plan and depending on your income you pay zero to $60 per kid per month for extremely comprehensive health coverage. We are at the upper end of the income spectrum so we pay $45/month per kid.
I didn’t even know we qualified for Child Health Plus. It was only because the health exchange existed that I learned about this (it was an option when I started researching insurance plans). Child health plus could’ve saved my family $20,000 in out of pocket expenses if I’d known we qualified. That’s how much we paid over the past two years on my old plan due to Ana’s illness. But what’s done is done and…yeah…moving on.
I signed them up back in October with CDPHP. Just about all the major NY state insurance companies participate in Child Health Plus, so I actually had my pick but I selected CDPHP because they had been covering Ana’s care all this time. They are the ones who made us go to Columbia when we wanted to keep her at Westchester for transplant. There was no obvious reason why they wouldn’t continue to cover her treatment at Columbia under the new plan. No OBVIOUS reason – nope – but I still called CDPHP back in October/November and asked them about this because Columbia is technically out of network for CDPHP – the only reason they covered everything is because Ana had a liver transplant and there are a select few hospitals where this procedure is approved by CDPHP. The person I spoke with on the phone said everything would need to be re-authorized, but it would be fine.
I shouldn’t have believed her. NEVER believe anyone at an insurance company who is confident and happy even when there is doubt gnawing at your gut.
Eagle-eyed readers may have noted that I said Child Health Plus is an HMO. Herein lies the problem. My old plan was a PPO and they pretty much let you go anywhere, even to out of network providers, as long as you can prove medical necessity (e.g., continuity of care, there are no comparable providers for a given service, etc.) But HMO’s are not as accomodating – not by a long shot. I learned this LAST WEEK, after days of trying to get an MRI authorized for Ana at Columbia Presbyterian. CDPHP refused to approve this authorization and instead authorized Ana to have the procedure at Benedictine!
After over an hour on the phone with CDPHP, the rep finally told me that it was probably a good idea for me to switch insurance companies if I wanted Ana to continue receiving care at Columbia. WTF?
“But CDPHP MADE us go to Columbia in the first place for the transplant” I said desperately.
“Yes, but each plan is different. There’s no guarantee that the same providers will be covered by the same insurance company if you switch to a different plan,” She replied calmly.
“How the fuck am I supposed to know that?” I said (in my head) but really I did know that, which is why I called and asked if switching would be a problem. My mistake was not double checking the provider network on CDPHP’s web site (and even if I’d done that, it probably wouldn’t have hit me that I needed to switch. Why not? Because I had a PPO with CDPHP and they use Magnacare for their extended provider network – this includes hospitals in the city. I’m (guessing) that the HMO doesn’t use this extended network which is why it’s January 12th and I’m shit out of luck.
Right about now my friend Tanyia T. who knows everything and then some about health insurance is shaking her head and mumbling, “I could’ve told you all of this,” under her breath. She has two kids who’ve both had multiple surgeries and understand the complexities of HMOs versus PPOs – I remember having a conversation with her about it years ago. Tanyia – I should’ve called you! But anyway…
I spent another hour on the phone with:
1) the healthcare exchange. Question: is it possible to switch to a different insurance provider under Child Health Plus now that I’m already enrolled in CDPHP?) Answer – yes it is and it’s damned easy to switch – just the click of a button
2) Empire BC/BS – I spoke with a very helpful rep who confirmed that Columbia, NYU, Westchester Medical Center, Dr. Denno and Dr. Hochberg (Ana’s oncologist) are all in network which is important because Child Health Plus is an HMO. I then explained the situation to the rep and said I needed coverage as of February 1st – she gave me an address to mail the check to immediately (e.g., before they invoice me for the premiums). Note that this address differed from the one provided by the NYS exchange’s site! The rep said that there’s been a lot of confusion with the referrals from the exchange and this was the best way to get my check there quickly.
3) CDPHP again – so they could transfer Ana’s MRI authorization to Ulster Medical & Surgical Specialists (the MRI place in Kingston) – this is a place she’s already gone to for an MRI so at least they have her records. Dr. Martinez doesn’t want Ana getting MRI’s anywhere other than Columbia because the specialists there don’t like reading outside films (they don’t get paid for this). This is an incidence where an insurance company’s decision directly conflicts with a doctor’s
4) Ulster Med/Surg & Columbia – lots of back and forth calls to move the MRI to the new place, try to get Ana’s last MRI sent to the new place so the doctors there can compare the reports, get the script written so they know exactly what test to perform, and also connect with Dr. Denno’s office because they need to refer Ana to all specialists – even ones she’s seen before – since her insurance is now an HMO (an HMO will not approve any specialist visits without a referral from a primary care physician)
It was about four hours – maybe five – all total on Thursday. We’re left with CDPHP through January for the girls (the cards just arrived on Friday. Yay) and a nagging worry that if something happens that requires that Ana be hospitalized – we’ll probably have to take her to Albany or Vassar or whatever because CDPHP won’t cover Columbia. We’ll also likely need to reschedule a check she has with Dr. Martinez on January 27th – figuring that one out will require more calls next week.
I don’t think the above mess is entirely due to healthcare reform, although that definitely complicated matters. I felt like we couldn’t afford the same exact plan we had last year and had no other choice but to put the girls in the Child Health Plus program. This program has no deductibles, copays or coinsurance – everything in network is completely covered including medication (Ana’s medication ranges from $600 – $1000 per month). So, five hours on the phone is a small price to pay.
The confusion I experienced is something I wanted to share because I’m hoping it will help educate people on some of the questions to ask (e.g., is this an HMO? If not, do you cover out of network physicians? Can I switch to a different plan if my current insurance carrier doesn’t meet my needs?) I don’t think it’s possible to anticipate all of the crap that can go wrong – and I don’t mean to say that to be disheartening or negative. It’s just that the system is so completely complicated that even the the providers don’t know what ‘s covered and what isn’t!
This is the true underbelly of what’s going on right now and Obamacare is making an already tangled system, much more difficult to navigate. It’s short circuiting all over the place. My advice to EVERYONE involved is to resign yourself to lots of time on the phone trying to clear things up. Make sure you follow-up when you don’t hear back – even if someone says they’ll get back to you. This is true for every single player involved in this massive, ridiculous game (doctors offices, broker’s offices, the healthcare exchange itself, the insurance company, your company’s benefits coordinator). I do have hope that some things will smooth over once the initial confusion has died down and people are actually enrolled.
My fears are:
1) Once I start to use my health insurance, I will be denied for things I can’t anticipate that I’d be denied for
2) I won’t be able to find a doctor I like under my new plan (Jim and I have a different plan than the girls)
3) My chosen doctors will stop accepting my chosen insurance and I’ll be stuck going to some guy in Poughkeepsie or Albany who I hate and has a 4 month waiting list
4) I’ll be on the phone constantly trying to get approvals/authorizations for every little thing
Time will tell…This has been a public service (rant) announcement.