Day Twenty Four: Health Insurance & Obamacare

I just got rejected for health insurance.

And then burst into tears.

And then got real angry.

I have lived in a bubble my whole life. I was ensconced in the warm glow of taken-for-granted-insurance: first, I was nestled inside my parents’ plan. Then, it was gently transferred to my plan as a college and graduate student. Seamlessly, I got my own health care through the Dept of Education in NYC upon leaving graduate school – always with the safety net of my mother’s insurance to catch me, should there be any problems. When I stopped teaching I was covered immediately by my new job with Bard College, never missing a day or a beat. I never had to really choose a plan, research them, worry about it. And I always knew that I would pay out of pocket if needed. For emergencies I went to my mother’s doctor if I couldn’t get an appointment with someone in-network. The specialists I went to were refered by friends and my other doctors, not by the insurance company. While I covered my rent, bills, fun, life, my mother helped to pay medical expenses if & when I couldn’t afford them.Yes, it became expensive at times – but we reasoned that it was worth it. It’s health, after all.

This October, I realized that I needed to figure out how to get my own insurance, because I was going to be self-employed starting January 1st, with no coverage unless I did some learnin’ right quick.

Husband and I, bunkered in our home for the impending doom of Sandy, decided that this was a good time to educate ourselves around insurance policies. Well, let me rephrase that – I wanted to call an insurance broker, have them tell us which plans would be best, and then choose the best coverage for the best price. Husband wanted to thoroughly understand all the components of the plans, what they meant, how they differed. I whined and groaned and walked around like a dishelved muppet, swinging my floppy arms around dramatically and wailing, “whyyyyy?????? that’s what insurance brokers are forrrrrrr.” But his reason prevailed, and boy am I glad it did.

Behold – the Ignoramus’ Guide to Health Insurance!

Types of Plans:

  • PPO – You can choose who you want to go to for your primary care physician (benefit: choice)
  • HMO – Plan chooses for you (benefit: cheaper)

Components of Plans:

  • Premium: The amount you pay per month. This is inversely proportional to your deductible.
  • Co-Pay: The flat fee you pay for designated common services – in-network doctors, drugs, etc.
  • Deductible: The amount that you pay out of pocket for “special” services , starting Day One (ex: hospital stays, tests, brand name drugs, xrays, specialists, procedures). Once you hit the deductible wall, you enter Co-Insurance Land.
  • Co-insurance: A percent (usually 20%) you pay for “special” services, once the deductible is met. You are in the purgatory of Co-Insurance Land until you hit the Out of Pocket Maximum wall.
  • Out of Pocket Maximum: The ceiling that you will have to pay (between working to meet your deductible & co-insurance); once you hit this ceiling, the insurance company will pay 100% of all costs incurred beyond that amount.

Your co-insurance is different from your co-pay. This was news to me.

I picture this process as walking through three different lands, each with its own set of rules and “benefits.” For your pleasure, here is an illustration of my feeble understanding of insurance.

Insurance Chart

Another learning for me was what is necessary to ask about when you’re signing up for an insurance plan. For example, I didn’t know that it can be near impossible to get insurance with maternity coverage if you’re already pregnant, so if you’re thinking of having children within the next century, get a plan now that has maternity coverage so you don’t have to worry about it.

Here are some other things I think are important to think about and ask:

1.) Which works better for you – a PPO, or an HMO?

2.) Which works better for you – a low deductible/high premium, or a high deductible/low premium?

3.) Is mental health care coverage a must for you? This deeply narrows down your selection, but is very important to consider.

4.) When you’re looking at a plan, ask which benefits start from DAY ONE of the program, and which don’t. Some benefits don’t start until you have met your deductible, meaning that you have to go to months’ worth of appointments, and spend thousands of dollars, before those bad boys kick in.

3.) What exactly counts towards meeting the deductible? You might think that anything you spend out-of-pocket counts, but for some plans that wasn’t true. So then you’d be spending, without even moving towards the target of the deductible.

4.) What is the out-of-pocket maximum?

Equipped with all this knowledge, I got on the phone with an insurance company, and spent four hours discussing my medical history, my medical costs, my priorities, my plans for the future. It was rather intimate – and very long. Finally, she helped me whittle it down to a plan that sounded perfect for me: Low monthly premium, higher-but-reasonable deductible, I had good coverage from day one, a vision plan could be attached. Perfect! Only problem was I wanted it to start Jan 1 and it was Oct 28th when I called, so I would have to phone again in a month, because I couldn’t sign up more than 60 days ahead of time.

Now that it’s late and I’m starting to panic (I see to always vacillate between absurdly far ahead of time, and last minute), I just called them back .

“Hi there; I spoke with one of your agents back in October and would like to sign up for a plan with you that she told me about.”

“Sure, ma’am, I’d be glad to help. I’ll just be asking you a few questions and we’ll get you all setup.”

“Great.”

This wasn’t so bad.

“Now ma’am, do you have any pre-existing conditions?”

I’d already reviewed their online lists of these, and talked about it with the other agent. I was good to go.

“Nope.”

“Do you take any medication?”

“Yes.”

“What do you take, ma’am?”

“Lialda.”

“And what is that for?”

“Ulceratie Colitis.”

“OK ma’am give me one minute, I’m just going to look something up.”

“OK.”

Hold music. I looked at the television, and took a sip of coffee. Scratched an itch. Saw the puppies staring up at me from the base of my stool, and pet them each on the head. I looked at my computer screen, where I’d pulled up the word document I used to take notes on the plan in October. Still on hold. This was taking too long.

“I’m sorry ma’am, but we can’t provide you with coverage at this time. ”

I gagged on my coffee.

“Excuse me?”

“You have a pre-existing condition.”

“But I looked at your website and I don’t have any of the pre-exisiting conditions you listed.”

“Ulcerative Colitis is a pre-existing condition.”

“But it isn’t mentioned on the list where you list all pre-existing conditions.”

“I’m sorry ma’am, Ulcerative Colitis is a pre-existing condition.”

“But I spoke with someone from your company for 4 hours a few weeks ago and told her I have UC, and she said it didn’t count. And it’s not listed on your pre-existing conditions list. But now – ”

“I’m sorry ma’am, Ulcerative Colitis is a pre-existing condition.”

“I heard you. But what I’m saying is – ”

“Ma’am, I’m sorry, Ulcerative Colitis is a pre-existing condition.”

I was obviously getting nowhere with this cyborg. And her total lack of humanity was making me get teary with frustration. I gulped the lump in my throat.

“So now what?”

“We cannot offer you coverage at this time.”

“I understand that. But now what? That’s it, there are no options? This is ridiculous!”

“Well ma’am, we have partners who provide coverage for people with pre-existing conditions.”

“Who are these partners?”

“Aetna, Signa, HealthFirst – hold on, let me check.”

Hold music. Face is hot. Fingers are shaking.

“Actually ma’am none of our partners provide coverage for people with your pre-existing condition.”

“This is outrageous. I spoke with someone from your company for four hours, and told her – ”

“Ma’am, I’m sorry, Ulcerative Colitis is a pre-existing condition. We cannot offer you coverage at this time.”

Click.

I stared at the phone in my hand – hung up on, shaken up, outraged. I felt furious, helpless, and scared. Now what was I going to do? How could they do this to me? What if nobody would give me insurance?

After a tearful call to my aunt, I realized that there must be some recourse. Time to snap into fix-it-mode. I decided to phone up the Pennsylvania version of the insurance provider I have from New York – Independence Blue Cross – to find out about rolling over my plan. Luckily there is a Guaranteed Enrollment Plan they offer to those of us riddled with diseases, so I was able to sign up for that one; I’m still waiting to hear that the paperwork has been confirmed, but it was such a huge relief to know it existed, speak to a human being, and not feel like a leper. I am able to get practically  the same coverage for (2x) higher premium than the other plan would have offered. It’s a lot of money to shell out each month on insurance, but it’s better than getting hit by a car and hit again with tens of thousands of dollars’ worth of hospital bills, or just shelling out of pocket for all my regular care.

Now that I wasn’t going to fall into the black vortex of medical free falling I felt better. But I also felt compelled to understand better what had just happened. Wasn’t Obamacare supposed to keep this shit from happening?

According to a government website about Healthcare Reform, 36% (12.6 million) of individuals trying to purchase individual healthcare are denied for a pre-existing condition, which can range in severity from cancer to hay fever. However, Healthcare Reform is going to remedy this:

Under health insurance reform, insurance companies will be prohibited from refusing coverage because of someone’s medical history or health risk.

Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies will not be allowed to refuse renewal because someone became sick.

And insurance companies will be prohibited from dropping or watering down insurance coverage for those who are or become ill.

So, if this is the case, how was I rejected? Has the reform not kicked in yet?

My next search was for “When does Obamacare start?” I found this article from the Washington Post that discusses the Affordable Care Act, and that millions of Americans may not sign up just because they don’t know they’re eligible. That’s awful – but it’s different from the problem I’m facing, right? The AFA doesn’t start until 2014 anyway, so that’s not much help . . .

I found another article at Think Progress that was incredibly clear and useful. For anyone looking to better understand the changes Obamacare will bring to the insurance landscape, I suggest taking a look. Unfortunately, it doesn’t help me in my current predicament. Take a gander:

An end to insurance company discrimination against Americans with pre-existing conditions. While Obamacare has already barred insurance companies from denying insurance to children with pre-existing conditions, this highly popular consumer protection will be extended to all Americans by January 2014. This means that Americans suffering from a host of genetic and chronic ailments that are completely beyond their control will no longer be relegated to expensive and inefficient high-risk pools, or be forced to forego critically needed health coverage entirely.

Well, at least now I know how and why that horrible phone call happened this morning. Fingers crossed that I’ll be able to easily roll over to that new plan within Independence. But it has also made me feel confused, wary, and a little disappointed in Obamacare. I know that it is incredible, and this is just my bruised ego and frayed nerves speaking, and I know it is an incredible step in the right direction – but while Obamacare is an outstanding improvement, how is it that this is the best we can get? What do we do for the next year? What about the people who are like me but can’t afford the Guaranteed Enrollment Plan?

What are your thoughts on Obamacare, and its benefits/limitations? 

 

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2 thoughts on “Day Twenty Four: Health Insurance & Obamacare

  1. Sorry this happened to you. Imagine if you did not have intelligence, computer access, etc. and had the same conversation!
    Scary!

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