Wednesday, August 29, 2012

Healthcare Woes

My first experience of feeling dehumanized by the U.S. healthcare system was in college, when I aged off of my Dad's insurance.  Before my birthday, I made phone calls like a mad woman trying to find a policy I could afford - as a college student.  I was horrified to discover that there was literally no individual policy I could purchase that would cover my kidney disease.  This was despite the fact that I had no lapse in coverage.  I also had no access to a comprehensive group policy.

Here I was 23, raising money and awareness for a good cause, generally trying to make the world a better place, teaching kids to play the flute (sometimes for free, because I firmly believe the arts should be part of everyone's life), and finishing two bachelors degrees in my usual ridiculous over-achiever style. But this healthcare system considered my health - my life - unworthy of insurance, simply because I planned to use it.  My last call before giving up on this plan was to the Ohio Department of Insurance, where I was told that yes, it was completely legal for a pre-existing condition not to be covered (I believe for the first year of an individual policy) even with no lapse in coverage.  They also informed me that I did not have any other options.

When Bean was born, the plan was to have me go on The Beast's policy.  Through a series of insurance company snafus, I soon found myself uninsured, postpartum after a complicated pregnancy, a brand new parent, and concerned that my kidneys would not recover from the pregnancy.  It was a terrifying time.  I sent an appeal to the insurance company, documenting everything I had faxed to them and when.

I soon found that my state has a program that I qualified for once I had been uninsured for 6 months.  As the six month mark approached, and I had foregone healthcare in order to minimize my out-of-pocket expenses, I received a letter stating the appeal to The Beast's insurance company was successful. I could now go on The Beast's policy, effective 6 months prior. We'd have to pay the more than $2000 in premiums to cover those six months of mostly-foregone healthcare.  I would also need to gather any of the small bills for medical services and medications I had paid out of pocket and submit them myself.  This could easily have become a full-time job - after all, submitting bills to insurance companies is a full-time job for someone at every medical provider's office!

During both of my pregnancies, I was on pregnancy-only Medicaid.  I started out my first pregnancy with insurance, but it quickly became impossible for me to keep the job that provided me with insurance because of my health during the pregnancy.

Because it was pregnancy-only, I always worried that something wouldn't be covered.  I was told that anything pregnancy-related or potentially impacting the health of my baby would be covered.  When I sliced my finger open while pregnant with A-Train, I was completely unsure whether the ER visit, stitches, and tetanus shot would be covered.  They were. After Bean was born, I was shocked to find that a hospitalization for mastitis was not considered pregnancy-related (does anyone else besides a lactating - i.e. postpartum - woman get mastitis?  I'm fairly certain no, but because of the way it was coded for billing, it was considered unrelated!). 

I also worried I'd be dropped from Medicaid, for no particular reason other than never being clear on much of anything, and the feeling that surely something my employer nor myself is not paying for is going to screw me over...or surely everyone would want the Medicaid system - or something similar (AKA socialized medicine) to cover them.

After A-Train was born, I planned to go back to the Healthy Indiana Plan (HIP)- I was told I could go from Medicaid back to HIP without another 6-month lapse.  But because of the timing of The Beast's paychecks (there are some months there is no paycheck at all) and A-Train's birth, the income verification via pay stubs ended up qualifying me for Medicaid.  I was afraid I would fall through the cracks if I spoke up and tried to get switched over to HIP.  So I ended up spending about a year feeling like I was committing fraud (I never lied about anything - our tax returns and everything else I submitted stated our annual income, and I always break down our monthly and weekly income by dividing what I expect we will make over 12 months/52 weeks).

At the next income review, I was given days between receiving a request for information and it being expected back via mail or fax.  This left me utterly unprepared for the speed with which I was dropped and left uninsured.  There was no time to switch over to HIP without a lapse in coverage; they would take weeks to process my application and would not provide retroactive coverage.

Having a lapse in coverage at that point was of concern because we were not sure what our work and, hence, insurance accessibility situations would be several months from then.  We opted to pay a hefty (for us, at least) sum of money to add me to The Beast's insurance and have no lapse in coverage.  It was a gamble against future income balanced with protecting my insurability.

I had no lapse in coverage.  I was much more careful in submitting this application and supporting paperwork, after the terror of ending up uninsured after Bean's birth.  We rejoiced when my insurance card arrived in the mail.  I relaxed.

I get tests done and see my nephrologist about every 3 months.  These are not particularly expensive tests, nor is my doctor charging an exorbitant amount for visits.  I also take two generic drugs.  The insurance company and I just about break even.  If anything, the insurance company still turns a profit and I get a bit of peace of mind in return.

But when the insurance company got their first bill for a round of tests and a visit to my nephrologist, I got a list of questions and a request for absurd information.  I spent a full eight hours gathering various information.  In order for me to spend all that time on the task, The Beast had to take time off work.  All that was required for my coverage to be valid was insurance coverage with no lapse for the previous year and something verifying a qualifying event had taken place (in this case, my insurance coverage was terminated).  All of this was included with my initial application.

Nevertheless, upon receipt of that first bill, the insurance company asked for a list of my medications, dosage, prescribing doctor, what they were for, the date they were prescribed, and the date they were filled.  The kicker was that they asked for the previous nineteen months.  From a random date I have never made sense of.  Of course, I jumped through their hoops.  I went all over town and gathered all the information they requested.  I was determined not to end up uninsured again.

This summer, we were planning to allow my insurance to lapse.  It is so expensive, and our finances are not what we had projected and hoped for.  When I found out I need hip surgery, we started looking into options to keep my insurance current.  We have managed to keep me insured, and now I'm dealing with yet another aspect of this ridiculous system we have.

I have called two doctors (I am on vacation) specifically to make an appointment to get an injection for pain relief.  I have gone to two appointments, having specifically stated I wanted to get this injection.  I have paid two co-pays.  I have yet to get an injection.  Further, no doctor knows what will be required by my insurance company before they approve this surgery.  To be clear, I am all about avoiding surgery if that is possible - but I would like to know what I need to get going on to expedite the entire process, which I'm pretty sure is going to end in surgery.  There is a rush because The Beast will be travelling for various work-related things, and the surgery will leave me on crutches for a stretch.  I can't have this surgery right before he's going out of town.

So I don't know what I own in this policy.  We have paid thousands of dollars and have no idea what we have purchased.  I can't even call and ask without the appropriate diagnostic and procedure codes!

This is also an issue for doula clients, who can call and ask if my services are covered, but likely will not get a correct answer.  Clients have been told doula services are not covered, but been reimbursed when they have submitted paperwork!

Suffice it to say that I live in constant fear of one day going bankrupt over healthcare.  While the Affordable Care Act gives me vague peace of mind, I'm also very aware that insurance companies are already hard at work looking for loopholes so they can hang on to profits. 

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