Thursday, September 13, 2007

Insurance Blues

For a long time, I've been a supporter of both equal-access public health care and a nationalized health care program for all Americans. I was rallying behind Bill Clinton when he put Hilary in charge of coming up with something economically feasible years ago. Now, faced with my own health care crisis (of the mini-sort), I am wishing that I lived in Canada, Australia or any country that offers free health care to it's citizens. The United States really needs to get on the ball. If we can't have nationalized health care because of the cost and putting the federal government further into the red, than can we at least have a "watch dog" type of organization to ensure fair and equal access to those paying top-dollar for private insurance plans? There are so many injustices and just-plain-wrong things going on that I wish someone was in charge of preventing. What exactly am I referring to, here's the skinny...

I called our insurance company today (Aetna) to ask about a claim that was denied when I truly thought it should have been covered because it was a simple clinic visit and we paid our co-pay at the time of service. So, I call up and speak to a Yolanda who informs me that the claim wasn't processed correctly and that she will re-submit it. I will get a final bill from Aetna after it's been processed again and may have to pay a portion if the $5K deductible hadn't been met prior to this appointment. Good, just what I wanted to hear. True, I wish we didn't have to worry about deductibles and co-pays but that's life. Gone are the days of covering my family members for free, no deductible, cheap co-pays and excellent coverage--only had that once in my life, while working at Baldwin Public Library in Birmingham, MI. There are days when I want that job back, just for the benefits. Anyway, I'm wandering...Next, I dared to ask about our plan's (Aetna Advantage Plus) coverage for physical therapy (PT) since Cara is going to require some to catch up on her milestones. This is where the dam of bad news broke loose. I was informed that our plan doesn't cover ANY (not one ioda, one dime, one session) of physical therapy unless the deductible has been met prior to any PT claims coming through. Now, thankfully, due to the $21K brain surgery and ER visit we have far exceeded our deductible this year so here is what Aetna will graciously cover:
-24 sessions of PT per calendar year
-$25 maximum per session to be paid by insurance
Whoa! Hold the phones, did she say a WHOLE 25 DOLLARS?! Wow, that's so generous. Now, while I have no idea what an average session of PT costs, I can almost bet the ranch that it's more than $25. I mean, when we saw the Nurse Practioner for 10 minutes for Cara's 1 week follow-up, $100 was billed to Aetna. Since physical therapy is a bit more hands on and involved, I just know that $25 isn't going to cut it. So, we're going to be shelling out some serious cash for every session that Cara needs and we will because we are going to everything we can to give her a chance to have the best quality of life--bills be damned.

Now, come next year, when we start all over with the $5K deductible, you have to wonder how in the world we will afford the PT. This question was on my mind too, so I asked Yolanda if there was a plan in existence (with Aetna anyway) that covers more, in terms of PT. She then transferred me to the sales department where I spoke to a gentleman who told me:
1. I couldn't change plans until we had been enrolled, with no policy changes, for 6 months which would bring us to Novemeber of this year.
2. If we wanted to change to a more inclusive policy, we would have to undergo the underwriting process again and Cara's hydrocephalus would be "exposed" and probably wouldn't be covered on the new policy because it would be deemed to be a pre-existing condition.
3. We are stuck with this policy and I just wasted 10 minutes of my time asking about changing.
I thanked him for his time and hung up.

The wheels in my head were turning and I was starting to get pissed off. I mean, what the heck is wrong with insurance in this country if the people who really need it (sick, poor) can't get it because it's either too expensive or because said insurance will not cover the medical condition that they so badly need coverage for? We pay just shy of $300/month for this insurance only to find out just how limited it is. I sometimes wonder why we even bother to pay for it at all except that I wouldn't want to be stuck with a $27K tab. It just bites (in lack of a stronger word to keep this blog at it's "G" rated status) that only the healthy can get good, affordable insurance these days. Yes, it's nice to have so that you don't have to pay for well-child visits and just in case something horrific happens but, when something does happen and heaven forbid, you need some special services, good luck! Hope you have a nest egg hidden under the mattress for such things.

Some would say to me that we should have sprung for a better, more inclusive health care package but, give me a break, who actually sits down, when selecting insurance, and says, "Gee, let's see how the coverage would be if Johnny needs brain surgery or Sally gets cancer." Nobody is that morbid. You get a plan that you can afford that covers the basics and you think life is good. Then your literature for said plan arrives, and you might read the little chart that explains the percentages of coverage and such, but you push it to the back of your mind--you're not going to need to know how much your plan is going to play for orthopedics because you're never going to need it, right? I don't want to go through life thinking about the worse case scencerio every time I purchase something, that's too exhausting.

Since I have discovered our fate due to poor insurance coverage, I've had to try to find funding from other sources, unless, we went to declare bankruptcy next year, which I'd rather avoid. I have a meeting with the financial counseling department at Children's Hospital on the same day that Cara goes in for her PT evaluation. In the meantime, I have to round up 90 days worth of pay stubs, bills and such so that our counselor can determine if we qualify. I have also contacted the county health & human services department to see if the state has any programs that might off-set our medical expenses. Short of having a fund raiser or setting up an account at a bank for donations, which will probably never happen, I'm fresh out of ideas. Of course, there's always payment arrangements, problem is, you have to have money to make those payments and things are already quite tight around the waist right now.

If we had nationalized health care like some other countries, while I may have to wait to receive some services, they would be free. Cara would get the treatments that she needs without us having to worry about affording them. What a wonderful thing that would be! Imagine that, everyone getting the care & services they desperately needed without having to be the next Bill Gates or Donald Trump. We claim to be a land of freedom, equality and opportunity and yet, there's an alarming number of people who an either uninsured or, in our case, under-insured. What's being done to help...not much at all. Some states are better at helping their indigent than others. Colorado just happens to be a pretty lean state in terms of social service programs. Just great!

My just might hear that we've jumped ship and moved to Aussie-land. Move over, Sarah, we're moving in!

**OMGosh, this just might be the longest post I've ever written so, bless your hearts if you take the time to read it!**


Judy said...

Oh Laura! I giggled when I read your last line. Of COURSE I read your entire post! You are so passionate about this, and I agree with you wholeheartedly. I'd be amazed and probably speechless (which is a rarity) if our country ever went to national healthcare. Too much money is to be made and the plan as it is now is so entrenched in our society - how do you get rid of it?

(((HUGS))) to you guys. I'm just glad Cara is okay. I hope the meeting with the hospital goes in your favor!

Mary said...

Well, here goes...I know how you feel about nation healthcare - BUT - I have just had a long conversation with a friend of mine who's mother lives in Canada and (to not get into it fully here because it would take far too much space) but my friend said we should be very thankful for the kind of medical care here in the U.S. because nat'l healthcare is a nightmare and anyone who thinks that isn't true hasn't really had any serious health issues and had to deal with the kind of care seriously sick people need.
Cara would not have gotten to see a doctor as quickly as she needed to so - many months
would have gone by and the care would be inadequate at best. She would not be able to see the best doctor for the kind of care she needs. More - but too long to get into here - if you saw what really happens under Nat'l Health Care you would probably be shocked.


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