There are two recent proposed changes to insurance and Medicare that can have a major impact to your wallet and potentially make insurance unaffordable for millions.
People with Pre-Existing Conditions Could Be Denied Coverage or Charged Exorbitant Amounts
There was a critical time in my life when I was self-employed and needed to get a private insurance policy from the marketplace. I was incredibly thankful that “Obama-Care” had recently been enacted and that people with pre-existing conditions (1) could not be denied insurance coverage and (2) were not required to pay higher premiums than healthier people. As it was, I was paying more than $1000/month for insurance coverage just for myself.
My home state of Texas, along with 19 other states, has sued to have these provisions revoked. The political intricacies are better explained in this Medpage Today article. According to the article this could impact 52 million people. A joint statement from five leading health organizations included the following statement: “Should this case be successful, people with cancer, heart disease, diabetes and any serious or chronic condition are likely to be denied coverage due to their pre-existing conditions or charged such high premiums because of their health status that they will be unable to afford any coverage that may be offered … Without access to comprehensive coverage patients will be forced to delay, skip or forego care. This was often the case before the law took effect and would likely be the same should these essential protections be eliminated.”
The US Department of Justice (DOJ) has declined to defend these provisions (meaning the DOJ didn’t object to them) so the lawsuit is continuing on. However, if this carries through, those of with RA, will certainly be included in the “pre-existing conditions” list. In the not-to-distant future we, and others who need insurance coverage the worst, may be denied access to it.
Infused Medications May Come Under Drug Plans Rather than Medical Plans
In an earlier post I described that how you receive your RA treatments affects how much you pay. Medications that are administered at home (pills, injections, lotions, etc.) normally come under the pharmacy insurance plan. Covered medications are generally assigned a “tier” with approved generics being the lowest cost and costlier medications (such as biologics used to treat RA) are the highest tier and, if covered at all, usually requires the patient to pay a significant portion of the cost.
On the other hand, medications used in treatments done at a facility such as a doctor’s office, infusion center, or hospital, are covered by the medical part of the insurance. this would include, for example, RA medications given at an infusion center. In this scenario, a patient will have a co-pay which may be considerably less expensive than they would pay for a medication under the pharmacy plan.
This breakout generally applies to both Medicare and private insurance.
To provide a personal example, I am covered by Medicare and have an infused biologic that is currently covered by the medical coverage. It costs me $0 out of pocket for my infusions. The medication I take also comes in an injectable form. If I used the injection instead of the infusion, it would cost me $6,283 each month.
The current drug plan proposed by President Trump would move drugs used in treatment settings from the medical coverage to the pharmacy coverage for Medicare patients. If this were to happen, I could no longer afford treatment. (To add insult to injury, patients like me who are on government-sponsored plans such as Medicare or Tricare, are not eligible for patients assistance programs.)
Right now this proposed change is limited to Medicare patients, but the plan is being promoted by Pharmacy Benefit Managers who also manage drug plans for commercial/group/private insurance companies. It’s not much of a stretch to think that if they can make this change for Medicare, then other plans aren’t far behind.
Not only are those of us with drug plans at risk, there is an estimated 9 million people on Medicare who do not pay the extra premium for drug coverage. There has been no proposal so far as to how these people would pay for their medications.
I used to think that the uncertainty surrounding the current administration’s drug policies was unnerving. As these plans become unveiled, I think the reality is much, much worse than the uncertainty ever was.
Thanks for checking in. I wish I had better news to share.
Nothing scares someone with a chronic illness more than changes in health insurance. So I have to admit that I’m terrified.
This doesn’t sneak up on you. About six months before you’re eligible, you start getting mail and emails and phone calls from insurance companies trying to get you to sign up for all the supplemental policies that come along with the government-provided coverage. But sorting it all out, trying to figure out what you’ve got and what’s going to be covered, is a bit of a nightmare.
I take about a dozen prescription medications, not counting my biologic infusion. I searched carefully through the 25 or so prescription plans available to me until I found one that covered most of these meds for a premium that wouldn’t bankrupt me (at least not immediately). As it was, I couldn’t find a plan that covered two of my drugs. One is a blood pressure medication, which is no big deal because there are loads of those. The other is the one that I consider critical because it provides amazing relief for my Sjogren’s symptoms. There is only one substitute that I can find and it doesn’t work as well and it has considerably more side effects. And even though it’s “covered”, it will still cost me more than $100/month.
The really scary part is that I can’t get anyone to tell me whether or not my biologic infusions are covered. I’ve talked to Medicare and they tell me that the fees for giving the infusion will be covered, but they won’t tell me if the drug (which runs about $15,000 retail) is covered. They need to speak to my doctor or the infusion company or both. Even if it is “covered”, if it’s a high-tier drug, it might only be covered at something like 50% — which is well beyond my capability to afford.
Right now I’m doing better than I have in years. My biologic, Simponi Aria (along with methotrexate), is working amazingly. I do not want to go backward. I would like to continue to feel almost human again.
I’ve been given assurances by a wide range of people including my rheumatologist, the infusion company, and even the great folks at Janssen (who manufacture the drug), that it should/will be covered. But I won’t know probably until a few days before my next infusion in June.
The interesting thing is that I consider myself lucky. Given the current uncertainty in the health insurance industry and the chaos that is going on in our legislature about replacing Obamacare, I’m glad I don’t have to face those challenges. At least I have a clear definition of what I’m facing.
I hope whatever you’re facing today brings a smile to you and those you love. Thanks for checking in.
It’s that time of the year when scary things happen. I’m not talking about Halloween. I’m talking about open enrollment into insurance and Medicare plans. Read more on RheumatoidArthritis.com here: https://rheumatoidarthritis.net/living/two-scary-words-open-enrollment/
Thanks for checking in.
I wrote about this subject a while back when I discovered my insurance company had listed all my lab/test results for the two-year period I had been covered with them on their website where I could refer to them. https://carlascorner.wordpress.com/2011/04/13/privacy-what-privacy/ And I also assume that the several thousand people who do customer service work for the insurance company could see them as well. I questioned (as I still do) the insurance company’s right to the information (and when/where I gave it to them) and certainly their right to publish it in such an open forum.
Let me just say that I am and will eternally grateful for insurance companies. Without them, my health and quality of life, which is dependent upon affordable health care, would be in a far different state than it is today. I further highly respect their fiscal responsibility to try to control health care costs. But I tend to think the boundary line needs to be drawn at approving procedures and medications, not being privy to personal test results. Or giving medical advice (which is the doctor’s job).
pissed me off come up again because I just received a letter from my current insurance company. It’s actually entitled a “Care Consideration” that’s an alert about something that might be improved. In this instance, they’re recommending that I get a Hepatitis B vaccination. I’m not exactly sure why they think this — they didn’t say. I suspect that it’s because one of my liver enzyme tests is slightly elevated and has been for some time. Between being a bit overweight (which translates into fat in the liver) and taking some very strong RA drugs that can affect the liver, you can pretty much anticipate things to be a lot more out of whack than they are. My gastroenterologist, my rheumatologist, and my primary care physician (PCP) have all weighed in on my liver enzymes and I’m monitored with lab work every four weeks. NONE of my doctors have said a word about getting the Hepatitis B vaccine. So where does the friggin’ insurance company come off giving me medical advice?
And then I kind of laughed because I immediately wondered if they would even cover it, even though they recommended it.
As it turns out I have an appointment with my PCP next week for the medical clearance for my upcoming ankle surgery. Being the good patient I am, I am taking the “Care Consideration” letter along with me. The discussion will no doubt cause my blood pressure numbers to go through the roof. I wonder what my insurance company will say about that?
I hope whatever care consideration there are in your life bring you a smile. Thanks for checking in.
So if you don’t want to read a long, whiney post, just keep on scrolling. I posted something earlier today that’s a whole lot more uplifting.
I officially left the workforce in November. From an insurance standpoint, this means that I was covered by employer’s policy through the end of the November. In December, I was able to continue that coverage under COBRA which simply meant that I paid 100% of the premium instead of the company paying a portion. As I had met 100% of deductibles, out-of-pocket, etc. and everything (including prescriptions) was being paid, it was a good deal. It took some diligence to make sure everything was in place and that coverage didn’t lapse. The Thanksgiving holiday slowed some progress, but everything worked out.
Now last year, through December, medical coverage was through Insurance Company A. My ex-employer switched insurance providers starting January 1 to Insurance Company B. In order for me to continue coverage, I had to pay my December premium to Company A. Once I paid for December, my information was to be transferred to Company B for coverage under the new policy starting in January. I then had to pay my January premium by a certain point in December. With some hand wringing and tooth gnashing on my part, all of that happened but we got down to December 28 and I had no confirmation (even though I paid the premium) that I actually had health insurance coverage starting January 1. This was important because the first two weeks of January, I have scheduled two sets of labs, one X-Ray, three doctors’ appointments, my Actemra infusion, three prescription refills, and four physical therapy sessions — all of which had to be verified with the new Insurance Company B. But finally on December 28 I was able to print out a temporary insurance card and start providing the pertinent numbers to those various people who needed it.
So I’m feeling pretty good. I start January with a sense of accomplishment that even though I had been treading some pretty treacherous waters, I had successfully transitioned from group coverage to COBRA and then to a new insurance provider.
I guess being smug is the same thing as pride because I was feeling smug and there was definitely a fall in my future.
I was on Insurance Company B’s website checking to make sure that my dentist (with whom I have an upcoming appointment) was in network. But the weird thing was that I didn’t see any dental insurance coverage listed.
I contacted my old HR department. We went around the mulberry bush a few times (metaphorically speaking) before we figured out what happened. In addition to the health insurance election I made back in December, I was to have also made elections (if I wanted) for continuation of dental and vision insurance. But guess what? Those were never transmitted to me, so I had no opportunity to make the elections. So my dental and vision coverages had actually lapsed in December and therefore had not been transferred to the new provider to begin coverage in January. I didn’t know they weren’t bundled altogether, so I didn’t raise a flag at the time. I selected the only thing that was made available, which looked like this (whatever those codes mean):
The “fix” was to go back to Insurance Company A, turn on those elections and pay the December premiums. Theoretically this would then automatically flow through to Insurance Company B where I could then pay the January premiums and once again have my eyes and teeth covered. Oh, and it’s now the first week of January and I only have until January 14 to make all this happen or I lose eligibility. Previously, it took more than two weeks for each step of the process for medical coverage.
So I immediately thought to myself, “Self: It’s still open enrollment. You can just find an individual dental policy and sign up for it and skip all that trauma.” So while I had my old HR department chasing down how to “turn on” the original elections that should have been available to me two months ago, I start on a multiple-hour investigative journey into the land of dental policies to see if I can find a reasonable replacement on my own.
I’m sitting there after a few hours, my desk littered with printouts of policies, trying to sort out which are affordable, which have my dentist in-network, which are insurance companies I’ve actually heard of, and my phone rings.
It’s my physical therapy provider. They can’t verify health insurance benefits for my PT appointment the following morning. It appears that Insurance Company B has my birthdate wrong. Since my provider has the correct birthdate, it doesn’t match what the insurance company (incorrectly) has and they won’t verify that I’m covered.
So this is the first Monday of the new year, right? Insurance companies are getting slammed by people with questions. Insurance Company B’s website has crashed. It won’t even load. (They eventually put up an error message.) I call the customer service number. I am on hold for 46 minutes until I finally get a representative. (Thank you, Sprint for unlimited minutes …) She immediately asks me to verify my birthdate. You can only imagine how that conversation goes.
It doesn’t get much better after that, compounded by the fact that English is obviously not her first language. But she tries to be helpful and eventually, after about 17 security questions, decides she’s actually speaking to me and tries to fix my birthdate. She can’t do it. It’s one of those protected fields that only authorized users can change and she obviously isn’t authorized enough. She says she’s sent the request to “operations” but it may take three to five days for it to be corrected. I explain that’s not good enough and ask if there is a supervisor or someone else who might be able to help. She puts me on hold. Comes back. Puts me on hold again. She finally comes back and tells me that no one is answering — she is rolling directly to voicemail. So after more than an hour, I’m not really any closer to getting the situation fixed than when I started. She did, however, tell me the issue with my birthdate. The last four digits of my Social Security number (which actually form a valid date) got input as my birth year. (I am momentarily elated as this makes me much, much younger than I actually am …) She also told me that my old company should be able to correct this issue on their administrator screens.
So I go back to my old company’s HR department (who is still trying to work on my dental and vision elections) and explain the new problem. No, they can’t fix it on their screens. But they did send in an urgent request to their Insurance Company representative.
Deflated, but not yet defeated, I return to my quest for dental coverage. It turns out the best policy I can find will cost about 20% more than what coverage would be through my old employer. That’s actually not a lot of money as dental premiums are not that expensive for one person. The problem is, that since my dental coverage actually lapsed (through no fault of my own), I was looking at a six- to 12-month waiting period for any kind of dental procedure other than a simple clean and check. I have not one, but two crowns that need to be replaced, so that issue made my finding my own, separate dental policy a really bad idea.
The next morning there is an email for me from the company HR department. They say the birthdate issue on the health insurance is now corrected. Sure enough, when I arrive at the PT appointment, they are able to verify coverage and my pharmacy has also been able to process my prescription refills.
I call Insurance Company A and ask them what the December premiums will be for dental and vision insurance. Even though neither the elections nor the premiums are showing up yet on the website, I make a payment online. As soon as the premium notice shows up, I need to have the payment waiting for it. Because it still has to be processed then transmitted to Insurance Company B in order for me to pay the January premium.
So things aren’t perfect (yet). But the truly large issue of health insurance has, at least, been addressed for the moment. I have people helping me work the issue of the dental and the vision coverage. True these are, no doubt, the same people who caused the screw up in the first place, but who better motivated to correct the situation?
It’s now the third work day of the new year. I hope this week is not a harbinger of the rest of the year. But I do hope your 2016 is not only starting well but will be filled with both health and happiness.
Thanks for checking in.
So last week and this have been filled with doctors. As posted earlier, I have a good bill of health from my neurosurgeon who did my recent back surgery and also had a fairly rewarding conversation with my PCP’s PA about weight loss.
I had a regular follow-up with the orthopedic surgeon who did my hip and knee replacements. The good news is he says both replacements are looking great, which is really positive news considering the hip replacement is now seven years old. Most joint replacements need revisions or replacing after 10-12 years so I’m encouraged. The bad news is that he’s making noises that we might be replacing the right knee sooner rather than later. 😦
Today I had my regular rheumatologist’s appointment. With the surgery and trying to get caught up with stuff at work, I really haven’t had time to think about it. I’ve just been taking my Actemra once a week and going on about my business. I told her that taking the Actemra injection was like taking a 5 mg or 10 mg prednisone tablet. It helped for a day or two, but then wore off. She has suggested that we try to get the insurance to approve Actemra infusions where she can modify the dosage to see if we can’t get a better result. She also wants to be a bit more aggressive with pain management so she has prescribed some hydrocodone. At this point, it’s just one tablet at night to help me sleep. I’m really not much of a fan of hydrocodone but I keep having doctors insist on prescribing it for me. I should be grateful. There are a lot of people who really need it that, because of the new regulations, are having trouble obtaining it.
I got my lab results back prior to my rheumy appointment and they, for the most part, looked good. All my labs have always looked great. The one result that was out of line was one of my liver enzymes (again). But it was just slightly high and is probably because I’m still on Lyrica after the surgery to help with some diminishing but continued numbness in my right thigh.
The big news is that I formally gave my notice to my company effective mid-November. I am in the midst of a major project and I don’t want to leave them hanging, so I’m going to wrap that up before I leave. One of the benefits offered at the company is disability insurance (both short-term and long-term), so I have applied for benefits. If awarded, I will receive a large percentage of my current salary up until my full retirement age. I’m not sure what they’ll say about RA being a pre-existing condition, etc. but I guess we’ll see. So in the midst of everything else, I’ve been scrambling trying to get my doctors to fill out the (really stupid) forms and get them in so we can get a determination. I never really actually thought I’d be retiring early due to health reasons — I more kept the insurance so I’d have income during surgery recovery if I needed it. But the point is I’ve been paying the premiums all this time so there’s no reason not to apply for the benefits. All they can say is no and I already have that.
The good news is that I discussed this decision with all my doctors that I’ve seen recently and they fully support my decision to step out of the corporate world. That’s a bit sobering. It’s almost like I’m seeing myself through their eyes for the first time. Not one of them said anything like, “Are you sure you’re ready for that?” In fact one of them said they have been amazed that I’ve worked for as long as I have.
Of course this will play havoc with my insurance. I’ll be covered by company insurance in November. Then in December, I’ll still be covered, but I’ll be paying for it through COBRA. Then in January, I’ll still be on COBRA, but they’re switching insurance companies. Am I nervous making three major changes in my insurance coverage in three months? You bet.
In other news, Dallas is set for a major rain event. We had enough rain in May that a significant part of our area finally came out of the five-year drought we’ve been enduring. But it’s barely rained since. In fact, October, which is one of our wettest months, has not logged more than a trace of rain all month. With highs in the 80’s and 90’s, it might as well be early summer. But all this sunny weather has lulled me into a false sense of security. Rain and stormy weather on the other hand, send my joints into a tail spin. So with four days and 3″ to 6″ of rain in the forecast, I may be glad that I’ve got that new prescription for pain medication.
Overall none of this is really bad news and some of it is actually quite good. I think I’m just tired with dealing with it all. I’m tired of not feeling well. I can’t remember the last time I actually felt good. I’m tired of the stupid back brace and I’ve got two more months to go on my three-month sentence. I’m tired of doctors and needles and insurance claims. The thing that keeps me going at the moment that this time next month, much of this will behind me. I’ll be officially “retired”, the determination on the infused Actemra will be in, and the determination of the disability will be in. My biggest problem should be finding something new to whine about.
Thanks so much for “listening” to me whine and thanks for checking in.
December brings a lot of milestones including the Christmas and Hanukah holidays, the Winter Solstice, and New Year’s Eve with its endless “Best Of” lists and unrealistic resolutions for the coming year. Equally ubiquitous are deadlines for making commitments for the coming year’s health insurance. Whether you’re covered by your company’s insurance (I’m not), purchasing health insurance on your own (that’s me), or by Medicare, you have to make important decisions that will impact both your health and your pocketbook for the next 12 months.
Read the rest of the post here: http://rheumatoidarthritis.net/living/insurance-trap/.
The first of the year is a busy “doctor time” for me. A week or so ago I had my annual mammogram and retina check (not the same doctor) followed a few days later by my every-four-month visit with my internist. This week I have my annual dermatology exam, meeting with the spine guy about the issues with my back and follow-up with my knee guy about the potential Hyalgan injection treatment for my left knee. In the upcoming couple of weeks I also have my regular rheumy check up along with the follow-up with my shoulder surgeon. And of course, there is the monthly run to the pharmacy that, between my prescriptions and my husband’s, runs me about $300 after insurance.
You see that’s the rub. It appears that there’s been yet another clerical error and not only am I not covered by insurance at the moment, I haven’t been since January 1. You’ll recall this happened earlier when I changed from employee insurance to COBRA at the end of November. This time it has to do with the annual open enrollment at the end of the year. The HR people are working on the issue, but I found out about this when I had to shell out $$$ for prescriptions this weekend. Going back to the claims statement, it appears that my earlier doctors appointments haven’t been covered, either. I am just hopeful that they will resubmit the claim and, when they do, this mess will be straightened out. With the cash flow hemorrhaging I’m doing on the house renovation, I really don’t need to be paying full price for specialist visits.
The good news is that the house is moving along. After some issues, we’re finally getting the floors finished. I need an extra coat of paint in one room, then the painting is done. The kitchen cabinets are being installed even as we speak. We have countertops, tile, and clean up to finish, then hopefully the end of next week we can move home. (There’s a potential disastrous delay on the countertops in the works, but that’s another story.)
This weekend I decided that I would clean the kitchen tile well before the cabinets were installed. It’s not a very big area, but by the time I was done with a mop and a rinse, I could really tell the toll that RA has taken on me. What would have been a quick, painless job just a couple of years ago turned into an arduous adventure. My hands hurt, my back hurt, my knees hurt, my feet hurt.
But again, good news. With all this stress and extra physical activity, I haven’t had a flare. (Fingers crossed.) I guess the meds are actually helping keep things under a level of control.
So that’s my life at the moment. Hope yours is rolling along smoothly. Thanks for checking in.