Many of us chronically ill patients won’t be affected by Ombamacare. We are either covered by Medicare or Medicaid. Others of us are lucky enough to still be employed full-time and have decent healthcare coverage through a job. Still others are covered through a disability pension (Yes, there are still such things as pensions out there!) But there are a couple of us who want and need affordable healthcare coverage. Now, some of us are happy to finally have the opportunity to be able to afford a policy, but others of us were forced into the Obamacare system after being dropped from a policy that was in place for a long, long time!
However you found yourself fishing in the pool which is the Affordable Care Act, you will need to be aware of the pitfalls which are being revealed to me by a friend of mine as we speak.
My friend shares that she was forced into choosing a plan due to her husband’s changing jobs. He is now a “contracted” position and thus, she finds herself and her family uninsured for the first time ever.
She carefully combed over all of her options on the website. She was dismayed to learn how little her $1400/month was going to give her family in the way of benefits. There is an “individual” deductible of $2,350 per person with a “family” deductible of $7,300. It has been explained to her that no coverage will be given until the deductibles are met. After the deductible is met, they pay only 50% of expenses, and that is, of course, if you choose “in network” providers, hospitals, radiology services, etc… Even still, she remained hopeful that this coverage would be a good choice for her family.
She chose “Amerihealth” through the Obamacare website. Suddenly she finds herself requiring a medical procedure which will be done on an “out-patient” basis at a hospital. She was happy and relieved to see her doctor (whom she has been using for almost 20 years) accepts Amerihealth as does the hospital.
But here is the reality. Her doctor’s office explained to her that although they take “almost every Amerihealth plan, we do not participate with the Value-Plan that you have.” What this means is that the $3,500.00 that the doctor charges for doing this procedure is not only going to be out of pocket for her, it will not even go towards reaching her deductible!
Secondly, even though the hospital does accept this plan, and the amount that they charge for this procedure should help her reach her “individual” deductible… two separate people from this insurance plan have both tried to explain to her that her deductible is “really $7,300.00 per calendar year because you have family coverage”.
Every one of us in group who has a family, understands that the “individual” and “family” deductible figures are numbers that the insurance company looks at in totality. No one is explaining things in a way that makes sense to her. Her husband even got on a three-way-call with her and a representative and still nothing was explained properly. What they were told was that “every insurance card has the information printed on it for an individual policy as well as a family policy… but you guys have the family plan.” This is, in my opinion, a negligent misunderstanding of the construct of the plan by the representatives who are on the other end of the phone trying to explain it to you! They are not even trained well enough to provide callers with a clear understanding of basic plan information!
The take-aways of this mess are the following: #1, check with any and all doctor’s offices prior to your appointment day to be sure that whatever plan you chose, that the office accepts your specific plan within the company you selected. So, for example, for my insurance, I can’t just say “Blue Cross/Blue Shield”. I have to specify further by saying “Horizon” and then adding “Federal Employee Plan”. Believe it or not, I have been tricked by saying only BC/BS and then getting billed later from a provider at the “out-of-network” amount because they don‘t accept the “federal“ plan! If you know and agree, that is one thing, but to get balance-billed when you expected only to have your co-pay can be a very trying experience.
#2, When having anything more than a traditional office visit, keep in mind that you will need to contact the hospital or surgi-center separately about insurance. If any biopsy is taken you will need to alert them as to which lab your insurance uses. Sending something to the wrong lab can ultimately end up your responsibility. Same is the case with x-rays and the radiologists who read the films! Every doctor that sees you should accept not only your insurance Company, but your specific PLAN. The Anesthesiologist is also a separate doctor who will bill you separately. The more investigating you do ahead of time, the less surprise you will be dealing with as you recover from your procedure or surgery.
#3, I didn’t see “Brand Name” drugs anywhere on the website so if your doctor is ordering any new medicine be sure to request generics. If you absolutely need Brand name, or if the drug is so new that it doesn’t come in a generic, let your doctor know that you will likely not be able to afford a Brand name and ask if he can keep you supplied with samples. If the answer is “no” then there are sometimes “coupons” that are good for a year. That is at least enough time to know if a new treatment is going to work for you and be worth your valuable resources. There are also need-based programs from most of the big drug companies but they are a hassle and you really have to be near poverty level to qualify.
#4, Trips to the ER can be devastating to your already stretched budget. Even if the hospital you pull up to takes your plan, the doctors covering the Emergency Room at the time that you go may not! And you might have no choice because of the nature of the emergency. Always ask. And if you don’t get the right answers, be sure to contact your insurance company within 24 hours of the emergency. Write down the date and time you called and the first and last name of who you spoke to. That is at least a starting point to work with the doctor’s billing offices so that you don’t get stuck with a huge out-of-pocket expense after an emergency.
If you are unlucky enough to have medical expenses that exceed the $7,300 family deductible, then between monthly payments and family deductible, you have essentially spent over $24,100.00 for the calendar year! (the $1,400.00 per month x 12 months plus the $7,300.00 deductible). And that is all before your plan kicks in even the 50% that they promised!
While law dictates that we must be covered by some form of health insurance, it certainly has become evident that what many believed would be “free” is not only unaffordable, but close to useless for many people.
If anyone has any examples of this working to the contrary, please feel free to email at