Saturday, January 14, 2012

Five Facets of Your Employer Health Insurance which may Surprise You

Health insurance purchased through your employer is an agreement between you and your employer to provide medical services and medications in exchange for payment premiums in the event such services or medications are required. It is similar to other types of insurance including automobile, homeowners, and life. One hopes they never have a need for the insurance, but if the need arises, one expects the agreement to be honored. From the time I entered the workforce in the mid 1970s to the time I left the workforce 30 years later in the mid 2000s, I always participated in and purchased health and life insurance through my various employers and didn’t give it much thought.

My journey into Cancer World has taught me a few lessons about health insurance worth sharing. The following points are some of my experiences and ones which I hope may help others.

#1: Black and white insurance company policy statements become grey areas once the bills begin to accumulate

Let’s begin with the basics, where do you find your insurance policy? Is it the few page description on your company’s website describing in-network providers, out-of-network providers, and co-pays? That’s a good overview and one that is useful to the vast majority of users and uses, but that is not your policy. The real policy is typically found in something called the “Summary Plan Description” or referred to as the SPD. My currently available Summary Plan Description is a 278 page document. To someone who hasn’t given healthcare insurance much thought, this document is intimidating. A brief somewhat comical side note is in order here. For about a year I tried to get the “full” plan document since what I had was the “summary” plan document. The “full” plan document turned out to be a 2 page agreement signed by an executive officer at my company. In short, I’m not sure what the word “summary” connotes in a 278 page document. But I digress.

In 2008, my SPD stated the following as a covered medical expense, “Prescription drugs approved by the Food and Drug Administration (FDA), used and sold in the U.S., and used for a medically accepted reason.

My oncologist, a highly regarded and published physician at the cancer center rated number one in the country, prescribed a medication to me that in his opinion was medically necessary, was FDA approved, and was sold in the U.S. Based on the information in the SPD, the situation seemed pretty black and white to me. What do you think? What if you were in this situation?

I’ll make a long story short. My insurance company denied reimbursement for this FDA-approved medication. I spent weeks writing an appeal while sitting on some very expensive bills from my cancer center which my insurance company refused to pay. The denial interrupted my treatment plan. About two months after receiving the denial letter and working through the appeals process, my insurance company agreed to pay for past and future medication expenses for the drug which they had denied.

#2: Where an insurance policy states that the company reserves the right to amend, suspend, or terminate a policy at any time, this should be taken seriously

I don’t have any advice here. As such, this is more of a heads up than a facet of your policy which can be reasonably anticipated.

By way of example, my insurance company implemented a new policy in the middle of my cancer treatment specifically targeting the medication used in my treatment. Instead of calling me and giving me some warning about this new policy, they sent me a letter about a month after the policy was implemented denying payment for the treatment. This was after eight (or nine) treatments had already been reimbursed. But, not before two others had been administered. I have no insider knowledge, but it felt like a case of being singled out.

#3: In-Network and Out-of –Network providers are not always clear cut

If your health insurance is like mine, it may cover procedures received in a large medical institution or cancer center. Periodically, I received notices of use for an out-of-network provider even though the provider I saw was in an in-network institution. This in turn would kick-off a deductible and I’d be faced with a medical bill which was unexpected.

Two instances where this happened to me are as follows. A new cancer center employee was not fully registered as an “in-network” provider. She provided medical support to me as part of a team of people in preparation for one of my surgeries. It took a few months to straighten this out between my cancer center and my insurance company. The second instance was a bit harder to sort out. The cancer center had hired an independent contractor and that individual provided medical services to me. This resulted in another surprise and an unexpected medical bill. My cancer center took responsibility for this oversight and ended up writing off her expenses to me. But, it took time and effort to make this happen.

#4: The impact on your insurance when you enter into Long Term Disability is surprising

A book could be written on this subject area, but I’ll cover the highlights. This gets really confusing. Once one has been on long term disability for 2 years, Medicare takes over as your primary health insurance, regardless of your age. Surprise! And, depending on your employer’s supplemental insurance, you may or may not receive adequate healthcare coverage. I’m actually fortunate to have had a reasonable supplemental health insurance plan through the end of 2011. On January 1 2012 my supplemental insurance changed and the premium went up 400%. Sorry, that’s not a typo, 400%. It’s too early in the year to assess the impact of this change to my insurance coverage, but I’m already facing a need for a justification for a medication which in the past needed no prior authorization. The fun (and surprises) never end.

#5: Watch closely for changes which impose maximum reimbursement caps

This would most likely happen during an annual open enrollment period. This happened to me this past year. My prescription drug plan (PDP) which had no cap in the past changed to one with a maximum annual reimbursement cap. This created a lot of anxiety and stress knowing that my oncologist and I had just had an in-depth conversation on my chemotherapy medication and based on the new maximum reimbursement cap, I’d surpass the cap in April and face tens of thousands of dollars in out of pocket expenses. I had some lengthy and productive conversations with my company during the open enrollment period and the month following open enrollment. In the end, the cap was removed from the plan. I don’t know how many people this affected, whether or not my conversations had some impact on this decision to remove the cap, or whether the cap was an honest error on the part of my company to begin with. But, I do feel good about being an informed consumer and believe my discussions had some impact on the removal of this cap.

Conclusion

I realize this is a long post. The above are not the only issues one may face, but they seemed like the top 5 from my perspective. Here are my recommendations:

  • Read and understand your Summary Plan Description (SPD) document
  • Stay aware of medical plan changes that may impact your benefits
  • Be diligent in assessing in-network and out-of-network service providers
  • Keep good records (by date) of your treatment to support billing issues
  • Watch for changes in coverage during open enrollment periods

If you have an insurance story you’d like to share publically, please send it my way. You can either post a comment or find my email address in this blog’s profile area. There are some good patient advocates groups that can help you work through your insurance issues, so you are not alone when the need arises. One such group which helped me recently was the Patient Advocate Foundation (PAF) at www.patientadvocate.org.

My last and most important piece of advice is to stay healthy and not need your health insurance benefits. Prevention is the best and least costly cure.

Happy and Healthy New Year Everyone,

Ed

2 comments:

Anonymous said...

Never assume anything. When you schedule an appointment and they ask for your insurance information don't assume that they will tell you if you're not covered. And even if your appointment is covered, don't assume everything they do will be covered, such as the lab work. My dr once sent the lab work to the hospital lab instead of a private lab, so my insurance wouldn't pay for it.

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