Blog Entries With Tag: PPO

Posted: Aug 17, 2009

Effective June 1, 2009 BC/BS Massachusetts has changed their CGMS policy.  It is a policy change.  It is NOT plan dependent.

They will cover (with doctor's recommendation) CGMS's without contortions for diabetics.  It is no longer dependent on the things like 1) seizures 2) passing out 3) ER visits 4) gastroparesis, etc.  They are covered period.

However, they are covered under durable medical equipment which tend to have a limit on them.  My old group PPO which is considered to be the cream of the crop and that I was paying $445 a month for had a $750 annual maximum - obviously not enough to pay for a CGMS or a pump.

The choices that I debated this time (as direct pay) were PPO/$1,000 deductible - $1,500 annual durable medical equipment max and the one I chose HMO Blue/$500 deductible - $750 annual durable medical equipment max.

So the good news is they changed the policy; the bad news is coverage is nominal at best. 

For those who have had their CGMS and pumps paid for/reimbursed, what category were they on your insurance plans?  What amount for the initial equipment?  What amount thereafter?


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Posted: Aug 8, 2009

Part Four - Final Chapter (Or is it?)


So, Friday July 31st was decision day.  I completed the application and completed the plan name line – HMO Blue $500 deductible.  I felt like I was making an unchangeable life-changing decision.  I was not happy but knew I had made the most practical decision for this moment in time. 


But what does it mean, at least for the short-term?  Is it that big a deal?  To someone like me who very much self-manages their health care and is very picky about seeing caregivers and choosing hospital affiliations, it is a big deal.  


It means I cannot seek assistance out of state.  Have I ever done that before?  Have I needed to?  Yes.  For three years while I lived in Florida, I came back to Massachusetts to see my endocrinologist.  Had I had an HMO back then, I couldn’t have sought the services of the physician I had trusted for years.  Have I ever thought to seek outside services other than Dr. Hudson?  Yes … I would have been down to New York in a heartbeat if Dr. Bernstein was an approved provider but he is not.  I know, for the most part, if I get cancer or have heart disease, I am in the right state.  We have some of the best cancer care facilities and cardiac care units in the country.  Is it possible there is something they couldn’t treat and some other facility could?  Apparently so … just ask Senator Kennedy who sought the services of a brain surgeon at Duke University. 


What else does it mean?  It means that I have to seek permission from my primary care physician to see a specialist.  The methods of referrals are easier these days as they are electronic but nonetheless, I am really dead set against asking permission from anyone about anything regarding my medical care.  In all practicality, with my current primary care physician, it merely means an extra step in the process.  I will still ask for a recommendation if it is appropriate.  I will still research the person on my own.  I will still seek other recommendations.  Then, I will have to call/email Dr. Meyerhardt and ask her and her staff to submit the referral “form.”  They are no longer hardcopy forms I realize.


It may also mean that there are fewer physicians and caregivers on the list.  I chose BC/BS because they are a widely accepted network.  I have not actually tried to diligently compare the two lists to see how different they are since they are also electronic and it is much more difficult to compare than when we had provider books.


I also chose them because I have rarely had trouble getting approvals (short one blood pressure medication).  I chose them because unlike a carrier such as United Health Care, I am not forced to use Merck Medco mail order pharmacy (or any other) to fill 99% of my prescriptions.  I can pay slightly more in copays and use my retail pharmacist (Dan at Big Y) who takes very good care of me and doesn’t try to manage care my prescriptions to death.  Nor does he break HIPAA laws or ship thousands of dollars in medications to somewhere I do not live. 


I also know that this is not the plan under which to need physical therapy.  The annual limits are much smaller than under the PPO.  As it is, physical therapy is very difficult get at the level necessary to properly rehabilitate injuries.  It will be more difficult with a much lower capitated coverage.  For the record, I have needed shoulder surgery for quite a while but I seriously doubt I will be able to “afford” it now anyway. 


Beyond these concerns, I am sure I will find out along the way the differences between the two plans and my sudden loss of freedom.  I know that it will, in the short-term leave me with less debt since office visits are not under the deductible; therefore, I won’t risk alienating Dr. Meyerhardt’s receivables person.  The alienation will be at the lab and hospital levels – blood tests, cat scans, etc.  Physical therapy, etc. is also subject to the deductible.


Massachusetts does mandate certain routine annual physical requirements be covered and NOT subject to a deductible.  I attempted to get a copy of the list prior to completing the application but the sales person said it isn’t available.  He said it might be included in the contract.  My dismay was with his comment that the doctor will know what is covered.  I don’t care if the doctor does know what is covered.  I want to know ahead of time what tests 1) I really need versus 2) what tests are covered and 3) the contract rate cost of those subject to the deductible.  I want that information prior to any office visit so I can have a reasonable give and take conversation with the doctor.  Diabetes require more routine lab tests than non-diabetics (e.g. A1C and creatinine) but they are considered “diagnostic” and therefore, subject to the deductible.  I also have an underactive thyroid, therefore, 2-4 sets of thyroid tests per year are “routine” for me.  So …I will have to work on getting my hands on the list and getting prices for other tests once I get my contract and new member card which should be prior to August 15th – the date coverage begins. 


Can you see how the process has not ended even though I made a decision and completed the application? 


The stress has clearly not ended either.  Though I believe I can keep myself healthy for another week or so and I am not in dire need for any prescription, the stress of being uninsured for any length of time is pretty high.  The stress of knowing I will incur $500 worth of additional debt I sure can not afford (being unemployed) is daunting.  The stress of not knowing how much less service I will get and how much I will have to fight to get what I need is daunting.  As a former employee benefits administrator and a diabetic adept at being my own advocate, I tend to know the rules and who to contact when laws are broken or rules are not abided by.  That does not, however, mean I want to undergo the arguments.  It does not mean less stress. 


However, I have to say I am very fortunate.  I live in a state that has outlawed pre-existing condition clauses, unwarranted cancellation of medical insurance and is forcing carriers to stick with premiums for one-year periods. as opposed to when I had a Florida conversion policy from United Health Care, earlier this decade, that had very hefty premium increases every 3-6 months whether I used the plan or not. 


As far as the “affordability” quest, there really is no good quality insurance coverage I would deem affordable for the average bear.  I do not consider $400-500 per month with or without large deductibles affordable for the average person.  That is more than a car payment – which is why I have not been able to buy a new car in years.  Once you pay the premiums you can not afford to actually go to the doctors with these deductibles and if you get stuck with a prescription deductible, it’s even less affordable.  To get assistance with premiums you must make less than 3x the poverty level.  To get assistance from the patient assistance programs, you must make even less than that.  Some only offer assistance at 1 or 2 x the poverty level.  In this state, you would be covered under one of the “free” insurance options. 


My head spins when I think about all this.  Sometimes (as you can tell) it all goes in circles and still ends up nowhere.  I can not imagine not having an understanding of medical insurance, COBRA and other employee benefits rules and regulations.  Some people will tell you anything thinking if they use an authoritative voice, threats, intimidation and the words “I have to” or the “law says so” you will give in, believe them and give up.  Do not be doing that! 


For those of you who have to go through this process without this experience and understanding, I am so sorry.  I can offer only this … open the window and scream “AAAHHHH”!  Then go get your favorite ice cream cone and savor it.  Diabetic or not, it  is my favorite stress reliever if not problem solver.


Doris J. Dickson

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