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Health Insurance Inefficiencies And The Cost Of COBRA

Crutch WalkingWhat is this?

An illustration from “Physical Therapy for Zombies”?

Seriously.

The crutches are way too long and there is no banister on the stairs.

Actually, I don’t even see a second crutch.

Is the nurse is standing by or running up to rescue this guy?

If he is trying to elope, he isn’t going to get far!

********************

I figure if you are trying to understand something, begin with how it affects you. Make it personal, and it’s easier to grasp.

So I took on my health insurance coverage. I am covered through my employer, but surely I could get comparable coverage as an independent buyer.

Right?

*crickets*

*****

I am covered by Anthem Blue Cross.  You know, Blue Cross. The company that used to be the Gold Standard of health insurance? The one my physician no longer accepts because of their reimbursement rates? I figured my best bet was to check out and compare coverage from the same company, so I hit the Anthem Blue Cross website to try and get a quote.

You can get an overview of policies, but they make you put in your phone number so a representative can call you. I didn’t mind, as I had some questions.  I spoke with Danny, who was very helpful.

But before I go any farther, you should know one thing.  Just in case you are looking to purchase a private plan.

If you have insulin-dependent diabetes, Anthem Blue Cross will not issue you a private policy.

Whoa. Found that out when I asked about pre-existing conditions. I had always heard that folks were denied coverage for pre-existing conditions, but to actually hear it coming from a representative floored me.

*****

If I wanted to quit my nursing job tomorrow and make my living blogging (offers accepted), I would need to purchase insurance. I could go with COBRA and buy through my hospital for 18 months, or I could buy my own policy.

The payment for COBRA coverage for a family of three adults (ages 55, 52 and 19) is $2157.00 per month. That is $25884 per year, and includes everything from pediatric well-baby checks to maternity coverage.

Twenty Five Thousand, Eight Hundred and Eighty-Four dollars a year.

Pardon me while I go take a meclizine, just typing that number gave me vertigo.

Private PPO insurance for the same family of three, through the same company, with coverage for brand-name medications is $897, or $10,764 per year.

Huge difference.

On the surface.

*****

To get the private-pay plan you must be vetted. Screened. They will take you if you have high blood pressure, but only if you are controlled and have been on meds for a certain amount of time. Same with high cholesterol.  Same with GERD.  I’ve already mentioned the diabetes. If you don’t meet their criteria, it’s “buh bye”.

My friend in Human Resources told me that our insurance coverage was “more robust” than what was offered in the private plan. Our deductibles are less, our out-of-pocket per-year expenses are less, our co-pays are much less.

She was right.

But I am still confused.

And I have a lot of questions.

  • Why is my employer paying for coverage I no longer need? I’m long past needing the services of a pediatrician and maternity coverage is not an issue (been there, done that, may my ovaries Rest in Peace). Why can I not opt out of these things, saving my employer money? What if I did not want coverage for mental health, for example? The private pay plan is available without maternity care.
  • Why can’t I have the money that is spent on my health insurance premiums (more than some people make in an entire year!) put in a savings account that allows me, as an individual, to choose what type of coverage I want to have?  And have whatever is left available to pay co-pays and deductibles? They are paying the money anyway – why not put it in the control of the patient/employee.
  • Where the hell does the private insurance industry get the authority to decide who they will and will not cover? Is that not discrimination?
  • What happens when/if I develop an illness that would have denied me private coverage to start with?  Am I dumped? Is the illness covered?  For how long?

And I still don’t understand…

  • Why my doctor charges $140 for a visit, I pay $15 and the insurance company pays another $40, and my doctor winds up with only 39% of his fee? No wonder he doesn’t take new patients with Blue Cross.  What other profession has no control over their reimbursement?
  • Why, with my background as a nurse, I still am unable to make sense of an “Explanation of Benefits” report. There is an actual fee, a negotiated fee, a deductible, a co-insurance portion and then what is left is for me to pay. And trust me, the amount paid by either the insurance and/or myself never, ever amounts to the actual fee.  Ever.
  • Why I have a bill for lab tests and screening exams that far exceeds what my deductible is for the year, and yet the deductible is not yet satisfied.  Seems to me I’ve paid out the deductible-times-five and yet it is still not satisfied.

I don’t even know where to start to try and get an handle on this.

Either I’m an idiot or the system is way out of control.

Maybe both.

But I do know this.  I am a 52-year-old woman who is welded to her employment solely for the medical benefits. I’m getting older, I am going to need coverage for conditions and diseases that I did not have to worry about in my 30s.  Every decision I make, whether it be a new job or attending school full-time at a university will be decided by the availability of health insurance and what it covers.

Thank god I have that coverage.

I just wish I had more control over how it was applied.

Lord knows I could do it more efficiently.

*This blog post was originally published at Emergiblog*

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