P.P.O. v. H.S.A. is Greater Than Or Equal To B.S.

That time of year has arrived, when it's time for the employer-sponsored health insurance to reset.

For starters, most know that Health Insurance can present challenging Diabetic Math Problems and it's common knowledge that anything having to do with health insurance coverage is B.S. But in the case of insurance coverage changes, you can pretty much count on it being Greater Than Or Equal To B.S.

We go through Suzi's employer, and like most people's plans we learned that several changes are in line forour health insurance coverage that runs June 1, 2010 - May 31, 2011.

1. Thanks to Anthem's outrageous hike of 45%, the small biz she works for switched to United Healthcare and that resulted in a roughly 14% increase from what we paying before. Aside from whatever plan coverage entailed, this is a company I've never experienced in my multiple insurers through the years and it's the one that was the subject of a recent news story about the insurance company's "anti-diabetes" program - that all set the stage for what I'd be walking into with this new insurance company...

2. With many insurers, PPOs are no longer available or they are being phased out for the high-deductible Health Savings Accounts. The claim is they are so much more cost-efficient and better for you. That may be true for "healthy" people, but for someone with a chronic condition that can tap out a deductible within a couple months, it's not the case. You have to apply everything - from doc visits, test strips, or lab and DME expenses - to your pocketbook through a HSA. But with a PPO you can utilize a Flex Spending Account, allowing you to access an amount that can be as much as your deductible up front and not have to come up with it from your own pocket. An HSA has a higher-deductible and is backloaded, meaning you pay as you go before the coverage kicks in full blast. For a Type 1 diabetic who uses an insulin pump, wants a CGM, tests 10 times a day, and has medical lab tests and doc visits regularly, this just isn't financially feasable.

3. So, we opt for the PPO or as they call it, the Buy Up Plan - I call it the Practicality Plan, as it's more out of the check but offers significant savings by not having to pay that entire $3,500 deductible up front from our pockets or risk having to set up multiple payment plans on top of what we already have in monthly bills. We will also continue our Flex Spending Account, which helps out on some of the more routine costs such as monthly prescriptions. This new deductible amount if about $500 more than our current annual amount, but it's half as the $6,000 we'd pay under the HSA plan. So there's that.

In making the switch, you have the usual annoyances of changing prescription and doctor office insurance information, calculating supplies to meet the coverage timelines, and making sure all the current pharmacy and docs fall within the plan. But there are also new restrictions being put onto this Type 1 diabetic with the new coverage.

A. Blood Test Strip Limits: Using the OneTouch Ultra Strips with my UltraSmart and UltraLink meters, I turned to the new Three-Tier Rx Drug Formulary that came with the initial reading materials. Finding a category dubbed Endocrine/Diabetes Blood Glucose Monitoring, I scanned the list to find my particular brand of test strips in the Tier 1 (read, most desirable and cost-efficient) list. There they were in the middle, with an interesting SL tag nearby... Looking that up, I smirked. The code key at the bottom said: "Supply Limit." I have never experienced this before, but have read many stories and discussed this with many Type 1s who have endured this limit. Basically, insurance companies (in some cases pharmacists) telling them that you can only test so many times and only get a certain number of strips each order, regardless of what your Endo says or your D-Management requires. Many have fought that battle and triumphed, and I don't doubt that I'll endure a different fate. But I've never had this issue before, and am actually in some weird twisted way looking forward to having that fool on the other end of the line tell me that I can't get the amount of strips needed for 12-16 tests a day. Bring it on, I say! (Yes, I am a little crazy... If you didn't already know that.)

This compounds the recent situation that came to my attention over the extended Memorial Day Weekend - one that I Tweeted about when finding it out on the Sunday just before the Monday holiday doubling as the final day of the month my previous coverage expired. The past insurer, Anthem, and its mail-order company NextRx, screwed up my final strip order and didn't process it, meaning that I had to spent two hours on the phone talking to five different people (a supervisor, and a supervisor's supervisor) to get any semblence of an answer. They passed the buck, and I had to phone Anthem to get it all straightened out (I think). Word is my strips are being processed and will be on the way soon, but the facts remain: 1.) I'm now low on strips; 2.) They've been delayed, even if they are going to be processed on my previous insurance; 3.) I'm sure someone will see the post-Anthem coverage date and try to deny my strip coverage, telling me I owe the full amount. It's happened before. 4.) More hassles will likely occur because of the insurance company changes and Endo Office coordination that is needed to get a new order processed with United Healthcare.

This is all Complete B.S.

B. DME Cap: We have an 80-20 coverage, meaning that our plan pays 80% after the deductible has been met and we'd pay the remaining 20%, in addition to whatever amount goes to paying down our deductible. Of course, that's not the end of it. A line that I've never experienced in my insurance plans as an adult says this about yearly DME benefit limits: "$2,500 per year and (supplies) are limited to a single purchase of a type of DME (including repair and replacement) every three years." So, to me that means no new pump within three years of buying a new one. That's not an issue as I don't forsee a need for a new pump. But it does apply to a CGM, as I'd hoped to pursue that option in order to achieve better D-Management as well as additional safety against Lows and Highs. Word is that these continuous montitors don't always get dubbed DME, but I haven't confirmed that with new insurance company and don't know yet how it applies. But I'll be phoning them soon to ask these questions, keeping in mind the monthly pump supplies that likely fall under that DME umbrella.

Of course, Pre-Service Notification is required for any DME or D-Equipment in excess of $1,000.

This is all B.S. x2, to the exponentially expanded powr of "What In The Eff is so wrong with you idiots that you want me to not have these tools in way to better manage my health and limit your end costs....?!?!?!"
3. Lab Tests: Amazingly, there's a new find in this insurance coverage: All preventative labs, X-rays, and diagnostic services are covered 100% with no deductible applied. In all the insurance coverages I've had through the years, never experienced this one. That's a new, welcome find that will come in handy for my typical two A1C and Lab Visits each year!

This new coverage began Tuesday and of course, we hadn't received any insurance card or Flex Account info by the time our coverage began... So, I'll have even more hassle when my regular three-month Endo visit happens Thursday and there's nothing for me to provide as far as new insurance carrier info. I'm sure that won't stop them from charging me the new co-pay, though: from $20 for any doc office visit to $25 for a "primary" doc visit, and $50 for any "specialist" visit. The plan doesn't define this even in the thick booklet and a company rep couldn't definitively tell me if my Endo falls into this category. I'd assume so, as she seems to enjoy charging more for anything possible. I'm sure it comes down to billing codes, though, so maybe there's hope from the front office... We'll see.

Of course, I assume that in changing my plans and matching all of my service suppliers and providers that I'll encounter the usual Insurance Coverage Stupidity that results from people being idiots and not having any clue about how their internal process operates. The common headaches will likely not be avoided, and there will be most probably be additional ones thanks to the change. Such as the Pre-Existing Condition Battle, which is almost guaranteed to happen and stretch on for way too long even though I've never had a moment's lapse in coverage during my 26 years of Type 1 diabetes and I've got multiple copies of all the documents proving this continuous coverage.

So, regardless of any silver linings that may exist, the bottom line D-Math Problem can be calculated as follows:

If a P.P.O = B.S., and an H.S.A > B.S.,
Then it can be concluded that: P.P.O v. H.S.A ≥ B.S.


Cara said…
We're getting ready to have some major changes on our prescription program. So I'm nervous about that. But, what can we do? Can't live w/ 'em, can't live w/out 'em.
As for an HSA, I didn't even thing that they'd take a person w/ a chronic illness. I've not done a whole lot of research though... Good luck with all of the changes and the craziness. Blah.
Judi said…
Be sure to check and see if you can get your pump supplies under the major medical portion of you plan instead of the DME part. Every company that gave me a plan with a DME cap had the provision that pump supplies fell under major medical. Somewhere in the fine print, DME is usually defined as something that is "permanent" and pump supplies are disposable, like needles and syringes. Sensors for the CGMS should also fall under the major medical if that were true in your policy. If your pump supplies fall under DME, your $2500 will go pretty fast. To find these answers, you're looking for someone fair high up in the food chain of your insurance company.
Scott S said…
You missed a few acronyms!! Try FSA and HRA (flexible spending account and health reimbursement account) to the list. My employer switched from United Healthcare to a NY-based plan last summer, and aside from brand new formularies, precert and preauth procedures, I also have a high-deductible plan, although my employer took some of the sting away by funding an HRA. The downside is that the paperwork is almost endless and neverending, as all claims have to be submitted in quadruplicte: to the insurer who doesn't cover until the deductible is met, but still needs the claim or they will never cover anything, then to the HRA administrator, then the FSA administrator for anything further that's not covered, then I get invoiced from the lab and/or anyone else who wasn't paid once all this crap was submitted. Then, by the time it's all cleared up, its time to start the who damn thing all over again. Speaking from experience, over the last 3 years, I've had United and Wellpoint/Anthem, and by far, United was superior on almost every measure. My new plan kind of sucks, but who knows, by July, they may switch carriers yet again!

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