Mike's Blog

Below is an example of why having a health insurance plan such as the one federal employees and members of Congress have would simplify things for patients and make coverage more fair, rather than allowing people to have the quality of their health insurance based on what type of job they have or who their employer is.

A couple of months ago I called CareFirst Blue Cross/Blue Shield’s Maryland Health Insurance Plan to ask what they covered for kidney transplants.  I had previously talked to the Financial Coordinator at a hospital who said that MHIP/BCBS does cover transplants – that you don’t have to get Medicare.

First, the person on the line at MHIP/BCBS strongly emphasized that a kidney transplant would have to be pre-approved in order to be covered.  I guess there are a lot of people who get kidney transplants who don’t need them. Maybe she thought I was trying to get the benefits of a kidney transplant when it wasn’t really necessary.  She was also kind of mean, which seemed strange.  Customer service reps are supposed to be nice, or at least neutral.

Anyway, I found out that MHIP/BCBS covers 80% of the allowed charges for in-network surgeons and 60% for out of network if you haven’t fulfilled the $1000 out of pocket maximum.  That’s different than the deductible.  If you have satisfied the out of pocket maximum, it would be covered at 100% of the allowable costs for in network doctors (I still don’t trust this).  They couldn’t tell me how much was allowable, though.  I asked a hypothetical question – what if I had fulfilled part of the out of pocket maximum – say $700 – then would they apply the first $300 of the costs of the transplant to the out of pocket maximum and then cover the rest?  She refused to answer that and just said that in order for it to be covered I had to have fulfilled the out of pocket maximum.  She said if I hadn’t fulfilled the out of pocket maximum, the benefits would be covered at 80% of the allowable charges.  I again asked what if I had fulfilled most of the out of pocket maximum – would the difference be taken out of the first few hundred dollars of the transplant costs, so that the rest of it would be covered?  For example, if the transplant costs $100,000 (it costs a lot more, but let’s say $100,000 for simplicity), and I had fulfilled $900 of the $1000 out of pocket maximum, would they apply the first $100 out of the transplant cost to the out of pocket maximum, so that the $99,900 remaining cost would be covered?  She and a second person refused to answer, though they implied that it would only be covered at 80% of the allowable charges if I hadn’t fulfilled the out of pocket maximum.  However, a third person did tell me that yes, the difference would be applied to the out of pocket maximum.  I had asked to speak to a supervisor, but I’ve probably asked about 15 times in the last year and a half and only once gotten to speak to a supervisor.

If you really think about it, an out of pocket maximum is just that – the amount that one has to pay out of pocket and no more – but I wanted to make sure.  I’ve had a lot of problems with this insurance company in the past.  (Just a couple of weeks ago I called to see if they received my medical claim.  The representative said it would be 30-45 days from the time I mailed it to the time that they could tell me whether or not they received it – not whether or not they accepted it or when I’d get the money.  So if they didn’t receive it, I could only find out that they hadn’t received it four to six weeks after I sent it).

I’m not even going to bring up the prescription medications.  This is confusing enough.

Then I found out that all the information above about what is covered for the transplant was irrelevant, because MHIP/BCBS requires you to use Medicare for transplants if you’re eligible.  MHIP/BCBS never told me this.

I called Medicare and got through after several failed attempts.  When I did get through, the person didn’t know if transplant recipients had to get Medicare.

Then I called another hospital’s Financial Coordinator and asked how much better would it be if I had a job with federal insurance.  She said she didn’t know because there are so many different federal plans.  But as far as I know – there are only two federal plans – Standard and Basic.  Each one covers virtually 100% of everything with just copays, and the process is transparent to the patient, without a lot of confusion and applying to different plans.  But she said she wasn’t familiar with them.  That was hard to believe because these hospitals do hundreds of transplants a year and I’m sure some of the patients are federal employees.

Then I called the social worker at the same hospital.  She said that the Financial Coordinator at the previous hospital was wrong that MHIP/BCBS covers kidney transplants, because MHIP/BCBS requires patients who are eligible for Medicare to take Medicare.  Medicare is automatically offered to anyone who gets a kidney transplant.

Medicare Parts A, B, and D seem to cover 80% of everything while a Medigap policy would cover most of the remaining costs.  I estimate that the total costs would be about $600 a month, about four times as much as the costs that it would be under federal insurance.  But it’s not the money that is the biggest issue – it’s more applying for different plans and dealing with people on the phone that could be stressful either right before or right after a transplant.

Medicare only lasts three years for transplant patients.  After that they consider that you are fine even though you need to take immuno-suppressant drugs for the rest of your life.

Luckily, I live in Maryland, which through MHIP/BCBS offers health insurance to people with pre-existing conditions.  But not all states have programs like this.

I believe the reasons that many people aren’t for the health care reform bill in Congress include the fact that even though tens of millions of people don’t have health care, a majority of people do have health care.  Also, while many people are discriminated against on the basis of pre-existing conditions, most people do not have pre-existing conditions.  Should people who have insurance care about those who don’t?  Should people without pre-exising conditions care about those who have them?  I believe so, but not everybody does.   In addition, the insurance companies are big businesses, so the people who work for them and invest in them want to see them continue to make big profits.  Finally, people don’t like change – they would almost rather be in a worse situation than a better one because their fear of change is so great.

In retrospect, maybe Obama and other Democrats should have had a more clear message, and listed about three major points, and used those points over and over in speeches, because the American people like slogans and soundbytes.  For example, they should have emphasized the following simple points (we need simple – let’s be honest, our attention spans aren’t that long):

1.  Many people don’t have health care.

2.  Insurance companies discriminate on the basis of health.

3.  If the money from the profits the insurance companies make were instead used for medical care and research, people would be healthier.

They should have also used real world examples of people affected.