“In America, no one should go without health care.”
~AFL-CIO
My husband is a teacher so we don’t have to pay for health care. They just take $3,000 a year in premiums out of his paycheck. We’ve chosen the most affordable “plan” his school offers. This year they didn’t even increase our premiums, they just doubled our co-pays.
With our Vermont Health Partnership Plan we get a “Primary Care Provider,” “preferred benefits,” and a “three-tier prescription drug benefit.” It’s fancy, and it takes an entire staff to explain the “features” of our plan each time we need to use it. But that’s not too much of an inconvenience because we rarely use it.
Our family of four actually relies on traditional care provided by a Naturopathic physician. Though Naturopathy is on the rise and is more affordable and effective in treating common ailments, it’s frowned upon. Thus in addition to our premiums and co-pays, we dish out another few thousand a year to cover our “real” care.
On the other hand, given our limited use of “the system,” we’ve never had to encounter some of the insurance sagas that we hear about from those unable to get the medical attention they need. Until yesterday.
Yesterday was the first time we’ve needed something from a pharmacy other than an antibiotic. A simple air cast is all we wanted. At the cost of $180. Our Naturopath put the order in, but then called us right back to say that there was a problem.
Apparently, our insurance plan with Blue Cross and Blue Shield of Vermont would cover pharmaceutical prescriptions, but not “durable equipment” prescriptions because this pharmacy was not in our “network” as a “durable equipment provider.”
After an aggravating amount of time on hold, my husband was given the name of two “providers” in network and he scrambled to call them before the end of the work day.
Unfortunately, he discovered that the two local “providers” did not have air casts. In fact, one of them was simply an oxygen supply company. Didn’t the insurance company know this? Thus my husband spent another half an hour on the phone after which he was told that he would need to use an out of state provider if he wanted insurance to cover the cost.
This seemed a ludicrous request given that the same product was available in our town– immediately–and given that my husband was in pain and required the cast to support his leg from re-injury. After another 20 minutes with the insurance company, they suggested we request “delivery” of the item, which was an additional expense that they would surprisingly cover. (Imagine how much that would cost from an hour away.)
However, delivery wasn’t available from the out state “providers” and neither was a cast– for 3 to 7 days. Thus my husband called the insurance company again, punching in all his numbers, giving all the same information to a new person, and finally being told that he should call our physician to have her submit a special “pre-approval” for the local cast– which could also take up to 3 days to be “approved” by the special “pre-approval durable equipment reviewers.”
Unfortunately by the time my husband got off the phone with the insurance company and the various “providers,” the doctor’s office was closed.
During this circus, we learned that had he used the Emergency Room over the weekend, rather than wait for our health care provider to see him on Monday, the hospital could have easily issued the air cast and all expenses would have been covered. (The system obviously doesn’t reward the cost-effective prudence of a doctor’s daughter who thought the Emergency Room wasn’t an appropriate use of our benefits in this instance.)
Toward the end of this escapade, I found myself wanting to rip the phone from my husband and scream bloody murder at the insurance company–or cry. This was inane and cruel and despairing. The poor guy just needed an air cast for his leg to relieve the pain and protect him from greater injury, but we had to play some crazy game to get it. (Imagine how many insurance “players” it takes to “pretend” that this game actually works.)
“Be specific in the pre-approval request,” our Blue Cross, Blue Shield Health Advocate tells us. “Make sure they know that it’s urgent. Tell them that you can’t find a local provider. Tell them that it will take a week to get one through the out of state provider. The “advocate’s” sincere (and misdirected) kindness makes me want to cry, and I’m appalled that I’m in the ridiculous situation of begging for a cast for my husband.
“Make sure the doctor includes all the details,” she repeats over and over again, saying “They can’t read your mind.”
Can they read an x-ray? I wonder. WTF!
This was our family’s first bitter “taste” of what many others endure in much more dire circumstances~ when it comes to having their medical needs met–or unmet–by our country’s “superior” health care system.
Our personal drama–and call to action– is aligned with the national one following the loss of Ted Kennedy’s seat (to a Senator who opposes health care reform) on the one-year anniversary of President Obama in the White House.
The politics of the healthcare debate may have changed,” says the Democracy in Action group MomsRising, ” but the needs of real people for healthcare have not.” Click here to tell your members of Congress to be strong and continue the fight for real health care reform.
(Click here to see additional posts on health care reform at the intersection of life and politics.)
Kelly Salasin 
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