Health Insurance for Dummies

So once again if this blog were the movie version of my life it would be time to cue a montage with cameos of my mother and I burning up the interstate traveling to other research hospitals, sitting in doctor’s offices waiting, going in and out of MRI tubes, blood work, endoscopic cameras, and the song “Bills, Bills, Bills” by Destiny’s Child playing in the background as so many poor innocent trees were slaughtered to send the copious amounts of insurance claim forms and bills from specialists and hospitals to my door.  That’s the thing about healthcare, even with insurance it’s expensive.  Before now I had only paid the standard 20 dollar co-pay to my GP for the annual cold or flu.  I had never seen or deciphered a claim bill, calculated my deductible, or worried about out of network providers.  I thought if you had insurance it meant you were set.  Your healthcare was paid for by your plan.

Well kids let me tell you this is very far from the truth.  It is my personal belief that a required course in college should be one that teaches you about all the “stuff” you will need to understand when you eventually go out into the work force.  It should cover basic health plans, life insurance, 401Ks/403bs, 529’s, IRAs, How to file a tax return, disability and supplemental insurance, how to apply for a mortgage loan, car loan, consolidate a loan, figure our your credit score, invest those precious paychecks you have been earning, etc.

But I’ll get off my soap box and back to healthcare.  There are so many choices, and which one is right for you? Should you go for the higher premium or the higher deductible plan? HMO or PPO? And what in the world is an EPO? K-CHIP? The answer is, it’s all a crap shoot.  Are you a healthy young adult non-smoker who exercises, eats right, and keeps drinking to a minimum?  You are? Well then you should just go for the cheapest plan with the lowest co-pays right? Usually this is your HMO.  The only drawback is that your network is pretty small meaning the doctors who are “covered” by your insurance are usually local.  When you go outside your network your plan gets exponentially more expensive.  But you’re healthy, you’ll probably never need anything but a GP to cure your common cold or flu. Unless you decide to grow a tumor at your skull base of unknown etiology that no local specialist will be able to remove and need to travel out of state for treatment. For that you’re going to need a wider network, which comes with more expensive co-pays….You need the PPO. I remember in the early 90’s TLC did a VH1 special where they broke down the math showing how you could have a record go diamond, win a grammy, be massively successful in the music business and still be broke due to contract obligations to managers, producers, taxes, etc.  Health insurance is the same.  It’s possible to have “great coverage” make a modest salary, and still be broke.

I have a lot of friends who have asked me to help them sort out which plan they should choose when they have switched jobs simply because they know I have used my insurance more than the average young adult.  I can only speak for myself and my experiences.  All plans are different and all people use their healthcare in different ways but here’s a breakdown of my own personal medical expenses and how they applied to my plan for any of you who are just beginning your professional lives and have never had to wade through the acronyms.  I think it is easier to understand what you are buying (because you are buying a product whether it feels like it or not) when you have a concrete example of how your own health will ring up at the register once you pick a plan….

To start, you pay your premium, which comes out of your check every month like clockwork, this part isn’t bad, you hardly notice it.  Think of it like your electric bill only better because it comes out pre-tax.

Then there’s your deductible, (I have seen them range from $500 to $1200 for a “single” person.)  Everything is full price until you hit that number.  It’s like your inititation fee.  If your negotiated rate for an MRI is $455 and you have not paid anything on your plan this year guess what? You’re writing a check for $455.

So you’ve paid your deductible finally, everything is covered now right? Not exactly.  Now you and your insurance plan are in it together.  They pay 80% you pay 20% (remember, this is my plan, all of them are different but I think 80-20 is pretty standard across the board) until you hit your out of pocket maximum.  Again I have seen them range from $2500 to $4000.

So we’ve spent our deductible and payed 20% of everything else and racked the total up to hit our out of pocket maximum, now everything is free right? Well, not exactly.  Now all of your procedures, surgeries, and tests will be covered but you still have to pay your co-pays.  This is the fee that you have to pay to walk inside the door to a doctor’s office like the 50 you slip a bouncer to cut in line at a really exclusive club.  For me to see a specialist it is $50 every time.  And I see a lot of specialists who never just let you come through the door once.  Normally it goes like this: initial visit $50, order tests, follow up visit to talk about tests $50, refer you to an even more specialized specialist, initial visit $50, order tests, follow up $50. And on and on and on…

And for me the more specialists I began seeing the more problems that began to be diagnosed.  It felt like a Ponzi scheme.  After a routine physical at my GP’s where I complained of feeling lethargic we ran a full blood panel and found out that my female hormones were running at levels similar to that of a 40 year old woman in pre-menopause. Yep, you can ask me, I get hot flashes at age 29.  My most recent one was while standing (as a spectator) at the finish line of Ironman Louisville.  I was sweating more than the participants crossing the line who had just completed 140.6 miles in the August heat.  As a result, I have started carrying a fan with me in my purse.  I now casually take it out and fan myself like a woman from the deep south at church on Sunday when I feel one coming on.  It’s quite stylish, I found it in an old dress up box at my parent’s house.  Perhaps the fan will make a comeback along with the parasol and white gloves.  Anyway, this explained why I had not had a regular cycle in over a year as well as the fatigue but it also meant that I needed to see an endocrinologist as well as an OB/GYN to try and correct the imbalance and address the now pressing question of fertility.  The co-pays for these initial visits added up to $250.  Ka-ching ka-ching.

And then there were the migraines my God the migraines.  I was having them four to five times a week and they started above my right eyebrow, crawled up my forehead to the right side of my scalp and then some invisible being would hold my brain in its grubby little fist and use it as a stress ball.  Squeezing it in a rhythmic motion to the beat of my pulse.  The only thing that made these stop was to lay down, turn all the lights off and hopefully lose consciousness.  No amount of medication was helping me with these and it was becoming difficult to work when they would unexpectedly strike.  The only relief I have found to date is trigger point massage therapy. (which is not covered by my insurance, I think it’s too “natural” for people at insurance companies to understand.  If there’s not a lab or a prescription involved I think sometimes it throws them for a loop). Ka-ching. Ka-ching

I had also started to have strange episodes where I would lose control of my muscle tone when I felt a jolt of surprise or extreme emotion.  If a friend said something that caused me to crack up with laughter sometimes my legs would buckle underneath me and my knees would hit the floor.  I would find out later that this is a condition called cataplexy which is similar to a seizure just without the seize.  Everything relaxes instead of going tense.  I would see another specialist for this plus be put on some pretty expensive prescriptions to fix all these new found quirks my body had developed after my brain had been “smushed” by my tumor.  Seriously that’s what my endo says.  “Smushed” .  My docs and I like to converse in formal and technical terms. Ka ching ka ching.

Something else to keep in mind when you are paying bills and calculating medical expenses is the timing of the fiscal year.  I was diagnosed in March, and had maxed out my insurance by early June.  I was set right? Let’s just rack up these procedures that would be covered 100% by my plan and cruise into the new year.  What else did I want to go get tested? I’d be like Oprah to all of my body systems, YOU get a set of labs! And YOU get a set of labs! And YOU!

But I worked at a University where the fiscal rolled over on July 1 and I had to start back at zero with my deductible.  In 2012 I hit my out of pocket maximum twice and I am currently close to maxing it out a third time.  Did I mention that I had also taken a substantial pay cut to come work at my University?

“Money doesn’t make a difference to me. I want to use my degree and feel like my work makes an impact” was what I had told my boss when I walked away from a very well paying sales position.  He laughed telling me I was a naïve idealist.

As it stood I was now making less and spending more. It made me feel like a true American. Financially overextended and overleveraged.

Oh and I almost forgot, traveling for healthcare is also expensive, there’s gas, plane flights, hotels, parking, and food that adds up quickly.

At the end of 2012 when I would turn in my tax return. The grand total would add up to a little over a 1/3 of my take home pay.  With what was left I still had to pay a student loan, pay rent, keep the lights on, the water running, put gas in my car, and clothe and feed myself. (at the very least) I had been so concerned with bleeding out during my previous surgeries I had not thought of the possibility of hemorrhaging cash.

I started hitting my nest egg that had taken me my entire 28 years to save.  Before all of this had happened I had been going to open houses on Sundays looking at 2 bedroom 2 bath bungalows and dreaming of owning my own place. I had enough for a down payment and had done all my homework to take on  a mortgage loan.

But as the bills kept rolling in I started hitting that account so hard that it cracked open like a shell hitting the sidewalk during the egg toss at a 4th of July picnic.

Nest egg to goose egg in a matter of months.

It was so depressing to watch those numbers plummet and to continue to write check after check after check.  But what could I do?  There was no other option. I signed those checks until my fingers cramped and rediscovered my love of peanut butter and jelly, hunting for bargains at TJ Maxx, and riding my bike everywhere instead of wasting the gas. It turns out Kroger brand Frosted Fruity Ohs taste exactly the same as Fruit Loops. Who knew? Those extreme couponers that I had seen on TLC might have been on to something.  And did you know you can rent movies from your public library for a very meager price? Better yet there are these crazy things called books in there.  They’re kinda like the Amazon Kindle but you don’t have to make sure they’re charged all the time.  You CAN survive without cable. (but not the internet, which you can “borrow” from the coffee house across the street if you sit on your balcony)  And did you know that your parents’ miss you enough to feed you every Sunday night and send you home with enough food to feed you until Wednesday?  Maybe life would be simpler with less dollar signs to worry about.  Like B.I.G. and Puff said, “Mo Money, Mo Problems” right?

Eh….I wouldn’t go that far….I think maybe those two were talking about a different tax bracket when they wrote that song….

As I said above, I am not an expert on health insurance and there are even things within it that I don’t understand.  This post was simply to help anyone who has never even had to try and decipher a fringe packet see “how the rubber meets the road” when you actually use your health insurance quite a bit.  I invite feedback. ~Steph 🙂

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3 thoughts on “Health Insurance for Dummies

  1. Pingback: Health Insurance for Dummies | The Chronicles of Mayo

  2. Hey Steph, the title of this post grabbed my attention on facebook and I wanted to weigh in a bit on options you (and others in similar insurance situations) can look into. I’m sure you’ve looked into this, but there are a lot of organizations built for “underinsured” patients that will give you grants to cover your out-of-pocket expenses I happen to work for one of them http://www.panfoundation.org (others are http://www.cdfund.org and http://www.patientadvocate.org).

    You should be hitting up the manufacturers of all our prescriptions for free drugs (they all have established programs for this) and working with the hospitals’ foundations to get your travel covered. Even if you don’t qualify for the manufacturer programs, almost all of them donate to a non-profit whose programs will likely be more generous. Getting labs and doctors’ office co-pays covered is a little tougher, but if you can knock out the other stuff it could help. If you go through a non-profit to get your medication co-pays covered, everything they pay will still go towards your out-of-pocket max.

    A good place to start looking for assistance programs is http://www.needymeds.org – the site lists all the brand name medications you’re likely prescribed to and all of the assistance programs available for each.

    Next – google foundations that are involved in whatever diagnosis you’ve received so far. Many of them will have patient resources for paying for treatment.

    Next – if your plan does not cover a specialist in your area that is capable of doing the surgery you need, insurance companies are (as a general rule) required to pay for your procedure at a center outside of your group.

    I hope this helps you (or anyone else going through similar struggles). Can’t wait to see you and catch up soon!

    • Emily, this is exactly the type of feedback I was hoping for. There are so many options out there that many are not aware of and don’t even know where to begin to look. Thank you so much for your response and for reading.

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