all things insurance

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My dear friends, it’s time to talk insurance. (Doesn’t that make you want to gag?).

Insurance is a sore subject for me. Perhaps that’s because I’ve been waiting 18 months for a large reimbursement? Sadly, I’ve had many more problems than this one. And likely so have you. I hate that. I’m so sorry.

Since I’ve started treatment, each year has been expensive. Two have been “oh man, whew!” expensive, and one year was “jaw-dropping, break the glass you’re holding” expensive. The fact is, it’s very likely, even if you do a lot of naturopathic or herbal treatment, that you will still fly through your deductible, and perhaps reach your out-of-pocket max for in-network and out-of-network. Being sick is expensive.

Nonetheless, I still think that (for me) there are better or worse insurance plans, or at least there are insurance plans which give you more or less peace of mind.

I’ve been with two different insurance companies in the last few years, and I’ve been on three different plans:

  1. A PPO with an Health Saving Account (HSA) attached. It had an extremely high deductible, low monthly premiums, and me paying full pharmacy costs until having reached the deductible
  2. A PPO with an average deductible, average monthly premiums, and reasonably priced pharmacy costs ($15, $35, $70 tiers)
  3. And I’ve just starting a PPO with a low deductible, high monthly premiums, and reasonably priced pharmacy costs ($15, $35, $70 tiers)

I’m by no means an expert, but boy… I am fully aware of what I do and don’t want in a plan. In case any of my thoughts are helpful, I want to share them with you!

Choosing an insurance plan: 

  1. HMO or PPO? — PPO all the way, my friend. HMO’s have lower monthly premiums, but PPO’s have much more flexibility when it comes to choosing doctors and acknowledging out-of-network expenses. In my opinion, there’s no question. Lyme is a disease with no cure, just experimental treatment, so flexibility of medical coverage is absolutely necessary.
  2. Get a Health Savings Account if you can (HSA’s are awesome!) An HSA is a tax-deductible medical savings account. What you do, is you put aside part of your paycheck into a separate bank account. You then make medical purchases with checks or a debit card linked to that account. Basically, the benefit of this is that this money is put aside before taxes, so you are saving a good chunk of money. And because you are a Lymie, you’re probably going to use all of it each year.
  3. I prefer a LOW deductible plan. Granted, that means higher monthly premiums, but friends… Even though a lot of Lymie things aren’t covered (your Lyme Doctor, Igenex testing, etc), you’re still going to have plenty of prescription costs and labs (at minimum). The main reason I like having a low deductible plan is because it’s relieving to know that you can go to the ER if you’re having chest pains without looking forward to a huge bill. There’s something so wrong about sitting in your living room not being able to breathe, but having to weigh the option… “Well, I could be dying from too much herxing, or it could be benign, ‘normal’ Lyme stuff. I can’t afford to pay a $5,000 bill, though… Hmmm, what to do???” Basically, I think having a low deductible makes you feel comfortable with doing the extra full-body MRI that your doctor wants to do “just in case”, or the EEG that your neurologist would “feel more comfortable if we knew for sure.” If you’ve met your deductible in February and your out-of-pocket in May… You can feel awesome about getting any procedure you want for free. Home health care… free. A $10,000 antiviral (yes, they exist)… free! Ah the joy of a low deductible.
  4. If you can find it (this might be hard)… Get a plan where your pharmacy costs are applied to your main medical deductible. Often, when you have a low-deductible plan, they exclude your “pharmacy costs” from your “medical costs”. Therefore, even though you’ve hit your $8,000 out-of-pocket max with medical bills… They can still keep charging you for prescriptions. Major pain.
  5. As depressing as it sounds, when it comes to my health I think in terms of “prepare for the worst, hope for the best.” That means I look ahead to see if home-health care would be covered (and for how many sessions). I look to see if IV meds through a PICC line would be covered (they are more expensive and sometimes a grey area). Read the booklet. Ask your insurance agent questions. Don’t go off of the one-page handout. Read it all, because there will likely be sad surprises along the way if you don’t (I say this from way too much experience being disappointed).

That’s how I pick insurance.

Now, once you have that insurance, here are some other things to keep in mind:

  1. You are you own biggest advocate. No one is going to work harder than you. So, you will have to drive your insurance company, your pharmacy, and your doctor’s office to all work together. If your pharmacy needs your insurance’s authorization for something, it’s likely you’ll have to follow-up to get them to approve it. It’s frustrating that sick people have to be the driving force behind getting things done. I call it the “hamster wheel”. I’m constantly spinning the wheel to make sure things keep moving. Persistence gets things done. It’s frustrating. I can’t emotionally / physically deal with it everyday, but I push myself to do it when I can. And it’s worth it.
  2. This is a bit of a repeat, but at a different angle — As stinky as it is, you have to be on top of your insurance company.
    • They will miss claims. They will make mistakes that cost you more money. If you stay on top if it, you can find errors that make all of the work worth it… I like to keep a spreadsheet showing the cost I paid, what the explanation of benefits (EOB) actually said, a column to show any discrepancies, and a place for notes. It’s important to write down inquiry numbers for specific conversations with insurance representatives, as well as the dates which you called them. Though it feels near impossible to summon the energy, paper trails can make your life a whole lot easier in the long-run.
    • Additionally, your insurance company will unintentionally be slow on issues that should’ve been quickly resolved (remember my story about the 18 month issue I’m STILL having?). There may be times when you need to call every day in order to get something done. You just gotta do it. Oh, doesn’t this make you want to cry a bit? It’s okay… You can come over to my house, and we’ll cry together.
  3. Send in ALL of your out-of-network bills. I send in my Igenex lab tests, my doctors visits, everything… It does add up, and they will count it towards your out-of-network deductible. If you have a medically-intense year, you may actually get reimbursed for some of the things. Worth it!
  4. Treat all of your customer service representatives with respect and understanding. They get yelled at all day. They get stinky attitudes from people all day. When they get a kind person on the phone who is cheerful and tells them over and over, “Thank you so much for your help. I really appreciate it”, their attitude changes. And they end up extra eager to help you. It’s a “win” for you, and it’s even a “win” for them. With as limited as we are, it’s exciting to get to spread cheerfulness to a stranger on a tough day. Many days, we are stuck in bed and there’s not a lot we can do. This could be your friendly, meaningful interaction of the day. Such fun!
  5. And don’t confuse being respectful with being timid. There is a way to be kind, but to be direct about your needs. I have actually said the words before, “Listen, ________ I’m so grateful for your help today, but I have to be honest. I’m REALLY sick, and this issue is making my life miserable. I need your help. I need to talk to someone who can push this forward and end this problem.” And it works. Every time. There’s a lot of mercy, a lot of understanding, and a big desire to help. For me, that makes my icky insurance problems feel a lot more human and bearable.

Whew — I just typed a lot of words. If you made it to the end, congratulations! I hope some of this helps as you pick an insurance plan and work with an insurance company. It is certainly frustrating. There’s no way around it. But, I hope that some of these thoughts make it a little less frustrating.

If you other Lymies have tips, please comment below… And of course, if anyone has questions, please ask, and I’ll do my best to answer.

You’re awesome. Go get em’ tigers!

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