Cover Me, I Need Healthcare

Apr 05, 2023

Good Morning Healthcare Advocates

I’m very thankful for your advocacy for healthcare reform. Let me take a moment to point out some resources for you. At the bottom of every newsletter are links to additional sources. The first is a link to the League of Women Voters Healthcare Reform Toolkit. It is a rich source of material on healthcare reform, especially single payer.

The second link is our collection or resources. As we find new important sources I save them there for you. There are links to lists of healthcare reform groups, reproductive health sources (where to get medication, for instance), US government and other healthcare data sources and more.

I’ve left the links in place for appeals and denials of claims in the resource section today.

If there are sites that you think are useful, please send them to me in the comments (which we all can see) and I will include them in our resource list.

Good News

Judge Janet Protasiewicz was elected Tuesday to fill the open seat on Wisconsin's Supreme Court She is more progressive than her opponent and so hopefully this will bode well for reproductive rights in Wisconsin. (Link)

More Good News

Washington’s governor Jay Inslee has purchased and has on hand 30,000 doses of Mifepristone, used for medical abortion. He estimates this stockpile should be sufficient for the next 3 to 4 years. Washington is facing an influx of patients seeking an abortion from numerous other states, such as Idaho and Texas. (Link)

Is My Medical Care Covered? Maybe, Maybe Not

This should be such an easy question to answer but, of course it isn’t. It depends on what kind of insurance you have, if you have any insurance.

Some insurance companies can choose to deny coverage based on their own clinical data depending on the type of policy. They can decline to cover certain drugs because their pharmacy benefit manager didn’t get a kickback from a particular drug maker. Of course, when you are buying the policy, you have no idea about this and it shows up as a rude awakening. Coverage can change without notice.

The US government is more transparent about what is and isn’t covered and puts rules in place for the policies that fall under their jurisdiction. This includes basic Medicare and ACA policies purchased through a federal (not state) exchange. Here is a Medicare document on the subject, and here is an ACA web page about coverage. Note that the Medicare document does not describe what a Medicare Part C (Medicare Advantage Plan) covers. You have to discuss that with that policy’s administrator since that is private insurance.

Generally, state ACA marketplace plans are similar to federal but they can differ from the federal plans. Check the plan you are considering purchasing and if you know of an upcoming procedure or treatment ASK THE PLAN ADMINISTRATOR IF IT IS COVERED BEFORE YOU BUY.

If you have Medicaid then each state has its own version of what is and isn’t covered. Is there a minimum level Remember the instance that motivated T. R. Reid’s book, “The Healing of America”. It was about a young woman with Lupus, who after an episode, lost her job and health insurance, and wound up on Medicaid in a state that chose not to cover her necessary prescription. Of course, after multiple organ failures, without the medication, she died.

Here’s one: I was employed by a company that has employees in many states and they chose to be self insured, a fairly common practice for large companies. They follow a different set of rules for what they want to cover and often many basic items are not covered as they follow a different set of rules. I needed a procedure to be performed. The policy covered my in-network doctor and in-network surgery center. I thought I was diligent and chose correctly, my procedure should be covered.

My insurance company told me, after the procedure was done, that they were not covering the anesthesia. To them it was not medically necessary. When I was naked on the table in the operating room, they applied anesthesia, they did not ask me about it.

I called the insurance company to complain and they told me that the company was self insured and they could not change it. Try calling your Human Resources office, I was told. I did and luckily was able to shame them into covering the bill.

The lesson is that up front, when you buy insurance from over 900 health insurance companies, you don’t always know what you’re getting.

They can decline to pay for drugs you need because their pharmacy benefit manager did not get a sufficient kickback for that item, they can choose to say that your procedure is not necessary and you can pay for it yourself or seek some other treatment, at your peril.

In the case of pre-approval we had Wendell Potter’s example yesterday about a young woman whose pre-approval was denied, and the appeal took days and inbetween, she died. She would have been saved had the procedure been done when needed. (Link to his Wikipedia page).

So what’s the answer? You know what it is. It is uniform, universal health care, with transparent decisions making about coverage for all of us, not some of us.

TAKE ACTION

RESISTBOT Text SIGN PNIKRO to 50409 to tell your Federal Officials

We have an unequal, unfair situation with regard to healthcare in America and I want you to address it. What procedures, treatments and drugs are available to you depends on who you work for, where you live, and what policy you may or may not buy. Too often we are faced with denials of coverage when we need help the most. Let me remind you that according to CMS statistics 17% of all federal ACA plan claims are denied. Just last week we learned that Cigna is using AI software to deny 300,000 claims in 2 months.

When you need the drug, or treatment or procedure that’s too late to find out your insurance won’t cover it. We need a transparent system that covers all of us with no surprises, cradle to grave.

Representative Jayapal (WA) will be reintroducing her Universal Health Care Bill (Single Payer) and I want you to cosponsor and vigorously support it in the House, the Senate and in Public. We all need this and we need it yesterday.