ins issues before the doc?

[wtfimpoz]

Are there suggestions that would be useful?  I'm specifically worried about insurance issues.  It'll be my first appointment.  I'm still not technically HIV positive as my first test was "indeterminate", and my second positive was based on a home-access test.  My insurnace company arbitrarily denied the s**t out of the tests they ran during my conversion, and i'm afraid of them doing the same thing for this.  Is there anything I should be aware of or watch out for?

[hotpuppy]

Take a deep breath.  Try to remember that stress is your enemy.  Relax if you can.

Some insurance companies consider HIV and STD's to be optional coverage for testing purposes.  Don't ask me how.

HIV is a medical condition, just like diabetes, cancer, the flu, etc.  It's a Chronic one.... so be prepared for the same bumps that every other chronic disease comes from.  The insurance company may behave badly and increase your rates or make your life unpleasant if they can.  Most of them are professional.

Where are you located?  (what state?)  It makes it easier for some of us to help if we know where you are.

Generally speaking you have a deductible on most plans.  You are less likely to have grief if you are on employer provided health coverage.  they can't raise your rates or drop you.

Insurance is supposed to spread risk among everyone in your "pool".  A pool is a group of subscribers.  So everyone who works at XYZ Airline who has insurance is a pool.  employers have to have a certain percentage of employees enrolled to have a group plan.  They also have to cover a certain amount of the cost.  These things are stipulated by Federal Law.

The problem comes when you are in a small group such as a 6 person company or an individual policy.  In these instances if you begin to make claims your coverage cost may increase.  The cost should be equal to the average expense plus an administrative overhead that includes a reasonable profit for the administrator (insurance company).

Part of the insurance companies job is to ward off unnecessary expenses by making certain procedures more difficult to get.  It's critical for those of us with insurance and HIV to read our policy and understand how everything works.

Now, my expertise is Texas so let me explain how my world works.  States are generally similar but each one is different and some are better than others in how they handle things.

I want to paint out for you what the world would look like if you were in Texas and for some reason you had to drop your policy.  Let's say they increased your rate to a rediculous point, canceled you, you lost your job...etc.  I just want you to understand that you will continue to have access to health care through a variety of things.   I also want you to understand how deductibles work on my policy..... yours will probably be similar.  Think of this as Insurance 101.  Up to this point I've explained the principles at play in how insurance companies operate. 

Okay, first off there are a variety of mechanisms that they can use to boot you out of the pool, but it depends mainly on what pool you are in (employer vs. individual).

In Texas you are eligible for Ryan White and ADAP care if you make less than a certain amount.  Ryan White is the Federal Government program to help people with HIV get care when they don't make enough money to afford care on their own.  Each state calculates it a bit differently.  In Texas it is 300% (3 times) the Federal Poverty Level plus your med cost.  So what Texas does is takes the FPLx3 and adds the cost of 12 mnths of HIV meds, which is about $9500.  They use their cost, which is often different from our costs, but it's not something they are required to do and it covers alot more people this way.  The FPL moves every year based on the cost of living, inflation, and the mood in DC.  The magic number, the combined FPL+drug cost is around $34,000/yr.  So if you make less than this and you live in Texas you have the option of Ryan White funded care.  It's not always convenient, but it will take care of you.  Different states operate differently, but there should be something similar.  Your ASO (AIDS Service Organization) is the gateway to this care.

If you make between $34,00 and around $50,000 you can receive subsidized care here.  You'll essentially have some costs associated iwth your care, but our ASO will do the heavy lifting for you.  Essentially what they are recognizing is that $34K to $50K still makes it too expensive to pay your insurance and  or meds costs.

Over $50K here and you are on your own.

In Texas we have something called a High Risk Health Insurance Pool.  It is for people who are denied coverage by insurers.  It is run by the State.  It is administered by Blue Cross.  This means that the world sees it as Blue Cross insurance because we are in their PPO Network.  I'm in this pool because I make more than $34K some years (I own where I work) and because I can afford the premium.  By law, our premium is 200% of the average, so my coverage is about $440/mo.  That's expensive, but meds are not cheap..... so I refer to it as my medical investment.  FYI the pool loses money and bills insurers for the losses.  While this generally sucks, I have decent insurance and I'm guaranteed eligibility.  The requirements are 3 denials, HIV, Cancer, Diabetes, etc.  Do you see a pattern here?  Expensive diseases find it hard to keep or get insurance coverage.  You may be just fine but I want to paint the unknown for you so you aren't stressed.

So here is how limits and deductibles work.  First, put "health care reform" in the "so what" pile because it doesn't apply for a few years.  Right now we have coverage limits.  Each policy has a lifetime limit of what you can use.  Some have annual limits.  this is why it is important for you to be familiar with your coverage.  My policy has a $2MM (million) lifetime limit but it excludes medications.  This means I can't consume more than $2MM in my life or I get dropped.  It's basically the same as your auto policy limit of coverage.  The key here is that this doesn't include meds which are the biggest expense for HIV+ people.  My guess is that they figure by the time you rack up $2MM you are poor anyhow and eligible for Medicaid/SSI. 

Now let's talk deductibles.  My policy has two deductibles.  One for drugs and one for everything else.  My drug deductible is $200/yr.  This means in Jan, the first prescriptions I fill cost me $200 out of pocket.  Happy New Year!  Pass the lube please.  After that, generics are $10, name brands are $25 and non-formulary is expensive.  Formulary is the list of drugs your insurance covers.  Not all insurance covers all drugs.  New drugs and obscure drugs are generally not on their list, which is called a formulary.  You can ask them to add new drugs, and most drug companies do this when they get approval.  Expiremental drugs are usually non-formulary as well.  This is the insurance companies way of discouraging you from using things that are usually expensive and that they don't know if they work or work well.

Okay, so now my other deductible.  My non-medicine deductible is $5K per calendar year.  This is met at the network cost which is blue cross blue shield's cost.  So when I do bloodwork, Labcorp spits out a bill for $1300 to BCBS.  BCBS has pre-negotiated the cost of this service at $160.  So I get a bill for $160.  When I pay the $160 that counts towards my deductible.  Unless I get sick, it's pretty hard to meet my deductible.  So my insurance ends up acting as a giant discount plan.  My routine chest X-rays were like $30 instead of being $200.  My doc gets $65 for an office visit, not the $125 he would bill me at "list" price. 

After I meet my deductible I'm not out of the woods yet.  I still have what is called co-insurance.  Co-Insurance is a split on costs.  So if the network (negotiated) cost is $100 and I have 20% coinsurance then my cost is $20.  This is usually your co-pay.  After the deductible is met I have a out of pocket cost that I have to meet for the year.  My co-insurance is 20% and I don't know my out of pocket cap off hand.  I think it's another $3000.  What this means is that if I go in and need $1000 of treatment I'll get a bill for $200.  It scales up btw until my portion is $3000. 

What this really means is that if something horrible happens like hospitalization, my maximum exposure is $8K..... which isn't bad considering the cost of hospitalization.   

Lastly.... you have a couple of things to try.
1) Your provider can appeal the denial of coverage.
2) You can call and appeal it. 

It's not uncommon for these things to go back and forth 2 or 3 times.  Normally you get a bill from the test company directly.  Now, if the test was $1000 and you are getting a bill for $100 my advice is pay it and don't attract attention to yourself.  You very well may not have met your deductible and you are getting a bill for the network cost of the service used.  On the otherhand if you are getting a bill for $1000 for $1000 of services.... yea squawk!

Each "provider" (and there are many) gets to bill you independently.  If you make the unfortunate mistake of going to a non-network provider be prepared for near highway-robbery.  I went to a little "emergency room" when I fell and cut my elbow.  I nearly fell again when I saw the bill.  My insurance company told them to go fly a kite and so they billed me directly.  I did get some credit (at network rates) for the costs against my deductible.  However I still got a bill for quite a bit.  I called them directly and negotiated a decent discount.  More than the network rate and less than the bill.  I then promptly paid that and got the heck away from there. 

In Texas, btw, Emergency Rooms are guaranteed coverage... thus the little independent ones don't have agreements with the insurers.... why should they?  They can over-bill if they don't.  Most hospitals have agreements with insurers.... so it's important to know who is in-network and who isn't.  Ah the games of insurance. 

My experience has been that the insurance CSR's are nice.  You might start by simply calling and politely asking why this was denied.  Dont' volunteer any info.  don't tell them you think you are poz.  Just simply stick to the facts.  Your doctor ran some tests based on his opinion that they were needed.  Until your doc "diagnoses" you.... defer to his opinion.  example: "Why did your doctor run this test?"  Answer: "You would have to ask him.  I didn't feel well and so I went to see him and he is trying to figure out why I didn't feel well.  He's a great doc and I trust his judgement."  (Code for bug the doc I ain't saying shit!)  In the medical world, patient opinion carries no weight with the insurance company.  we are not a qualified opinion.  The doctor and nurses are.  Play that to your advantage. 

[hotpuppy]

Okay, so I read and responded to your other posts.... and I decided to come back to this one.  Let me explain what the normal first steps are for someone who is poz in Texas.

1) Do complete bloodwork
2) Take inventory of existing medical issues.
2a) Treat other chronic issues such as blood pressure, etc.
3) Check for STD's - they often come with HIV at no extra cost.
4) Treat for STDs
5) Bring immunizations up to snuff.  Flu shot, swine flu, pneumonia, hep A, hep B (takes 2 shots 6 months apart)
6) Check for TB and do X-Ray
7) Get dental up to snuff.  Cavities can be bad as they are infections.... so you want your dental under control.
8 ) look for and deal with underlying mental health issues such as bipolor, depression, etc.  Counseling and or medication if needed.
9) evaluate bloodwork and coverage (insurance/ADAP/Self-pay) and determine if meds are appropriate.  There are 4 answers here (No, At patient request, at doctors suggestion, at doctors insistance).
10) Take "FirstSteps" class which is basically HIV101 and teaches overview of HIV, nutrition, over of meds, and other topics that are important.

Chances are you will go through a similar list wherever you are.  Most of this stuff is a normal part of your phsyical or is just basic preventive care for HIV+ patients.  Healthcare is a team event and you *are* on the team.  So if your doc doesn't suggest a flu shot, ask for it.  The shot is way better than the illness.  Go to the dentist on your own.  

A note on the dentist.  You might call and ask if they treat HIV+ patients before you have that conversation.  Dentists in particular sometimes aren't comfortable with HIV.  Dentistry almost always involves blood.  My dentist is gay and is good about HIV.  HIV is very affected by dental health and your dentist needs to know you are poz so he can watch for HIV related issues and be more aggressive with treating infections.  I was extremely nervous about telling my dentist.  He is a friend and I've known him for over 10 years.  My ex-bf goes there, my mom went to him, my employees see him, my ex's parents go there.... I was terrified he might tell someone who DID NOT need to know.  He promptly re-assured me that he is a health professional and like all professionals patient information is confidential.  Heck, my ex and I (we are still close) had appointments the same day a couple hours apart and only found out the next day when we were talking on the phone.  Since I told my dentist he has gotten a little more aggressive with getting no cavities and perfect dental.  Whereas before we didn't seem to be as aggressive with fighting plaque etc.  As an example, my dentist put me on a prescription toothpaste which is higher in flouride to help knock down the plaque.  (I breathe through my mouth at night which exacerbates plaque)

I personally have had enough drilling in my mouth..... hate it.  Nitrous is my friend at the dentist.  At my insistance I go in for a cleaning quarterly so we can catch anything while it's small.  Overkill?  maybe.... but it's better than having a root canal or several cavities.

[wtfimpoz]

Thanks for all the info.  I'm gonna start from the top.  If i miss anything, please forgive me but there is a lot of information to absorb.  I'm in Ohio.  Employer plan.  Just converted so I'm hoping and praying that I may not have to start meds until a lot of the health care reform has gone into effect.  As a result, please bear with any questions about changes which haven't taken effect yet...

"Some insurance companies consider HIV and STD's to be optional coverage for testing purposes"

*Any chance this will change with new healthcare legislation?  Will it change once i'm officially positive?  My state just readjusted ADAP guidelines.  I've blown WAY past the income max for ADAP, which now has a waiting list anyways.  Since these tests apparently run into the thousands of dollars, what suggestions would you have to afford them?  Does anyone know the EXACT formula for Ohio ADAP is? 

What kind of copayments am I looking at?  I'd assume that it'd be my regular $15/prescription, but somehow I know that won't be that easy (maybe its because I'm staring at a drug company ad offering $150 rebate on copays).  What should I be wary of?  Since I likely won't remotely qualify for ADAP, and they've basically shut the program down anyways, what should I be planning on doing?  Anything more useful than "win the lottery" would be appreciated .  My income is rightaround 50k, variable, so give or take a few thousand every year.  As you've pointed out "thats too expensive to pay my med costs".  Shouldn't my prescription drug plan be doing most of this?  Can my employer rescind the prescription drug plan?   

"now we have coverage limits.  Each policy has a lifetime limit of what you can use.  Some have annual limits.  this is why it is important for you to be familiar with your coverage.  My policy has a $2MM (million) lifetime limit but it excludes medications."

*I thought this was stopped effective now.  When will this stop?  I've *just* converted, so its unlikely that I'll necessarily have to start meds immediately.  How do I find out what the limits are? 

"Formulary is the list of drugs your insurance covers.  Not all insurance covers all drugs.  New drugs and obscure drugs are generally not on their list, which is called a formulary.  You can ask them to add new drugs, and most drug companies do this when they get approval"

*So appalling!  So effectively my insurance company can kill me?  God bless America  ...  Is this eliminated by the health care legislation, if so when?  How do I find out what my plan's formulary is?  There are horror stories floating around the internet of my company removing ATRIPLA from the approved formulary.  Somehow, that results in the copay being $150.  I can stand $150, but much more is kinda freaking me out. 

I feel a little immature in admittig this, but I'm looking at the whale of the insurance problem, and I just wish there was someone else to eat the damn thing for me.  Is there anyone I can go to who will tell me how MY insurance is going to deal with this?  I'm not comfortable calling my insurance company directly with the announcemnet that I have a chronic, supremely expensive illness...i suspect that come a week, i'll randomly be fired if i do that.  Is there a third party who I can turn to who knows the ins and outs of this BS?

[phildinftlaudy]

Hi wtf -
I have health insurance through my employer.  Best to look through your coverage book and usually the summary of benefits sheet they provide.  My insurance company knows about my condition - as I coordinated my meds with them.  I was going monthly to the local pharmacy to get meds and paying $20 copay each time (Atripla) --- by going through them they were able to hook my up with one of the health care system pharmacies and I get a 90 day supply delivered and only pay $40 total copay.  It is also cheaper for them to as they get the script at the 340b rate - which is federal program cost. 

I do everything I can not to be "as expensive" of a client for them and I let them know this.

They have actually been great --- I pay standard copay for my doc visits - nothing for my labs and they fully covered my upper and lower GI.  When I went to the ER and the bill was $12,000 -- they had a negotiated rate and paid $900 - I paid $75.

Suggest you get as familiar as possible with the particular insurance plan that your company has and the drugs covered.  I am hoping that the rate my employer pays doesn't go up because of my high costs (as we are a company of about 60).  I suppose if that happened then they might start acting crazy, but I have learned not to worry too much about things that haven't yet happened and are "if comes"

Keep us informed       
Best to you,
Phil

[leatherman]

Does anyone know the EXACT formula for Ohio ADAP is?

Eligibility is now limited to people with annual incomes at or below 300 percent of the federal poverty level; that puts the threshold at about $32,000 for a single-person household. The level had been 500 percent.

What kind of copayments am I looking at?  I'd assume that it'd be my regular $15/prescription, but somehow I know that won't be that easy (maybe its because I'm staring at a drug company ad offering $150 rebate on copays).

many of the drug companies now offer rebates, reduced payments, benefit cards, etc. Once you get prescribed meds, you should check at the manufacturers websites to see what offers they have that might coordinate with your insurance.

[hotpuppy]

"Some insurance companies consider HIV and STD's to be optional coverage for testing purposes"

*Any chance this will change with new healthcare legislation?  Will it change once i'm officially positive?  My state just readjusted ADAP guidelines.  I've blown WAY past the income max for ADAP, which now has a waiting list anyways.  Since these tests apparently run into the thousands of dollars, what suggestions would you have to afford them?  Does anyone know the EXACT formula for Ohio ADAP is? 

Whoa cowboy....   HIV testing is about $100 at the most... and STD testing is *routine* for sexually active gay HIV positive men.  We are talking about syphillis primarily.  I was simply suggesting that a few things could be going on with your STD tests:
1) You have a deductible that isn't met.  As such you have some out of pocket expenses to deal with.
2) The cost of them may be minor, in which case it isn't worth digging a trench and stringing barbed wire.    I consider $100 to be minor.

There are a few sources of help and you can get a little information from each.
1) Your HR department will answer questions about your plans.  You don't have to tell them. "hey I got screwed a few months ago and decided to get an HIV test and our insurance is kicking it back."  Instead, you can ask them what your company deductible is and how it's met.  Just explain your doc ordered a couple of tests and you got a bill for it and couldn't quite understand it.  Don't go into detail and it's completely okay to tell them that you prefer to keep your medical information private.  Chances are really good that they don't care anyhow.  Trust me on this one.
2) Your doctors office.  How they bill something can impact if it is covered or not.
3) The insurance company.  Always refer to tests as "diagnostic test" and defer to the "doctor's judgement."  Example:  Hi, Suzy?  I recieved a bill in the mail and I'm having trouble understanding it... can you help?  My doctor decided to run a diagnostic test when I went to see him.  Why am I being billed and what do I need to pay? 

Lastly, you may have received a "statement of benefits" which looks a hell of a lot like a bill.  It's a statement that shows what the insurance company paid for services you received.  Make sure you aren't freaking out about a SOB....   If you are, don't sweat it.  Everyone does at least once until they understand what they are.

Let me share some more with you.

Regular bloodwork, i.e. complete blood count is $165/pop.  My cost is $10.63 because that is the negotiated rate. 

HIV specific tests + regular bloodwork is $1000 something, to which my cost is $160.  CD4 and Viral load are expensive tests done only in a handful of labs.... I only need those quarterly.

If you don't like the whale analogy... try figuring out how you dig out from a 4 foot snowstorm.... one shovel full at a time.  Slowly but surely.