- Health Care, Drugs & Insurance
Goldilocks and the HMOs
A Fractured Healthcare Tale
Once upon a time, Goldilocks lived in a country where medical care was not a right, it was a privilege. Goldilocks loved her husband and her son so much that she decided to give them the most precious gift in the whole wide world: healthcare coverage.
When she married Hubby she discovered he had been playing Russian Roulette with his health for years. She shuddered. She did research. She filled out an online application with Kaiser Permanente. She herself had Kaiser, and for the most part had had good luck with this giant HMO. Ok, there was that one time in 2003 when she slipped on a rock at Loon Lake and twisted her ankle and her PCF (primary care physician) declared it not broken without doing an x-ray and Goldilocks walked around on the ankle for a full week before going back and insisting on an x-ray, which showed a spiral fracture. Oops! Oh yes, and before that when her OB/GYN prescribed a medication for PMS, but she was on a similar medication already, and no one bothered to tell her she needed to taper off the first medicine before introducing the new medicine and she ended up in seizures and burst a blood vessel in her eye.
The important thing is that Goldilocks had health coverage. And Hubby did not. So she set out to sign Hubby up.
She read the Health Information questions -- all 8 pages of them -- aloud. Hubby supplied the answers. Many of them he could only guesstimate. It had literally been years since he'd seen a doctor, although he had gotten a sample of some blood pressure meds from a nurse practitioner about 6 months before.
When Kaiser (aka The Big Bad HMO) accepted Hubby Goldilocks was ecstatic.
But it soon became obvious they were only luring him into a false sense of medical security. Not unlike that cross-dressing wolf Goldi's friend Little Red Riding Hood kept running into in the forest.
Hubby immediately made an appointment to see his new doctor. He was so excited he told the doctor things he probably shouldn't have. Things about his medical background. Things about the aches and pains he was struggling with. Things that ultimately got used against him.
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Hubby Was Too Big
A week or so later, Hubby received an official looking envelope from Big Bad HMO. His doctor, it seems, had blown the whistle on him. The doctor's notes indicated a plethora of "preexisting conditions" which Hubby had failed to disclose on his application. One of the most serious was that in guesstimating his weight (he and Goldilock owned no scale), Hubby was off by about 20 lbs. And those 20 lbs. were enough to tip him into an unacceptable BMI (Body Mass Index) range.
Big Bad HMO rescinded Hubby's membership. They went so far as to accuse him of FRAUD. Now, if there is anything you don't ever accuse Hubby of, it's dishonesty. From then on Hubby paid out of pocket for his healthcare.
If At First You Don't Succeed
Goldilocks was a quick study -- or at least she thought she was. She had learned her lesson with the acceptance cum rejection of Hubby's coverage. She was not going to let that happen to her again, no sir!
Now Goldi's offspring (Sonny ) had always been covered under his dad's plan. A very rich plan. A plan that Goldi did not want to deprive him of, especially now that his dad was dead.
Alas, the monthly premium to continue his benefits under COBRA was more (a LOT more) than poor Goldilocks could afford. Even though she was used to paying high Kaiser premiums for herself, $350+ a month for a healthy 17-year-old seemed outrageous.
Hoping for a loophole, any loophole, Goldilocks read the fine print of the letter from the COBRA administration. "Ah ha!" she exclaimed. "Here's something interesting!"
Notice of Premium Reduction
And Second Election Period
"If you have become eligible for COBRA continuation as the result of an involuntary termination of employment (as determined by the Employer) between September 1, 2008 and December 31, 2009, you may be eligible for a federally subsidized premium reduction. In addition, you may also be eligible for a second election period if your qualified event was associated with an involuntary termination of employment that occurred on or after September 1, 2008 and you did not have a COBRA election in effect on February 17, 2009 (i.e., you failed to elect during your original election period or you elected but lost COBRA coverage prior to February 17, 2009)."
Surely Sonny's father's death qualified as "involuntary termination of employment." His dad would have continued being employed if he hadn't died. Except that by dying, he involuntarily terminated his employment. Likewise, Sonny would still have health benefits under his dad's plan if his dad hadn't died, his death thus triggering the involuntary termination of employment. Goldilocks thought out loud: "I think this scenario would fit any reasonable person's definition of involuntary termination, don't you?"
Actually, no, they didn't. It turned out to be part of a federal stimulus program to help the unemployed through the recession. The only way Sonny would qualify for the reduced COBRA premium would be if his dad had been laid off before he died.
Hearing this explanation from the COBRA administrator lady, Goldilocks didn't know if she was
a) Relieved that her ex-husband had not had to suffer unemployment on top of death, or
b) Angry that he had not been unemployed, so that she could afford the COBRA premiums for their son (or at least 35% of them).
Sonny's Needs Should be Small
Goldilocks decided it was worth a shot to see if Sonny qualified for an individual plan. If he did, she could bring his premium down under $200 a month. If he didn't... well, she'd worry about that later...
When she sat down to apply for health insurance coverage for the second time in recent years, Goldilocks decided to be uber-thorough. She would go with the full disclosure approach, leaving nothing out -- at least nothing that wasn't already in Sonny's medical file.
Since Sonny had been a Big Bad HMO member since shortly after birth, Goldilocks figured the medical review team could just go online and get any/all information they wanted to about Sonny's health history.
She also knew they were wont to toss the "F" word (fraud) around. And she didn't want it directed at her or at her poor son!
Sonny's Too Damaged
So once again, Goldilocks diligently filled out the 8-page questionnaire. She filled in names of Sonny's doctors. She didn't hold anything back. If a piece of information might be in his chart, she wanted to make sure she put it on the application.
Five days later Goldilocks logged on and saw she had a message from Kaiser. She eagerly went to the page, anticipating good news. What she got instead pushed her blood pressure to the boiling point.
Their denial of coverage letter spat back in her face the very details she had so carefuly disclosed. Big Bad HMO was unable to offer Sonny coverage due to the following:
1. He's sought treatment in a medical professional's office within the past 12 months.
2. His history of acne.
3. His history of situational stress, anxiety or depression.
I am not making this up.
Goldilocks was furious. Was it her fault their stupid check "yes" or "no" format did not allow for clarification or explanation? Yes, Sonny had suffered "situational stress, anxiety or depression." In point of fact, though, he had never, ever been diagnosed with depression. But he definitely suffered stress and anxiety. What 17-year-old with a chronically ill -- now deceased -- father wouldn't?
As for seeking medical treatment in a doctor's office within the past 12 months, whatever happened to "wellness visits" or "annual checkups" anyway? If Sonny had sought treatment 12 times in 12 months, sure. That might be considered excessive consumption of resources. But one visit to the pediatrician (required to sign up for sports each Fall) and they jump to conclusions that he's gonna bankrupt the whole system. Geesh.
And last but not least, acne. Sonny does not have a "history" of acne. He is a normal 17-year-old with a few random breakouts. He didn't even see a dermatologist. His PCF placated him (truly, his skin is not bad at all) with some prescription topical creams. Goldilocks only checked "acne" because she didn't want the medical reviewers peeking into Sonny's prescription history and finding -- God forbid -- undisclosed zit cream.
And Goldi, She's Juuussssstttt Pissed
In the original story, Goldilocks eventually got it just right. She found the perfect porridge, chair and bed for her. And she even made friends with the 3 bears. Aw. Isn't that nice?
But our story, remember, is fractured. There is no happily ever after when it come to negotiating with the Big Bad HMO. Sure, Goldi still has health coverage, but she pays a pretty premium for it, let me tell you. And at least Sonny is still eligible for COBRA. All Goldi has to do is find an extra $350 in her budget every month to pay for it.
But back to the story.
Being a true heroine, Goldilocks took on the challenge.
Did she suffer from situational stress and anxiety over it? You bet.
Did she pray every day for a new, perhaps statewide or even national system that could never deny coverage to anyone, or any reason? Absolutely.
But shhhh... please don't tell the Big Bad HMO ... or they'll probably find a reason to drop her as a member, too.