Thursday, February 07, 2008

Blessings and curses

This shouldn't be a surprise to anyone, but western Massachusetts has a much more reasonable cost of living than does the Bay Area. For example, I bought a gallon of store-brand skim milk the other day at Stop & Shop for $3.69. A month ago we were buying store-brand skim milk from Safeway for $4.59 per gallon. (The gerb demands a lot of milk these days, so milk prices make me a lot happier than they probably ought to.)

The Commonwealth of Massachusetts is also a lot more concerned about health insurance than is the State of California. California's approach seems to be "let's wait until something goes horribly wrong, then get medieval on some asses" (as in the Blue Cross recission fiasco). Massachusetts' approach, by contrast, seems to be "let's see how much ass-medievalizing we can prevent." Recent legislation requires pretty much every resident to have his or her own health insurance--with steep monthly fines to deter potential law-breakers. Most employers are required to provide at least some kind of health benefit. There is even a state agency, the Commonwealth Connector, via which one can obtain insurance if one can't get anything through one's employer.

Unfortunately, the requirements placed on employers are pretty vague in terms of what constitutes minimum coverage. Mrs. Gerbil (who has found part-time work) and I (with the promise of temp work) have both been offered extraordinarily crappy coverage through our new respective employers. The plan which I've been offered has a very low maximum annual inpatient benefit which stands an excellent chance of being exhausted by the birth of the gerb--assuming, of course, no complications. The outpatient benefit doesn't cover preventive care, and the plan certainly doesn't cover mental health treatment.

Mrs. Gerbil has a choice of three coverage levels, two of which will only pay for 5 outpatient doctor's visits and 3 emergency room visits (presumably excluding ER services that lead to inpatient admission) per year. WTF? Now, I'm all for getting people hooked up with outpatient providers instead of using the ER for primary care, but if you've used up your five (again, WTF?) outpatient visits and you get a sinus infection, the only way to get the treatment covered seems to be to go to the ER. ('Course, the ER deductible might be more than the out-of-pocket cost of an office visit...) Again, there's no coverage for mental health treatment, and maternity care is subject to the same limits as other conditions.

My stint as a managed-care monkey gave me a very solid lesson in what sorts of questions one should ask about benefit design. However, it also taught me what constitutes a reasonable coverage limit. Naturally, I decided to call both of these insurance companies and press them a little on what exactly they cover and exclude.

First I called the plan I was offered. I waited on hold a long, long time and was eventually bumped into voicemail. The outgoing message promised a call back within 24 hours. I was not surprised when 26 hours went by with no call back, so I waited on hold some more and finally spoke to a very nice representative who really knew her stuff. She informed me that prenatal care is not considered preventive care (after all, pregnancy is a sickness), and therefore it is covered. She explained the various components of the inpatient benefit, the process by which one obtains reimbursement for prescriptions, and how to get documentation of prior coverage so as to be exempt from the pre-existing condition clause.

Verdict: plan sucks, but not as much as it could.

Then I called the plan Mrs. Gerbil was offered. I asked whether the outpatient visit limit also applied to prenatal care. The representative confirmed that it did. "That's amazing," I said, "and not in a good way. I'm in my third trimester, and even with a perfectly normal pregnancy I have to go to the midwife every two weeks!" The representative made an ambiguous little noise. I decided not to tell her that once I reach nine months, I'll have to go every single week. Instead I asked whether well-baby care and immunizations are covered, and if so, are those also limited to five visits. The answers: yes and yes. (The American Academy of Pediatrics' recommendations include no fewer than seven well-baby visits in the first year of life.)

Then I posed a more complicated question. Massachusetts has a fairly extensive mental health parity law. This plan has no mental health coverage whatsoever, so how is it exempt? The representative put me on hold, which I knew to mean that she had to ask her supervisor. When she came back on the line, she said that her supervisor (ha! I was right) told her it is because of the "delivery state." It didn't sound like the representative really understood this herself, but I happen to know from my all-too-recent managed-care-monkey days that exemption from parity laws depends on the state where the policy is written (and not where the patient lives) and how it is funded. (I swear, I wasn't trying to fake her out or anything! I just wanted to know!)

Verdict: plan sucks far more than expected.

And this, my friends, is reason #392 why I support universal health care.

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