Allow me to demonstrate exactly how I feel about dealing with all things financial and/or insurance related:
As I mentioned earlier this week, I went for a consultation with Dr. Warmenfriendly, the man I’m really hoping will be my reproductive endocrinologist (RE). I say hoping because right now I just want to bash my face onto my keyboard I’m encountering insurance hurdles I hadn’t anticipated.
Let’s break this down into the three distinct insurance nightmares that this is turning out to be.
Insurance Nightmare #1: They don’t take our insurance.
So when I made an appointment back in late Feburary to see Dr. Warmenfriendly, I couldn’t find my wallet so I told the scheduler on the phone I’d call back with my insurance info. I never did. I ended up sending it via email the morning of my appointment last week, only to receive this whopper of a detail just 3 hours before my appointment:
“We’re not covered under your insurance, so your initial consultation will be $375.”
My rookie mistake: when I called to schedule my appointment, I never asked if they took my insurance.
*facepalm*
A very rookie mistake indeed. That said, I have to give their office credit for calling my insurance company on my behalf to see if they can make it work. The staff at Dr. Warmenfriendly’s place is pretty incredible like that. They gave us 2 options: either get my Primary Care Physician (PCP) to send a referral or they could work with our insurance plan directly. The latter would take about 2 weeks whereas the former should only take a couple of days.
“Should” being the operative word here.
Insurance Nightmare #2: My PCP won’t make the referral.
When I left my job back in November, I had to buy new insurance since Larry’s job doesn’t provide it. Since we’re paying for our premiums 100% out of pocket, we cheaped out on the insurance plan as much as we could, keeping in mind that we both have chronic health issues that need regular monitoring.
My PCP belongs to a group of doctors that have satellite practices throughout the state, perhaps even throughout New England. I’m not sure. Let’s call them Colonial Doctors Group for the sake of explanation here. (Obvs, not their real name.)
Regardless, I didn’t know that when I started seeing Dr. Hipster, I’m only entitled to receive care from Dr. Hipster’s network of specialists; that is, the larger network of specialists that are an extension of Colonial Doctors Group because they just so happen to have a fertility clinic of its own.
No matter how many times I’ve tried to get one, my PCP will only write referrals to see REs at their Fertility Clinic. Which, on one hand, I feel like is a conflict of interest. On another, it’s standard practice for doctors’ groups like these.
The Referral Coordinator has a message to call me back tomorrow. I get the feeling this is going to be a challenging call because they refuse to budge, even when I tried contacting my PCP directly about it. Because at no point did anyone say, “Hey! We only refer to our little group of specialists, even if they’re not the specialists you want to see.”
I plan to lay it out pretty plainly when I talk with the Referral Coordinator tomorrow:
I get that Colonial Doctors Group refers out to their own Fertility Clinic because hey, it’s more money for Colonial Doctors Group. But are they really going to tell me that they’re willing to lose me as a patient – and thus, my ability to make patient referrals to CDG – because they’re more interested in my money than the highest quality standard of care I could receive?
Because let’s face it: Dr. Warmenfriendly is my guy. He’s got good stats (better than CDG’s clinic) and he really understands my unique situation. And my PCP is going to hold me up from attaining the best care I possibly could all because CDG only refers to their own?
I call bullshit.
Insurance Nightmare #3: I’m in Open Enrollment right now.
So on top of all of this, my third insurance nightmare is both blessing and curse. On the one hand, it’s Open Enrollment so hey – new insurance. On the other hand, we’re tying to select the best insurance possible that we can afford while still meeting our unique medical needs.
One of the biggest factors is the prescription plan. Between Larry and I, we take 4 daily medications. We simply can’t afford a high Rx co-pay. Sadly, this means having to settle for other high-cost price points, such as annual deductibles and out of pocket annual maximums.
So we’re factoring in how much a year’s worth of each of our prescriptions would cost in co-pays, then factoring regular doctor’s visits, the insane amount of blood work that comes with infertility treatments and oh yeah – the infertility treatments themselves.
Nightmares 1 & 2 have proven that we need to ditch our current insurance carrier. They are a beast to work with. But it would also allow me to go back to Doc Awesome, my PCP who specialized in thyroid treatment. He also wasn’t a complete dick about referrals – just the opposite in fact. (Would that make him a vagina about referrals? Probably not but you know what I mean.)
We’re looking at 2 different carriers, 2 plans each. The one carrier will cover fertility drugs for egg donors while the other one won’t, so we’re definitely favoring one over the other. The fun is then parsing out the finer details of co-pays, deductibles, and all that other crap.
It’s enough to make you want to pull your hair out.
I’ve been quite the vocal advocate for equal access to healthcare. Until last week, I sat comfortably in my little bubble of “I live in the best state in the US when it comes to infertility treatment coverage! Insurance issues are going to be a cakewalk!”
But that bubble has popped and for the first time, I get the healthcare reform debate because I’m up to my eyeballs in this insanity. All this meshuganah just to get me knocked up. Could you imagine if I had a life-threatening disease as opposed to a life-altering one? How do people negotiate this never-ending bureaucratic rigamarole just to receive the care they need?
Madness, I say. Madness.
Oh, and did I mention this Sunday will be my 3rd anniversary of my infertility diagnosis? Yeah, D-Day is this Sunday. Just glorious timing.
And now, a shameless plug to round out this post.
You can help cheer me up by voting for my limerick in Lori’s Limerick Chick Contest! I made it to the final round of just TWO limericks – the final showdown – and I need your vote to help me clinch the lead. I wrote a limerick about the ever-amazing JW Moxie of The Smartness, so a vote for me is a vote for JW Moxie. All it takes is just one click to vote and voila! You’re done.
Seriously, every vote will keep me from losing my mind over this insurance junk 🙂
I enjoy, cause I discovered just what I was looking for. You’ve ended my four day lengthy hunt! God Bless you man. Have a nice day. Bye
Posts like this make me sooooo glad I’m Canadian. It is not a perfect system (especially when it comes to infertility treatment — which is, for the most part, not covered) — but this sort of stuff is generally something we do not have to deal with. My mother is American & waves the stars & stripes at every opportunity ; ) but she thought she was going to go insane when she had to deal with all my grandparents’ medical paperwork.
Loribeth, thanks for commenting. I am often envious of socialized healthcare but I hear it’s not all sunshine and roses in Canada either. Still, it’s a helluva lot better than what we’ve got down here. Thanks for commenting!
Oh insurance. Hugs. I hope it gets fixed and that things are covered enough so you can afford to have that baby! I’m terrified to find out how much 3 days in the hospital to eventually have my gallbladder out cost, and I imagine the D&C will cost us a fortune too. Hopefully some day we get insurance fixed so it’s less awful. I work in a pharmacy and so I see how many people it frustrates and how many hours we spend trying to get things covered that really should be covered but for a mystery reason are not. It’s so sad that we have to live this way. Ugh America.
Marie, I couldn’t agree more with your comment. If anything, my post and all these comments illustrate a desperate need for major healthcare reform in this country. Thanks for commenting!
Oy, insurance. It blows. I should know, I work for an insurance company- the funneist part? Even though I work for a MAJOR insurance company- they offer NO infertility benefits.
At all.
Not a penny. In any plan.
Yeah, let that one sink in a moment…
Also, I live in Maryland which is an IF mandated state. I’ve held several jobs in Maryland, and not one met the IF mandate qualifications. You have to have your insurance provider in state (meaning, for example, your employer is in Maryland, has more than 50 employees, is not a religious institution and has bc/bs of MARYLAND, not of Virginia or anywhere else). And that is extremely, extremely rare because the laws/taxes in Maryland make insurance a difficult game here so everyone outsources to carriers in other states. So our insurance covers NOTHING infertility related, at all. Even if its for medical reasons (my DH’s insurance had a $5,000 lifetime cap that included diagnostics. We ran out of that in ONE MONTH. Thanks, hsg and sperm anaylsis!)
It blows. 🙁
Becky, this is blowing my mind: “Even though I work for a MAJOR insurance company- they offer NO infertility benefits.”
That is beyond bullshit, as far as I’m concerned. Massachusetts has similar mandate language, but I wasn’t aware of how difficult it is for insurance co’s to get set up in Maryland. My husband’s last 2 jobs both had insurance that was out of state, in non-mandated states, so they didn’t offer infertility coverage either. At least now that I’m the subscriber and we get in-state, we get a little something.
Ai, yi, yi. And I thought insurance in the surrogacy arena was a loaded landmine.
Having read the comments above, I’m also surprised at how exclusionary much of the coverage is in the states that mandate infertility coverage. Good grief.
Every day – good or bad – is one day closer. That was my mantra back in the ttc days. This is a hurdle, and one you’ll jump…hopefully without a crunch to the balls. Figuratively speaking, of course. 🙂
Lol, you said crunch to the balls.
And you’re right. I can’t wait to look back with my bounty of nine children, bouncing ALL NINE on my knee and laughing, “Ha ha ha, insurance was so hard to deal with, ha ha ha!”
No but seriously – I think I will have to laugh at the absurdity of what it’s taking to have our family 🙂
Believe me the practice you are getting now is preparation for navigating Medicare in your old age. Except now you are young, strong and, hopefully, mentally sharp. Insurance coverage need not be so complex to understand but it is financially to the insurance companies benefit to keep it hard to track. They use this in dealing with patients and in paying hospital insurance bills where paying from the “Wrong” coverage just seems to happen “by error” and then stall up to 10 years in correcting their underpayments while hoping the hospital financially goes bankrupt in the meantime.
I certainly wish you luck with building your family, dealing with insurance coverage, and protecting all of us against anti- woman laws and medical restrictions.
I totally believe that. It’s like the tax code. Thanks for commenting!
Aw yes, the nightmare that is insurance. Washington State has zero coverage for fertility treatments and medication. It’s both a curse and a blessing. A curse because everything is out of pocket. But a blessing because we don’t have the hoop jumping until you become pregnant. When I was going through a miscarriage in January, it was the insurance provider that was causing most of the stress: they didn’t agree with the prescriptions I was one and they fought covering the D&C. Thankfully my clinic is skilled with dealing with HMOs, but it pissed me off that we’re paying for coverage for services that they whine about having to provide.
Wishing you all the best as you navigate through finding new insurance.
Just FYI… you do know that you can claim out-of-pocket medical expenses up to 7.5% of your adjusted gross income on your taxes, right?
Insurance is one of the main reasons why we gave up trying to conceive after 2 1/2 years. We live in a state (PA) that does not mandate coverage and I’ve had 2 jobs and 2 insurance companies over the last 2 1/2 years. The first company did not cover any testing, treatment, medication, etc. related to infertility. Thankfully, I had an awesome doctor who was able to code some of my tests in a way that would allow the costs to be covered. But, the treatments and drugs were all out of pocket. The second company for the new job will cover anything related to infertility testing, but will not cover treatment or drugs. Unfortunately, this company also didn’t allow me to see my old doctor, so I started all over again with a new doctor with the same tests, but this time, they were covered. Well, except for the HSG. I had it pre-approved since it was a test and made sure that the facility where it was being performed was in-network. Then, a few weeks later, I get a bill for $600. It turns out that the procedure was covered, the hospital was in-network, but the doctor performing the procedure was out-of-network and I have no out-of-network coverage. Thankfully, I was able to fight it and was given a one time exemption from this, but I can’t for the life of me figure out how I was to know that the doctor was not in-network when he was working in the hospital which is in-network.
Even though I’ve stopped all infertility treatments, tests, etc. because we could no longer afford it (along with a TON of other reasons), I am still fighting the insurance company for other things. Lately, they’ve been trying to deny my PCP doctor visits because some moron can’t type the correct code that shows that he is in-network. So, every time I see him, I get a bill and then have to call and have them reprocess it which takes 20-30 business days. Why it takes so long to punch in a 5 digit number into a computer and click OK is beyond me.
I think insurance companies are the lowest level of scum and should go to the lowest level of hell. Dealing with them is a nightmare. I wish you luck, but I am very pessimistic when it comes to insurance companies. In fact, I’ve considered moving to Canada for the socialized healthcare system.
Gail, thank you for sharing your experience. I can tell this is a sore subject for you, but I appreciate you sharing your experience here so that others can read and learn. I agree – insurance is a fucking nightmare. And this is all just for a life-altering disease, not a life-threatening one. I can’t imagine what the hoops must be for cancer patients. All to get the basic care you need. You’re right – you have every reason to be pessimistic. I don’t blame you one bit after everything you’ve been through.
I hate insurance. It is so ridiculous that it doesn’t cover infertility.
It’s a good thing you have a great doctors office though!
PS – Your “Ggugghh” face cracked me up!
Hope things get going in a positive direction ASAP!
Thanks Suzy! I’m so inspired and encouraged by this RE, I think I have a little bit of a doctor crush on him. He’s going to be a great fit for us, I can just tell! How are you??? I lurk and I think about you a lot.
Ugh ugh ugh ugugugugug. No fun.
I lived in an “infertility-mandated” state too (California), but worked for the state, so massive loophole = no coverage. It sucked. Now I live in a no-mandate state and still no coverage. Still sucks. Ugh.
Oh man, Sara – that blows. It seems so incredibly wrong that mandated states exempt state employees.
Insurance can be such a nightmare, we are lucky to have a few plans to choose from with dh’s job, but reading all the fine print to find the right one is so tough. I called an insurance company to go over coverage before we picked them and went with them because of what they said. So what happens when I go to use the coverage they said I had before I signed up, they say it’s not covered. So the next open enrollment I switched plans again.
Thank G-d for open enrollment, seriously! If we had stayed with the plan I talked about in this post, we’d be effed. Just effed when it came to treatment time. Thanks for commenting Jenn!
I, too, live in an “infertility-mandated” state. Let me tell you the truth about that where we are: 1) the mandate only applies to heterosexual, married couples who have been diagnosed infertile for at least two years and are using their own gametes (no donor eggs or sperm allowed); it has a lifetime cap of $15,000, and 3) self-insured companies / small companies (less than 50 employees) are not required to cover it.
What that means is that as a STATE employee (my hubby and I both teach), we are EXCLUDED from the mandate. The very people who passed the law also passed stipulations that mean they don’t have to follow the law. (State employees are all self-insured). So, if I go work for Wal-mart, they have to cover me, but the school district does not. And don’t even get me started on the exclusionary language of the mandate — I mean really? UGH.
Sorry, you clearly hit a nerve here. I am hoping your insurance nightmare is not nearly as awful as ours has been. (Let’s talk about the $7,000 D&C I had to have while uninsured because of a missed miscarriage — while anyone else could go to Planned Parenthood and have it done for about $300).
No worries at all about hitting a nerve, Jo. It’s kind of amazing how often state employees are often excluded from state mandates. It boggles the damn mind, honestly. Also, the hetro/married requirement? Bullshit. I’ll say it, because it is. LGBT folks can be infertile too, as can single people. Unbelievable, but something’s better than nothing, I guess? I dunno, I struggle with that.
I’m so sorry for your loss, too – the financial costs on top of that are such an insult to injury. Thanks for sharing your experience too, about your infertility mandate. I think people think that the mandated states have it easy when in reality, it’s just a whole other level of bureaucracy.