You Can’t Always Get What You Want

That was the tune sung at the latest Pulse on the Road in Baltimore,
Maryland on Friday, October 2! Speaking at the 12th Annual Insurance and Reimbursement Conference—an NHF gathering of social workers
and executive directors of local hemophilia organizations— speakers Laura Summer,
health care policy consultant, Michelle Rice, vice president of public policy
and stakeholder relationships at NHF, and yours truly spoke to this group of our nation’s
frontline defense, the people who handle insurance issues every day. Indeed,
when I asked the social workers how much of their time do they spend on
insurance issues, even I was shocked to hear “75%.” Health care is complicated
and complex; workshops like these help everyone share the journey, learn from each
other, and learn new things.

One way we learned was from role playing! We had two volunteers pretend to be consumers calling the payer (Michelle). Michelle tested them by deflecting their questions, providing wrong information and putting them on hold–a lot. 
Michelle really
set the tone. “For years we’ve been asking to be treated like everyone else.
Well guess what? Now we are!” Payers now look at us not the helpless victims of
a genetic disorder, but as patients with medical needs who have bills that must
be paid. Unfortunately, our former reasoning of “But, we have hemophilia! We’re
special!” is not going to work anymore. We need to get smart, savvy, and
strategic.
Michelle asks: Is
your request to the payer a question of access [to a particular brand of factor
or HTC or home care company]? Or is it a preference issue? “We can’t spend time
on preferences anymore. If you want homecare company A and not B, and B is not
in network, then you must use A, or pay a lot more for B.”
She reminded us
that if your desired factor brand is not on the formulary (the list of drugs
that the payer will cover), that doesn’t mean you aren’t going to get your drug;
you’ll need documentation from your medical provider, and it will cost you
more. And if your factor is not on formulary, check the major medical side of
our policy—it might be there, and might be covered.
Bottom line is
we need to accept a new reality in insurance.  We need a personal budget for out-of-pocket expense each
year. We need to read our insurance policies carefully and completely, each
year. We need to open and read those letters from the insurance company. No
short cuts!
Michelle
stressed that we must take responsibility for our own insurance situation, even
as the NHF, HFA and our local organizations continue to advocate for us on many
levels. It starts with each of us first and foremost. Start with your policy:
if you have private insurance, speak with your human resource department to get
answers. If on Medicaid or Medicare, visit your social work at your HTC.
You can’t always
get what you want, but you can read, document, question and hope! Working
together, we will get many things need and maybe even want.
                                                                                                                                               

Good Book I Just Read
Selling the Invisible by Harry Beckwith

Written in 1997, this book is a bit dated as it doesn’t mention email, cell phones or social media. But still, there are many good lessons to learn that are timeless classics. This quick read teaches why focus groups, value-price positioning, discount pricing, and being the best can fail; the vital need to focus on one message; the one emotion that most influences why your prospects will buy from you. Three stars out of five.

Welcome to the Jungle, I mean Marketplace! Part 2

At NHF’s Social
Worker Insurance Workshop in Baltimore on January 16, there were some great questions
asked from the audience concerning the Marketplace. Social workers know they
will most likely be the first line of defense for patients with bleeding
disorders facing the many challenges of the ACA. Here are some questions asked
and other snippets of information from the workshop.
Very cool illustrator maps out the discussion
Q. What if you
don’t like the insurance plan options in the Marketplace. How do you file a
special appeal [concerning coverage]?

Go to Healthcare.gov; there is a link for an appeal. Appeals are
worthwhile because sometimes codes are entered in wrong, and sometimes people
get approved for procedures and benefits that were originally denied.
Is there a limit
to the number of appeals?
No.
Laurie with social worker
Ed Kuebler, Texas
Q: But after you
pick a plan and don’t like it, what if you just don’t pay the next month’s
premium? Won’t you just get canceled and then you can choose another plan? Isn’t
that easier than an appeal?
There is an open enrollment time, so you can’t choose to switch
outside that time period. After March 31 you can’t get into a “QHP” (an insurance plan that is certified by the Health
Insurance Marketplace, provides essential health benefits, follows established
limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum
amounts), and meets other requirements.)
Joanna Gray, of CRD Associates told us that the ACA says HTCs must be included in-network. But… plans don’t have
to include any specific medical procedure. They only need to cover “sufficient”
providers, and they don’t say who those providers are. The ACA hasn’t come through
in its promise. NHF says be careful! Don’t pick a plan that doesn’t include
your HTC or product, because now it’s legal for providers to avoid HTCs. We can’t
change the policy for this year. Maybe next? We need to complain to get
changes made
.
Mike Bradley (Baxter), Laurie
Kelly, and Derek Robertson

(Apogenics, Inc.)
NICOLE of NHF said that every state has its own
definition of EHB (essential health benefits). So picking a plan is harder, because
there are more plans, and picking one that covers what you need is hard.
Q: To use the Marketplace, you must be a legal
resident.  What happens to legal immigrants,
who are not citizens? In Nevada, they are currently covered under high-risk
pools but will lose this soon (the pools are closing). Are there alternatives?
No. You can still get emergency medical through Medicaid; and of course, anyone
can buy insurance in the commercial marketplace.
Nancy Hatcher and
Ed Kuebler again!
JoAnn Volk of The Center on Health Insurance
Reform, Georgetown University Health Policy Institute, said that
six states will not enforce the ACA: Alabama,
Missouri, Oklahoma, Texas, and Wyoming. The ACA gives primary responsibility to
states to enforce the rules, but there are 10 state benchmarks (Essential Health
Benefits) that must be followed, and
will be reviewed by the feds.
If you find a QHB but it doesn’t include factor,
JoAnn thinks that the appeals process will work, recommending that people get
their drugs for 20 days, during the appeals process, even if they are not on
formulary.
Q: How do I find the benchmark plan for my
state?
All benchmarks
are listed in the state insurance department website. www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/Vermont
 (for example)
Q: What’s the advantage of going into the Marketplace?

The advantage of going into the Marketplace is subsidies; you can be eligible
for discounts within limits. To buy into a Marketplace, you have to be physically
in the state, not incarcerated and be legally present. There are no other
limits.
Q: When we couldn’t find what we were looking
for (was our hematologist covered), and we called the website, we couldn’t get
any help.
Don’t call
the health.gov website. Call the plan provider. Sometimes it’s best to work
with your HTC contracting department! 
They will know who is in network.
And there is so much more information! Be
sure to keep reading your HemAware (from NHF), Pulse (from us), and tap into your
chapter’s or your local hemophilia organization’s efforts to educate their
families about insurance changes. Lots happening; don’t miss deadlines and
opportunities by not staying on top!
Great Book I Just Read (Again)
Ada Blackjack: A True Story of Survival in the Arctic  by
Jennifer Niven [Kindle]
A secret exploration to Wrangle Island, in
the Behring Sea, in September 1921 goes terribly wrong when food runs low and
sea ice keeps a relief ship from rescuing the stranded four young men and one 25-year-old
Eskimo woman trapped there. The trip sets off an international crisis when
Russia, Great Britain and the US learn that the trips leader, the opportunist and
greedy explorer Vilhalmur Stefansson, who never even went, was trying to claim
the island for Canada. Only Ada survives the horrible conditions, and her
return sets off a media firestorm. Did she kill her companions? How did she survive?
Diaries are stolen, Ada is hounded and used by the press and her own sponsors.
She becomes at once a hero and a villain. Fantastic read and Ada will amaze you
with her spirit and ingenuity. Her real survival started when she returned home.
Four/five stars
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