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Grant D Griffiths

After my heart attack some 6 years ago, BCBS started to raise my premiums so much that they finally priced me out of medical insurance. When it hit almost $2,000 a month, I gave up and dropped it. Needless to say, I can not get it anywhere else either. So I am one of those Americans without medical insurance.

Corinne A. Tampas

How true! Anyone who thinks that they have good medical insurance has never been sick!

In 2005, I was diagnosed with breast cancer. Between November 2005 and December 2007 I have had seven surgeries at four different hospitals. During one of those surgeries I contracted (from the hospital itself) Methicillin-resistant Staphyococcus aureus or "MRSA", the most serious form of staph infections. I think I know a thing or two about medical insurance.

I have a HSA with Blue Cross of California. I am in a PPO. My deductible is $3,500 and Blue Cross pays all my medical bills once I meet that deductible IF ..... IF ..... the physician/hospital/health care provider is a Blue Cross provider.

If the physician/hospital/health care provider is not a Blue Cross provider, then Blue Cross will pay 50% of what BLUE CROSS THINKS THE SERVICE IS WORTH. As a general rule, Blue Cross automatically thinks the service is worth 33% less than what was billed. Then it whittles down the value of the service from there.

So, those who have never been sick ask, "why don't you just use doctors that are Blue Cross providers?". The answer is, sometimes you are forced to use those that are not Blue Cross providers. Often you do not know until you receive a bill:

1. Prior to my first surgery, I made an inquiry of every physician involved and the hospital. All of them were Blue Cross providers except for my general surgeon. Since I wanted that particular surgeon, I accepted the fact that Blue Cross would pay very little for his services. However, I was stunned to receive a bill from the pathologist.

Even though the pathologist works through the hospital, a Blue Cross provider, and is the ONLY pathologist at that hospital, the pathologist is not an employee of the hospital, but is an independent contractor and NOT a Blue Cross provider.

The pathologist billed Blue Cross $3,600. Blue Cross decided the value of the service was $1,200 which Blue Cross paid 50%, or $600. My share of the bill was $3,000 which was in addition to my $3,500 deductible and my general surgeon.

2. After one of my last surgeries, and while still in the hospital, I developed what fortunately turned out to be a minor complication. It was about 3:00 a.m., so instead of contacting my surgeon, that hospital contacted one of its "hospitalist", a group of independent contractor doctors. Again, this hospital was a Blue Cross provider, the hospitalists were not. The hospitalists insisted on seeing me twice a day for the remainder of my hospital visit as they needed to finish what they started. Guess who paid the big chunk of the bill? (Me, in case anyone does not follow!)

THE ISSUE OF INDEPENDENT CONTRACTOR DOCTORS THAT ARE NOT PROVIDERS WITH ANY INSURANCE COMPANY, YET WORK OUT OF HOSPITALS THAT ARE, IS MORE COMMON THAN YOU KNOW. IT IS EVEN AFFECTING HOSPITAL EMERGENCY ROOMS.

Moreover, there are services that Blue Cross will not pay for even if you use a Blue Cross provider. Just one example: I had two skin tags removed. I told the doctor that they were skin tags, but he insisted on sending them out to a pathologist. Then slapped band-aids on the places where the skin tags had been. This doctor was a Blue Cross provider and he billed Blue Cross $900 (including the cost of the pathology) and Blue Cross paid almost $500 as I had met my deductible. However, I was charged separately for band-aids ($27 each) and the cost of sterile razor blades ($36 each). They were just skin tags and if I ever have another, I am going to remove it myself.

(Another one that I heard about from fellow patients over the past few years concerns medical insurance that does not include the cost of prescriptions. Some insurance companies consider ORAL chemo therapy a prescription even though it is administered at an oncologist facility and can run up to thousands of dollars per month.)

And lastly, by FEDERAL AND CALIFORNIA STATE LAW, if an insurance company pays the cost of breast cancer treatment, it must pay the cost of reconstruction. However, few plastic surgeons are Blue Cross providers. Hence, you get into that paying what Blue Cross thinks the service is worth, Blue Cross pays 50% of that, and since the plastic surgeon does not have a contract with Blue Cross, the patient must pay the remainder of the bill.

(Not all Blue Cross plans pay for even a portion for non-Blue Cross providers. So if you have one of those plans, and no plastic surgeon in your state is a Blue Cross provider, you do not get reconstruction unless you pay for it no matter what the law says.)

You get into ridiculous arguments over this one. I had a tissue expander for over six months. When my plastic surgeon swapped the tissue expander for a silicone implant, Blue Cross agreed to pay for the silicone implant, but would not pay for that portion of the surgery which the tissue expander was removed reasoning that the tissue expander was not defective. Since the plastic surgeon was not a Blue Cross provider, Blue Cross paid for that surgery $400 and I paid $3,800 plus another $3,500 deductible (for the hospital) because I was into a new year.

When you figure deductibles, cost of travel, lodging for my mother (in her 80s) to be near me while I am in different hospitals, I have probably spent about $40,000 since August 2005 when I was initially diagnosed.

To add insult to injury, when you travel for medical reasons, the IRS will only let you take a deduction of about 17¢/mile which is far less than business mileage. Since many of my physicians, and testing and treatment facilities, were 75 miles away and many weeks I traveled three-four times a week, the mileage racked up very quickly!

My last two surgeries were by a specialist 268 miles from my home. Many of my follow up visits I drove myself the roundtrip in one day because even though I was recovering from surgery, I could not afford the cost of lodging. If I got tired, I simply pulled into a coffee shop until I was not tired!

None of my medical expenses were a tax deduction for 2005 because I did not fall into some magical ratio of income to medical expenses.

And, even though as a self-employed person I did not make a dime in 2006, I have a tax bill of $2,500 from the IRS sitting on my desk right now for that year because I had to take some funds out of my pension just to pay my medical bills.

Yet, I consider myself one of the lucky ones. I hear far worse stories than mine, and at least I am now healthy enough to work and get back on my feet. That does not mean, however, that I am not going to verbally clobber some idiot when s/he recites the Bush/McCain/GOP mantra that HSAs are the solution to the healthcare crisis, or that private insurance is the answer to everything since the marketplace will regulate everything.

In 2005, the year I was diagnosed, the HSA deduction allowed for an individual was limited to $2,650 for a person under 55 with an additional $600 for those over 55 and not on medicare. This amount does not even cover my deductible of $3,500 per year.

John Edwards said it best when he proposed that members of Congress should be forced to purchase their own health insurance. I think we'd have some changes, muy pronto!


Peggy

We've had Assurant Health High-Deductible HSA individual health insurance since 2000. At that time our deductible was $4,500 + 50% of the next $1,000 - total out-of-pocket for each calendar year of $5,500.00. The premium for our family of four was $892 a quarter. Of course every year the premium went up and we never were able to save anything in the HSA because of several catastrophic illnesses experienced by my husband (a small town attorney with a solo practice) and son (cancer & ameloblastoma & sports injuries). We'd borrow the money to put in the annual "medical IRA" and then almost immediately need the funds to pay for the deductible. Every year since 2002 we have had medical expenses that exceed the deductible. The premium this year was $2,615 per quarter.

We just got notice that our plan is being discontinued as of 9/1/08 and a new plan is being offered to us...."comparable" to our old plan. Yeah, right.

The new plan has a $5,700 deductible for in-network providers and up to an $18,700 deductible (which may now be adjusted upward periodically) for out-of-network providers! Under the old plan the deductible was the same for both in and out of network. The last poster is correct - it is not always possible or advisable to use in network providers and often you don't know until the bill comes who is and who isn't in the network.

The new quarterly premium is $3022 and covers my husband, me and our son who will turn 24 next June. At that point, he will no longer be covered. We are stuck with this company because of illnesses that would be considered pre-existing by any other company. Counting the annual premium plus deductible, we will be out of pocket a minimum of $17,788 to a maximum of $30,788 per year before the company will pay a penny toward our medical expenses. And instead of 1 1/2 pages of exclusions listed in our old policy....the new policy has 7+ pages of listed exclusions!

Because we have already met the $4,500 deductible for the calendar year of 2008 under the old policy, I assumed we would be covered for anything further needed for 2008. Not so...as of 9/1/08, the company says we have to pay $1,200 more in deductibles because that is when our NEW, IMPROVED policy with its $5,700 deductible goes into effect!!! It is new and improved....for Assurant Health. It is certainly not better for us. We will be paying much more for much less coverage.


We are between a rock and a hard place. Due to the nature of the illnesses which have befallen our family, we can't go without health insurance without risking bankruptcy. Yet the extreme increases in our premium and deductibles is seriously threatening our ability to remain afloat.

Something has to be done to alleviate the situation for self-employed people. We need to have pools for self-employed and small business owners so that we can purchase reasonable health coverage regardless of health history (just as large companies provide for their employees).

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