Motherfucking Medical Insurance

We had no choice of insurers when my husband started his new job. It was Cigna or go pound sand. So we have Cigna with a high deductible plan. 

I spent $2,180 for insulin pump supplies and CGMs for Maggie's continuing care (eleven years and counting) in February assuming that it was more than halfway to the deductible. I now doubt whether the supply company checked with Cigna for prior authorization before shipping the supplies, but I know I DID provide the insurance information. Cigna still hasn't finished processing the claim. I don't know whether they are ultimately going to cover it and will apply the $2,180 toward the $4,000 deductible. I'm about to need to order more, still not knowing whether they will cover it. If they do, this would put us over the deductible and mean that we would be done spending money on Maggie's T1D care for the year. Or maybe we are just on the hook for it because they just don't consider that the gold standard of type 1 diabetes care that she has been getting for over a decade through two different insurers and multiple policies is "medically necessary." Every trial done shows the very DUH result that "sensor-augmented pump therapy" is the best way to control blood sugar in type 1 diabetes and to minimize both short and long term complications. That sounds pretty fucking medically necessary to me, but what do I know? I'm not a claims specialist at an insurance company. 

It is now been a full two months since our pharmacist told me that Cigna will not cover the brand of insulin that the previous TWO insurers approved without hesitation. I asked the endo office if Maggie would really have to switch to less effective insulin, and they said they would request prior authorization. I'm still waiting TWO MONTHS LATER, and we are down to the last of the kind of insulin that both CDPHP and BCBS paid for without question or fuss. 

It is INSANE that an insurer can decide that they will not pay for PERFECTLY FUCKING STANDARD treatment that has been working brilliantly for a decade. 

I have been pinging the endo every week or so and the latest was that Cigna says have no record of Maggie being insured. Weird because she has an online account with claims that are being processed, and the pharmacy told me that Cigna would pay for Humalog rather than Fiasp, so THEY know she's insured.

We happened to have a lot of insulin backed up, but it's been two fucking months. We have about three weeks before she runs out of insulin and becomes gravely ill. There is URGENCY here, folks. You'd think healthcare people, both doctor's office and insurer, would know that.

I'm sure that a hospital will view it as medically necessary to admit her when she goes into DKA. Maybe Cigna won't. Who knows?

Fucking Medical Insurance

The good news is that I am finally down to only ONE medical claim from 2022 that is in dispute! For...reasons, Edgepark Medical Supply submitted claims for some, but not all, of Maggie's CGM supplies to our insurance company as durable medical equipment with a 50% copay instead of diabetes supplies with a $15 copay. I've spent the last two years trying to get them to fix this. Edgepark blames BCBS, BCBS blames Edgepark, and I keep getting bills I shouldn't have to pay. And I keep calling to explain, yet again, what happened and why it needs to be fixed, only to be told that it will all be resolved in 45 business days. Rinse, repeat. 

But like I said, down to just ONE claim left and then maybe they can stop calling me. And emailing me.

On the other hand, I am utterly flummoxed by our new health insurance. With Jose's new job, we did not have a choice of insurers, but we had a choice of plans, all with Cigna. We made our best guess about how much each plan would cost us, given our particular medical needs. The cheapest seemed to be a high deductible plan where the employer reimburses us for the majority of the deductible. 

I've never had a plan with a deductible, so this was gonna be new. I thought I understood it. We pay the first $8,000 in expenses, of which the employer reimburses us for the first $6,500, and insurance covers whatever exceeds the total deductible.

The first test was picking up prescriptions for me and Jose, our cheap-ass generic blood pressure meds. There was no copay at all. OK, cool? I knew some insurers were not charging copays for (cheap) preventative drugs to encourage people to manage chronic conditions, so maybe this was that.

Jose went to two cardiology appointments that had been set up the year before under the old insurance. They said they would bill him. I'm still waiting for those bills...two months later. 

Then I went for a checkup. I paid the office's estimate before the appointment because there was a discount for prepayment. At the pharmacy afterward, I was charged $3.25 for a clonazepam prescription, necessary for those days when I have to spend hours on the phone calling about health insurance. The $3.25 appeared quickly on the insurance webpage as counting toward the deductible. 

Both Jose and I got MRIs for calcium scores, which are recommended by doctors, but NOT covered by insurance because why would they? Fuckers. But they're relatively cheap by American medical care standards, so $85 to know my heart isn't ossifying was a tolerable price.

I waited some more.

Finally, a claim for my checkup appeared in my benefits portal, and it showed $176.32 paid to the doctor and nothing owed by me and nothing counted toward the deductible. Is it because it was preventative care and therefore the ACA required it be covered 100% without copays? Dunno? If so, why did the doctor's office charge me, knowing I had insurance? And if Cigna paid them $176, where is my $250 prepayment?

More critically, I ordered infusion sets, CGMs, and insulin pump cartridges for Maggie. The CGM sensors should retail for less than $100 each; the sets for about $80/box of ten; the cartridges for another $50/box of 10. We have always gotten all of it from Edgepark for a small copay for three months' worth of supplies at a time. However, trying to meet the deductible, one might expect that I would have had to pay about $900 for sensors, $320 for sets, and $200 for cartridges, for a total of around $1400. The retail prices listed on Edgepark's paperwork are INSANELY higher than those average figures from a quick google search. But WTF? We are going to hit the deductible one way or another, and those internet sites don't take insurance, soooo.... I paid the $2180 and quickly got reimbursed. 

However, the cost hasn't shown up as counting toward the deductible. And we will need another three rounds of those supplies by the end of the year, easily exceeding both the $6,500 reimbursement allowance and the deductible that they're not seemingly counting toward. 

Fuck.

The next thing is insulin. The pharmacy tried to fill Maggie's insulin prescription, but they said that Cigna doesn't cover Fiasp, which she has been using for years. I asked the doctor whether we needed pre-authorization and if could she get it. I've been pinging her regularly, but we don't seem to be connecting on the problem. I am guessing she is assuming the pharmacy is asking for preauthorization, but they seem to think that is not a possibility so maybe they haven't even asked the insurance company? Dunno. 

So I decided I would call the employer benefits people, the customer care team whose job it is to help us navigate this mess, to ask about these two things, and while I was at it, whether Cigna covers the Omnipod insulin pump, which Maggie would like to switch to. 

That was...protracted and ultimately pointless. 

A very nice guy named Ed said he didn't know what to say about my checkup but he would get back to me about it. Then he looped the pharmacy benefit people into the call to ask about Fiasp. (I could have called them myself, but whatever.) A very not-nice woman took all my information, and Maggie's information, then told me that Fiasp isn't on the formulary, which I knew. But she simply would not tell me whether it was covered after pre-authorization because it's not for me, it's for Maggie, and she's over 18, and I would need her permission to call on her behalf. 

FFS. I didn't ask for Maggie's medical history. I asked whether the insurance policy covers XXXX. For anyone at all. Nope. She wouldn't say. She then forced me and Ed to go through their customer service survey, and let me tell you, she did not do well. Lots of 1s out of 5. No, my question was not answered with this call, and no, I would not recommend Maxor+ to other people. 

I guess I can call tomorrow while Maggie is home and get her to give them her permission to ask questions on her behalf. Or I can call again and just pretend to be her. I know more of the answers to their security questions than she does. So then maybe we will find out whether they will pay for her insulin or not. And while we're at it, whether they will pay for the Omnipod, because I now have ZERO incentive to try to save them money by stretching the life of Maggie's Tandem pump if they're gonna be shitty about my kid's life-sustaining healthcare. 

#MedicareForAll