Tag Archives: insurance

Finding a Primary Care Provider

Recently, more and more health insurance providers are moving toward a system where signing up for care means being assigned a primary care provider (general physician) until you choose to change that physician to someone else.

The trouble is (and I’ve found this on more than one occasion) many of the lists these primary care providers (or PCPs for short) are coming from are outdated. These lists on record often contain the names of physicians that no longer work for the hospitals and clinics found on the list, or they are no longer accepting new patients.

Yesterday I found myself in something of a pickle. My medicaid plan (signed up for near the end of the affordable care act enrollment time) assigned me a sub plan automatically (until I chose another) which also assigned me a primary care doctor that didn’t exist.

What’s worse is that when I tried to fix this (and pick another plan under medicaid) I found out it wouldn’t kick in until May, leaving me a window through April with a wonky plan and no doctor.

Fifteen minutes of tears and a panic attack later, I made an attempt to find a new primary care physician under the plan I was stuck with, only to have the plans’ customer service people assign me a second, non existent doctor. 

The point of this story, to me, is pretty clear. Relying on someone in a cubicle and a phone to choose my doctor for me is ridiculous. Trying to pick a doctor out of a list of names also seems ludicrous, after all… how do I even know which ones are good?

In a blog about mental health, you might be wondering just how important general physicians are anyway… but there are many reasons having a good primary care doctor can work in your favor.

Primary physicians can be the gateway to mental health treatment. I know several people who are prescribed mental health medications by a primary physician (though I’ve had terrible luck with that myself). On top of that, many insurance plans require a primary physician to refer (basically give you an “in” and a stamp of approval for mental health treatment to your insurance provider) you to mental health specialists before you can get treatment.

Primary physicians are often a gateway to all realms of physical health. If your insurance doesn’t require a referral for mental health services, it is much more common to require referrals to all other specialists, including anything from dermatology to neurology to allergy specialists. Doing what we can to help our minds is only half the battle, we need to be able to take care of our bodies as well. This might even include a primary physician helping counteract physical side effects of psychiatric medications, something that has been super important in my own search for better health!

Yes, these people are important, but when being assigned phantom PCPs, how do we find good doctors accepting new clients who also take my insurance??

My advice is not to start too small. Start by looking for locations that generally accept your insurance. You can do this by doing a search online at your insurance provider’s website (usually, you might have to google the addresses you find to see the actual locations), or you can call your insurance customer service line (though I’m warning you, this can be a huge headache). Something that worked for me was calling the office of my phantom PCP (via a number on my new insurance card) and finding out there were several (real) doctors there that do take my insurance.

I find that if you need to choose between calling insurance people or calling clinics, you will often get much more help from the clinic receptionists. As long as you try to remain calm and friendly, they can usually point you in the right direction.

We have several hospital systems in Seattle, so finding out what hospital system takes the health insurance in question can also help you find primary care doctors and specialists in your area. I called my usual hospital (who didn’t take my new insurance) but found out another hospital down the road who does. 

Don’t underestimate the knowledge of friends, family, or co-workers who have the same insurance as you. If you know someone on your plan who claims they have a great doctor, ask for their information! This rings true for not only primary care doctors, but psychiatrists, therapists, and any other specialist you might be interested in seeing.

Once you’ve found out if a location (or if doctors at a given location) take your insurance, you can call and ask the receptionist if anyone is accepting new clients. I’ve met some really wonderful receptionists who have even gone so far as to give me brief descriptions of the available doctors dispositions!

Writing down the name of the doctor (with correct spelling), the phone number of the location, and the address is important. Once you have this information, you can go back to the insurance website or customer service line and request a change of primary care physician.

This last step is IMPORTANT, because if you don’t follow through with the choice that you’ve made your insurance company can potentially deny your claim (aka not pay for it) if the doctor you see doesn’t match the doctor listed in their database.

Some insurance companies will allow you to change this information on their website, while others have an automated phone system. On occasion you might need to speak to a customer service representative (who may also put you on hold to call the clinic you just talked to and verify the information). In any case, once you have finished the process you can expect to receive a new ID card in the mail with your new (and correct) PCP information listed.

I realize this is a lot of information, and I know nobody likes insurance nonsense, but finding and selecting a primary care physician before attempting to interact with insurance representatives can save you a lot of hassle. I know it would have saved me a panic attack, and three hours of yesterday’s morning!

The Hoops We Jump Through

As many of you may know, I’ve been pretty bummed out lately because my therapist I’ve been seeing about a year now is graduating and moving on from internship. As I see her through a clinic, I am not allowed to follow her to her new business, or, at least, I’ve signed a contract saying I wont. As our time together has come to an end (today is our last appointment) I have been thinking about the improvement I’ve been seeing in my life. Less panic attacks, more fun mood charts. Less spontaneous angry outbursts, more of an ability to shield myself from people’s (seeming) attacks on me. More perspective, more assertiveness, and more relaxation.

It seems to me we’re learning our whole lives anyway, why not speed that process up a bit? Learn through an actual teacher?

Anyway, the last several weeks I have been trying like the dickens to find a new therapist. And that is no easy feat, apparently. Finding one that is somewhere between work and my home, is near a bus route, female, available after 5 pm, specializes in trauma and anxiety (which is what I am currently focusing on), while also not being someone who generally creeps me out or makes me uncomfortable has been tricky, to say the least. I’ve probably contacted about 15 different people, interviewed two, and have just now set up a first appointment with one of them.

In order to reach that appointment, though, and be able to bill my insurance, I am asked to see a general physician and get a referral.

Now, the definition of “referral” is pretty different depending on the insurance company. Sometimes it is making a phone call, sometimes it is paperwork, and sometimes it is a magical word that doesn’t actually mean anything, it is just there to scare people away. 

My insurance kicks in next week, and I figure if I can make an appointment with my general doctor in the days after that, I can make it to my first appointment with my new therapist by the end of August.

I saw my psychiatrist yesterday and he caught me wringing my hands.

“Can you do something for me?” I asked.

“What is it?” he said.

“Can you write a little letter that says my diagnosis and that you would suggest I get therapy?” I asked.

Then I explained what I just explained above. A general practitioner (someone I may not have ever met before) is going to have to decide whether therapy would benefit me, and will be the deciding factor between my insurance covering it or not. All I wanted, really, was a letter of recommendation -a letter to recommend… therapy!

It was first thing in the morning and I think he was a little miffed, but he wrote the letter for me. I really just want something that says I’m not just someone walking in off the street claiming I have bipolar disorder and want to see a therapist. Some kind of… members only card, or something. A nice, smooth ramp to help me jump through those insurance hoops!

As much of a benefit as insurance is, the beginning stages are so frustrating and stressful. Trying to do things in an order that unlocks special level-ups and gets you that damn flute so you can travel through several worlds in Super Mario Bros. 3 can be totally unnerving and leave me confused and holding on to my prescriptions saying,”what the hell?”

Choosing an Insurance Plan

For the first time this year, I am going to be eligible for medical benefits under my new employer. This particular place of business offers three types of plans with different coverage, and at once I went to work spreading all of the papers over the living room floor trying to distinguish which would be best for an employee that needs a lot of healthcare, namely me.

Corey walked in and said,

“You know, you are the only person I know who actually reads all that stuff. I never read any of it,”

“And that is why you are shocked when you get a bill in the mail for several hundred dollars after a doctor’s appointment,” I replied.

I think a lot of people believe that as soon as they have whatever it is called benefits, healthcare is suddenly free, available wherever they want, and their benefits cover everything kind of appointment they’d like to make. I think that is the first mistake, and by not reading (or even by reading and not understanding how your benefits work) about your benefits package you’re really setting yourself up to have your pockets picked.

You should be taking advantage of these benefits, not the other way around.

I thought I would talk briefly about how you can go about getting the best care under whatever insurance plan you choose, which is something that can be difficult when you have a chronic illness or disorder (like bipolar disorder).

Looking Back

First, I’d just like to point out that for a very long time, someone with a mental illness could be denied coverage for treatment of that illness if they had it before receiving insurance coverage, or if they switched insurance providers after being diagnosed. Obviously, that is total bullshit, and I can’t tell you how many times I have been denied coverage for having bipolar disorder.

Thankfully, Obama (whether you love him or hate him) did away with that, so it is now illegal for insurance to deny coverage for “pre-existing conditions”. That is a definite win for those of us with diagnosed mental illnesses, though there are still several ways health insurance providers can deny coverage to what we need. I’ll get to that.

The Deductible

Ok, now when you’re looking at an insurance plan, they will often tell you how much it will cost you to see a provider in their “network” (one that takes that insurance plan) and how much it will cost you to see a provide who doesn’t (“out of network”). What many people skip over, though, is that chunk of money called the deductible. 

This is the amount of money that you have to pay before your insurance provider begins to chip in on your bills in many different types of situations. The higher the deductible, the more you will have to pay out of pocket before sharing the cost of your healthcare with the insurance provider.

Some insurance companies will allow you to avoid paying this if you see doctors in their network, and will only charge you a “co-pay” (a flat rate to see these doctors). However, the deductible will still need to be met for other types of care (so think about things like lab-work if you are taking lithium) or if you want help paying for doctor’s visits outside of the network.

Your Doctors

The first thing I would suggest doing is making a decision about what doctors you want to see. Do you currently have a psychiatrist or therapist who you can’t see yourself leaving, or would it matter if you saw someone brand new?

  • If you are willing to see all new doctors, you can probably use “in-network” doctors to avoid having to pay the deductible right away. If this is your chosen course of action, I would suggest going to the insurance provider’s website and doing a search for the types of doctors you want to see (to see if there are any in-network in your area).
  • If you already have a team of doctors you like, I would suggest calling each of their offices and asking if they take the insurance you are considering purchasing. If you are lucky, there is a chance that they might! If they don’t, though, that means they will be “out-of-network”, and will require you to pay for all visits until that deductible amount has been met. After that, some plans share the cost of visits (60%/40% for example).

If your doctors are out of network it may be wise to figure out if you will be paying for enough visits to actually meet that deductible.

Take your (cost of one visit) X (number of visits you plan to take in your plan year) =

If n is less than your deductible amount, it is possible you will be paying for all of those visits out of pocket. Remember, the insurance doesn’t kick in any money until this amount of money has been paid.

If is more than your deductible amount, you can expect to meet that deductible and then have insurance help pay for the remainder of your appointments.

So, if I see my psychiatrist (which costs roughly $100 per visit) once a month, that would mean $1200 annually (as I’d be in there 12 times per year). If my deductible is $500, that would be a great deal, whereas if my deductible is $1000 it would be a bit less-so. I would probably only save (in that case) about $80.

At the same time, I want to be sure to be clear that just because the amount of visits you predict doesn’t meet your deductible, it doesn’t mean you wont meet it. Other things like lab work might go toward it, or emergency visits you may not know will happen in the future, or the cost of certain types of appointments.

What do they cover?

Most of the time I have had the option of being enrolled in an insurance plan, I am provided with a booklet that outlines everything that is covered or not covered. If you were not provided this information, ask for it. Remember when I said there are still some ways insurance can deny certain things? This information is particularly important for mental healthcare, as some plans with not cover or limit the number of therapy appointments they will cover, among many other things which may be vital to our care.

What types of appointments do you expect to use? Acupuncture, massage therapy, talk therapy, inpatient hospitalization (in the event of an emergency)? Make sure you look up whether those things are covered by your potential insurance plan or not ahead of time. Some things, like therapy, may not be covered, but the amount you spend on it might be able to go toward your deductible. Other things, like massage therapy (or even psychiatry) might only be covered after a series of approvals from other doctors (basically someone signing off that you do need these services). This notion can be a bit daunting, but I’ve found that with a solid history of mental illness in place, I have never had problems being “approved” for the type of care I need. It is just another hoop to jump through, because without jumping through it they can potentially charge you without covering any of the amount for the appointment.

Personally, I’ve found it difficult to find a therapist that will actually take insurance, most of them are extremely wary (because insurance companies generally don’t pay the therapist in a timely manner). If you go to a clinic (and not an independent provider) you may have more luck with insurance and therapy fitting together better.

Annnnnd Medications…

Not all insurance plans are created equal, and not all medication coverage is equal either.

Most plans no longer have a “one-size-fits-all” approach to medication coverage, so it is no longer a question of whether a medication is covered or not. Many of the newer setups I’ve seen involve tiers, with generic drugs being in the cheapest tier. This part gets tricky, because anyone who has to be on a brand name version of a drug with a generic counterpart pays heavily for it, so if I were to need Risperdal (instead of the generic Risperidone) I’d probably pay $100 for my prescription instead of the $10 it would cost for the generic.

Mental health is one of the areas where I see this as being something of a cheat, because there are many people who either don’t have any luck with the generic counterparts of our medications or are on a medication that doesn’t have one yet.  Obviously, these drugs are still discounted, but not as deeply discounted as others.

I would suggest making a list of your medications and looking them up (most insurance companies should have a database of how much each given medication will cost). In one instance, I found that it is cheaper for me to buy Lithium at Target than it is to get it through the insurance plan I signed up for (which is a little baffling) so getting an idea of how much your medications cost now vs. how much they would cost on insurance can be an eye-opener. If you want to multiply that cost by 12 (if you fill monthly) you can get an idea of how much it will cost for the whole year.

Oh, and most insurance companies do not count medication co-pays toward your deductible, so anything spent on medications probably wont count toward reaching that amount.

Putting It All Together

Alright, so I am kind of a nerd so I usually like making up a grand total of what things are going to cost me. For those of us that need more healthcare than others, I have run across some insurance plans that would actually cost more for me to have than if I didn’t purchase insurance at all (which can be a little disheartening).

To see the difference between how much things will cost with insurance and how much they will cost without (or to compare one insurance plan with another) you can create the total cost for each situation.

First, figure out how much healthcare is costing you now:

1. The cost of your doctor visits for the year (the cost of the appointments times the number of times per year you go)
2. The cost your medications for the year (the cost of each medication times the number of refills you get per year)
3. The cost of other expenses, like therapy, lab-work, etc. (the cost of the appointment or lab-work times the number of times you go/have it done)

And add 1-3 together. For me the total is averaging about $10,000 this year and I would say that is probably a more modest estimate (compared to other years).

So next, figure out how much that same healthcare would cost with the insurance plan you are looking at. You will need to take into account everything we’ve talked about so far, so whether you are planning on using in-network doctors or out-of-network doctors (or a combination), if things like therapy are covered, and what the deductible looks like. This is a little more tricky, but here is a general step-by-step.

1. The cost of your doctor visits for the year (the cost of the appointments with insurance (either an out of network cost for non-network doctors, or the in-network copay) times the number of times per year you go). You can repeat this step for each doctor you see, or each type of doctor you see. You may also want to use this step to figure the cost of seeing your therapist, or you can wait for therapy until step 3.

Now, if the amount totaled here for non-network doctor visits is bigger than your deductible, subtract your deductible from this total cost (so if I spend $1500 on non-network doctors visits and my deductible is $1000, that leaves $500). With the amount left, multiply by the amount you are responsible for (so if your insurance covers 60% after the deductible is met, for example, you are left to pay 40% of the total amount. $500 x 40% = $200). Instead of paying $1500 on those doctors appointments, you would meet your deductible and only pay $1200.

It may not seem like this is saving much, but if your deductible is already met, that means you will have no deductible left to fill for lab-work or out-of-network therapy appointments.

2. The cost your medications for the year (the cost of each medication co-pay times the number of refills you get per year). Remember some medications might cost more than others depending on the insurance plan.

3. The cost of other expenses, like therapy, lab-work, etc. (If your therapist is in-network, multiply the co-pay times the number of visits. If they aren’t, have you met the deductible with other out-of-network visits? If so, multiply the total cost of therapy appointments for the year by the amount you are responsible for. If you go weekly and your visits are $100 apiece, you would potentially spend $5200 for the year. If insurance covers 60% (for example) after the deductible is met, you are left to pay 40%, so $5200 x 40% = $2080. If your deductible isn’t yet met because you’ve only seen in-network doctors, we would subtract the deductible ($1000) from your total ($5200) and multiply the remainder by the amount you are supposed to pay ($4200 x 40% = $1680). If you were only using an out of network therapist (and nothing else) you might still only pay $2680 instead of all $5200.

Lab work usually works the same way.

So, again, add 1-3 together and then for this total we will also:

4. add the cost of your insurance plan for the year. Let’s not forget, unless your insurance cost is covered entirely by an employer or government plan, you are probably paying weekly or bi-weekly to keep it active.

Ideally, this is when you would know if the insurance is a good deal or not, or if it covers the things that are important to you and your healthcare. 

My final suggestion is to consider the FSA.

If you are being offered insurance by an employer who also offers the option of a Flexible Spending Account, I would highly recommend it. I am not someone who has had much money, so this is the only way I’ve been able to pay for healthcare before actually saving enough money from my paycheck to do so.

The FSA deducts equal amounts from your paycheck on a pre-tax basis, and you can choose the amount you want deducted. That money, though deducted evenly through the rest of the year, is available to you immediately for using on your deductible, co-pays, medications, and a whole long laundry list of other things. The only thing I would say to watch out for is that at the end of the year, if you don’t use the money in that account you lose it. Personally, I’ve never had trouble with that (and always used all of mine very early on with the number of doctor visits I have) but it is something to consider.

I just had to decide between three different plans, and I read everything I could get my hands on and then made an excel spreadsheet to help me add everything together and compare. I requested more information on the insurance provider several times, called my doctor’s offices to ask about their relationship with my potential plan/insurance provider, and I feel confident that I know what is and is not covered.

Yes, I have bipolar disorder, and I am now working at a job that is pretty huge. If nothing else, that is a big reason to pay attention to how my new insurance works and know how it will support me and when it will not.

I think it is important for anyone to understand how insurance works, but it may be much more critical for those of us with pre-existing conditions that require careful monitoring and care. Knowing how to get the most from your insurance provider allows you to tip the scales in your favor, and might mean the difference between taking advantage of your insurance or your insurance taking advantage of you!

Rapid Cycling Sans Bicycles

The last few days I’ve been averaging 3 mood shifts per 16ish hour period I am awake. Up, down, mixed, down, up, down, and on and on.

I’ve recently had the stomach flu as well, which went away for a time but has returned with a vengeance. I wouldn’t bother writing about that, but I think it may be effecting my lithium levels. I have been having trouble staying hydrated because of it, and yesterday I was having tremors again (which have been long gone, for months at least) and the worst case of lithium brain I’ve had in a while. Every sentence I started had to be cut short because the next word I was going to say would suddenly disappear. Hunting for words that disappear is extremely frustrating, especially when the word is something like, “mailbox” which is right in front of you. Also, related or not, my left eyelid has been twitching for a solid three days, which makes me feel like I look like a total spazoid.

I am also now officially uninsured again.

This means I must begin the dance, the dance where the sick are pretty much screwed and only the well thrive.

The rapid cycling I can probably handle easily enough, but I must concoct a solid plan before January when Seattle winter rears its ugly head and tramples on the souls of the Seattle Bipolarites.

Unfortunately, I must hold off on paperwork for these plans until I have some evidence of my income. I don’t foresee having that for at least another two weeks.

Virginia Mason charity program, you are my only hope.