Archive for the ‘OMIP’ Category

healthnet and multiple sclerosis

Saturday, May 16th, 2009

Well, well, well. I had been a subscriber of healthnet (relegated to the lowercase convention I use for things that I refuse to let affect me) insurance for over a year, previously I used them to supply health insurance for my business. I am happy to report that I have once again kicked them to the curb, much like they have already done to me. In their case they are no longer getting $300 a month from me for my individual coverage (I use the term coverage very lightly, as if it were a helium balloon). In my case I am no longer wasting my money on this so-called coverage and have no become a poster child for the scam that is health insurance in our country.

So let’s start when I was diagnosed with ms. My first dealings with healthnet and ms occurred when they tried to claim it was a pre-existing condition even though my plan started before I was diagnosed. A nice roadblock to experience right after finding out I had ms. Once I managed to get them to look a a calender we were able to straighten that out. Next up, rebif! Hurray I get to inject myself on a regular basis, well at least the monthly $2500 expense is covered by healthnet. Whoops roadblock #2, I have find out from the pharmacy I have a $4000 deductible. So I call healthnet and find out that was actually incorrect. I have no deductible for what they consider specialty medication (“specialty”? you mean like viagra or botox?) Turns out they designate rebif “specialty” because it is injectible, WTF? I have a CAP! So they will only cover $4000 a year (pretty close to what I actually pay in fees BTW) and I would be on the hook for the remaining $21000. Um, what? Now I am freaking out.

So the calls begin and I discover that I can actually get on an assistance plan with the pharmaceutical company Serano for the first year where they will pay for my meds and then offer further assistance once the year is up basically relegating the meds to a co-pay. Oh man did I feel the relief! I almost considered dropping healthnet then, but decided I had batter keep insurance in case. There plan is called Access Made Simple and I have to say it was extremely simple and they actually have a nurse drop by the house to train you and help out with any problems.

So fast forward a year and 156 injections later. With my plan ending I apply for further assistance for which I am denied. I simply made too much money apparently though a $25K hit to our income was not even possible. I was told by one representative that the figure for income was about $40k (sure anybody could live on 15K a year, with a mortgage that would leave me $3K to live on, sure, I could do that!) No one else at msLifelines would confirm this figure and they all encouraged me to appeal the decision. They were very nice but it was pretty apparent that I was going to be denied.

So the scramble begins. I called a ton of prescription assistance programs that are out there, When I mentioned my problems qualifying with msLifelines and the $40K figure they all said that they had a similar income cap. Crap, strike, strike and strike (still not out though). I kept searching. Being a freelancer and having an individual policy with healthnet I tried to see if I could get into a pool plan with the Freelancers Union. Turned out they offer no plans in Oregon. I called an insurance broker who offered no help but warned me about things like Freelancers Union. I do think they are legitimate and I really wish they had something for me, I love the concept.

Ok, so back to the scramble. I kept hearing try msLifelines from these programs, well that wasn’t going to work out. I called my neurologist and explained the situation, they also recommended msLifelines. Ugh. I have to say they did do some research for me but also hit the same stumbling blocks. The somewhere along the way I found out about the Oregon Medical Insurance Pool. This plan covers Oregonians who are denied coverage for a variety of reasons, ms being one of them. So I immediately called them. OMIP is managed by Providence but is a state program. All customer service goes through Providence which was difficult as they weren’t totally up on the program. But I got good help and the person I talked to told me that I “should” qualify and that she didn’t see any roadblocks to getting the rebif, after all why would there be it’s a medicine I need? Make sense, right healthnet? SO I am still a little nervous, but feeling like I have a pretty good alternative to going to apitherapy or guzzling more flax oil that I already do.

We continued to talk and decided I should tap my $4000 cap with healthnet for my “specialty” medication before I turned to OMIP which was $100 a month more. Ok, phew, now I am feeling like I have an actual plan (not an imaginary one.)

Ok, time to take a small step back in time. At the start of this year healthnet discontinued my plan. They told me that I would need to move to a comparable plan if I wanted to remain covered. Surprise, surprise it was more expensive (but not that much more). They made it sound like it was basically the exact plan I had before with some “minor” differences. I was encouraged to read through the giant booklet they sent me (is that the new phone book?) to see the specifics of the plan. I was also told that I had “one of the best individual plans healthnet has to offer.” What choice do I have? Can’t switch providers as that would mean ms is a pre-existing condition. I love our health system in the US where I have a choice! Come on Barak, don’t let us down. On a side note, IMHO a “plan” to reduce the yearly increase in costs is not a “plan”.

Ok, back to my final days of Access Made Simple. The pharmacies always shipped the rebif next-day air as it needed to be kept cool. I would always call for a refill when I had a week or so left of syringes. So with four injections remaining (yeah I played it safe and gave myself an extra dose!) I called the pharmacy to make arrangements for the grand plan. I told them I had healthnet and I needed to get two months worth before I would shift to OMIP. They said great and that they would call to verify my coverage and then call me back. So when the call back comes they ask me how I wanted to arrange to make payment for what I assumed was the co-pay. I say lets put it on my debit card. The asked if I could put the entire cost on it. Weird. I asked them sure, what is it like $100 (figuring for 2 co-pays of $50) + whatever is above the $4K cap. They say no, and calmly state I have a 100% co-pay. [sound of car breaks screeching.] I tell them about the $4k cap and they ok lets us verify that.

After a nervous wait for a return call, the phone rings and the pharmacy informs me that yes I do have a 100% co-pay. So I am freaking now. I call healthnet and they confirm that I don’t have a $4k cap at all, the reality of my “plan” is that they won’t cover rebif at all. I say thank you and call again to verify with another call center worker. They tell me the same thing. Crap, now what to do?

With OMIP being my only option I call them and ask for advice. Fortunately it is three days before the start of the month. If I get my application in before the 1st, and I am approved then I they will back-date my coverage to the first! Phew! Except I now need to get approved for sure. Nobody at Providence can tell me for sure whether or not I will qualify, they only manage the plan they don’t underwrite it. So I take my app down to hand submit it and to make sure I am not missing anything. My app is complete with the exception of a Certificate of Coverage from healthnet to show I had previous coverage (a part of OMIP’s determination that I would not be denied for a previous condition). The problem was, I had to drop healthnet before I could get this letter. I didn’t want to not have coverage if OMIP denied me for some reason. Crap, but what choice did I have. The Providence customer service person assured me that I could send that Certificate of Coverage in after I applied. Again, what else could I do but hope the system grinds me up properly. Ugh.

So I apply, then go home and cancel my policy with healthnet (a nice feeling I have to say, though sort of anti-climactic, nobody cared there or asked me why. In my mind they just clicked delete.)

So back to rebif, I know have one dose left and no approved coverage. My only option (sort of a theme eh? Country of choice my ass) is to pay for the rebif out of pocket and then submit the bill to OMIP after they approve me (if they do.) I order up and make a $2300 charge to my debit card (the pharm does give me a discount for paying out of pocket which lowered the cost to the same as The next day the meds arrive and I am able to stay on track with the rebif.

Next I get a letter from OMIP. I think hurray, its my approval. Nope, it is a letter saying I need to get them the Certificate from healthnet about prior coverage before my policy will be approved and if they don’t get it they will send my app to the shredder. Crap, I haven’t be able to get that yet. To there credit, healthnet was able to send me an electronic copy very quickly that I was able to submit to OMIP. Phew! Another crisis resolved. Still I wasn’t approved yet and I was still unsure if I would get the $2300 reimbursed. Just last week I got another letter from OMIP welcoming me to their plan. Phew! But they still hadn’t processed the Certificate from healthnet, so I still have the pre-exisitng condition deal to worry about. But I am 95% sure that it won’t be an issue. Of course who the hell know?

So if you have made it this far in my post about my journey with multiple sclerosis and healthnet you are probably as tired as I am. I will stop in just a second. I am incredibly disappointed with healthnet and their non-existing coverage for multiple sclerosis. I consider their classification of “specialty” for the medicine I need to live with my disease to be a farce and shameful on their part. Changing my policy without regard to the very condition I was using their services for illustrates one of the largest problems with insurance in America: when people are relegated to a number and a button to press we lose our humanity. The shear number of people who need medicine to survive, the ever increasing costs of research and advertising for the pharmaceutical industry and the developments of more and more medicines that are more and more effective has driven the cost of “living” close to beyond the reality of our country. Something needs to change and as far as I am concerned, the very first thing to change should be healthnet. Stop being a place to process my checks and start being an insurance company that “insures” me that I will not be punished for the frayed neurons in my brain.

Lastly, I went to healthnet’s website to see if I could find a slogon to make fun of. They apparently don’t have one. They apparently can’t even come up with an empty marketing promise.

Plenty of time for work, not so for running

Saturday, March 14th, 2009

This has been a really busy week with work for me. Not that I am complaining, but I sure would have liked to do some running. I have to admit there were a couple of mornings when sleeping ingot the best of me. I blame that on daylight savings time. I grew up in Az and we had no DST. Neither does Japan. I sure wish we didn’t here, it kills me every year even though I have lived in Portland for 20 years now. So I am going to try to get back on track tomorrow.

I got an interesting phone call today from a woman who read about my troubles with getting assistance for rebif. She is in much the same boat as me: self-employed, lives in Portland, same recommended treatment, same neurologist! She was just diagnosed and read my post on my search for help. Sorry to scare you! But I do think we will find relief with the Oregon Medical Insurance Pool. Here are the eligibility requirements which don’t cleanly match us, but the person I talked with said there wouldn’t be any issues. Good luck to us both! And don’t worry about that first shot, it will get a lot easier, believe me.

Run arround with ms

Wednesday, March 4th, 2009

Today I did two runs with ms. The first one was much more enjoyable despite teh chilly morning and having drank something called Bad Road at a local restaurant. Piece of advice when drinking a Bad Road, when they ask if you want 10 mile or 5 miles, don’t respond with “10”. So the run went pretty well, a base run of 5.75 miles. It was sunny out as it usually is when it is that cold in Portland and that kept me going strong.

One thing that I found interesting from a radio station I was listening to: Portland was named the #1 most unhappy city in the US by Business Week. I think it is really funny as I know Portlanders are going to get all “unhappy” about it. To me it is good news as it means fewer people will be coming here and clogging up our roads. Won’t do much for my clients that rely on tourism though. In truth Portland is a pretty optimistic place if not overly so. They don’t call us the city of rose(colored glasses)s for nothing.

So my second run(around) with ms happened later this afternoon. I am ending my one year of free rebif from Serano and MS Lifelines. Thanks for the free drugs, I’m sure they have been a help to my situation. The down side to having hope with ms, is that to continue having hope I will have to shell out over $2000 a month for the rest of my life. Turns out the medical assistance program they offer after the first year has very low income requirements which I don’t fall under. I make too much to get assistance, but not enough to be able to afford it.

So I know all of you are asking, come on Marco, you have ms, don’t you have insurance? Well yes I do. Turned out the plan that I originally purchased and read to cover prescriptions doesn’t cover “specialty” medications such as rebif. No soup for you! Healthnet actually will cover up to $4K of “specialty” meds which almost takes me through February every year. Nice job Healthnet, you got me covered! The day I found out about this I just about pooped myself. After several phone calls I found out about the MS Lifelines Access Made Simple program which provides ms patients with free (or nearly free) rebif for a year and then offers assistance after the first year. I was so relieved. Well, it turned out I just put off the pooping a year. As I said earlier, I don’t qualify for further help.

So what to do now? And let the run around begin! I have always gotten really good help from MS Lifelines. Their call center was always helpful and easy to understand. Well, that is until you get transferred out to fulfillment or in today’s case Assistance Program. Seems like a change of company or at the very least pay scale as the service level drops off significantly. Part of me has to wonder if Serano wouldn’t do more for me if I just got to speak to someone else.

My first thought is to get on Ruthann’s insurance, which would “only” run me $800+ a month Good insurance though, eye, ear throat, the whole deal. Well at least that would be my final option. But still not a concretely solution.

So cut adrift I look into the Oregon Prescription Drug Program, a program to lower the cost of prescription drugs. When I first found out about the cost of rebif it was $1800 a month. With OPDP teh cost was lowered to $2300 a month. Oh wait, that is more? Has their been a huge increase in the cost of rebif in a year? Not out of the realm of possibility. I ask if there are other programs that I could try and after some searching she replied, Oh yes there is “the MSLifelines program that will…” Grrrrr. So I call Partner for Prescription Assistance, they also tell me of the low. low price of $2300 a month AND if I order by mail I can get it for only $2000 a month. In addition there is this program called “MSLifelines that will…” Next I try RX Assist and Needy Meds which both tell me of a program called “MSLifelines that will…”. Needy Meds does tell me of several drug card programs that are available: Drug Card America, Patient Card (or something like that), Free Drug Card, PS Card and True RX Services. All of which had websites that looked as if I was going to be ordering a set of knives or Obama coin sets. Id did appear that I could get some sort of discount through them. So now I am down to about $1500 a month.

Not to be discouraged I call on my last hope the Oregon Medical Insurance Pool. This group covers individuals as if they were a group. But, because I have MS, my costs would be pretty high. The woman (Mary) I talked with was very honest about this. In fact if I got the $500 deductible plan, my meds might cost me as much as $40 a month and the plan itself could be as much as $436 a month. She paused for the shock of the high cost to ease from my shoulders. I think I totally surprised her when I said, “Wow that’s great!” Great? she replied. When I told her the cost of my meds I think it made her feel really good to have been such a help. My next question was a doozy though, did OMIP consider rebif a specialty drug and were there any constraints associated with it. After being on hold four separate times she came back to say she wasn’t positive, but it appeared there weren’t. I was just relieved I could afford that, best news I had gotten all day. She promised to send me info on the plan. I think I have a winner.