At, Limits and Exclusions Apply

Thursday, December 5 2013

I posted my views of the ACA as policy. Now I want to talk about, as a patient and customer.

I live in a state whose leaders decided the Federal government is so awful, they were going to give it all its uninsured sick people to look after. (Good job, grown-ups!) I don’t need Medicaid, so is my best option for buying health insurance.

I was up at 4am the day the exchanges went live: I have insomnia, nothing else going on that early, so I figured ‘what the heck — I’ll give it a try’. I was totally locked out. Nothing. Not even a beach ball.

A week later I got as far as the part that sends me an email confirming my account: that email never arrived. When I tried to log on again, the system did not recognize my password. I clicked the link for ‘forgot my password’ which — and this is important — sent an email to the correct email address, with a link that promised to reset my password. When I clicked on that link, I was returned to the page, only to get an error message. I tried again a half dozen times.

A week ago, I finally called their phone number, and explained that I wanted my password reset. This is a very ordinary tech-support type problem. The operator asked for my social security number (for a password reset!), and then spent ten minutes humming and mumbling until finally conceding defeat. She told me my problem had been forwarded to the appropriate corner, and that my password should work in a few days.

Today I tried one last time — it didn’t work — and finally gave up. I started a new account under a different email address. At long last, I was able to shop for health insurance.

Now that I have a chance to use it, I can say that the eligibility and demographic part of the website is easy and friendly — all very painless. I skipped the whole ‘subsidy’ eligibility part, and finished the rest in a couple of minutes, which is a lot less hassle than most of the preliminary stuff I have had to do for employer-provided benefits. There were some weird questions intended to verify my identity, but other than that it was a good user experience.

The problem came when it was time to actually pick a plan to enroll in. I have issues, so I quickly honed in on the ‘platinum’ level plans, which are supposed to provide customers with 90% coverage of their costs. For these plans, the premiums were quoted at around $400 — which is just amazing. For all of my adult life, decent health insurance has been my Golden Fleece and Holy Grail and One-Ring-To-Rule-Them-All: to think that I could be $400 a month away from that goal gives me goosebumps. And that’s without any subsidy.

The site has a helpful comparison shopping tool to show you what various plans cost and cover. I picked the two platinum plans I was eligible for, and easily decided that the “CareFirst BlueChoice, Inc. HealthyBlue Platinum $0” offered a better value. Again, this was way easier than any time I have tried to comparison shop for employer-provided insurance plans.

Unfortunately, my major health expense is not listed in the comparison tool: namely, ‘durable medical equipment’. That’s okay, because you can click through to a Blue Cross document (PDF) that gives a more complete summary of benefits, and it shows that this plan would cover my appliance needs with a 20% (an total out-of-pocket expenses of $2000, which is not great but manageable).

However, that document also shows some discrepancies between what advertises and what Blue Cross says it covers. For example, the summary shows for outpatient mental health services: “$30 In-Network; $30 Copay after deductible Out-of-Network”, but also “Limits and Exclusions Apply” So you click on that link to open up the same Blue Cross document, which says “no charge” for participating providers for outpatient mental health services. In this case, the discrepancy works in my favor, because outpatient mental health is another major expense.

But that’s not the only discrepancy: infertility treatments are reported on the as: “$30 In-Network; $100 Copay after deductible Out-of-Network; Limits and Exclusions Apply” — which document lists infertility treatment under “Services Your Plan Does NOT Cover”.  I don’t care that much about infertility (I am probably obliged to Nature and Nature’s God not to reproduce) but I would be seriously upset if I thought I was buying a plan that covered those treatments, and then learned it didn’t. That seems like a pretty big exclusion, damn rough fine print. For the record, offers the benefit of getting everyone who reads it the best sex of their lives; limits and exclusions apply*.

The Blue Cross provided summary says, “If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at, or by calling 1-855-258-6518″. Since I did not want to spend the next half-hour yelling ‘operator’ into my phone, I clicked on the link, which just takes you to their front page. You have to search for the ‘policy or plan document’, and this is the best I could find: something called the “Healthy Blue 2.0 / Healthy Blue Advantage CareFirst Blue Cross Inc your member handbook  (also PDF).

I am still not sure this is the right document (and it doesn’t say jack about infertility or durable medical goods), but in any case it says in bold print on page 1: “However, this isn’t a contract. A detailed description of specific terms, as well as the conditions and limitations of your coverage, is included in your Evidence of Coverage/Agreement.” So even if I memorized the “your member handbook”,  I still couldn’t be sure what I was getting until I actually bought it.

At which point I decided my little experiment was over. If I needed insurance — if I was still paying $600 a month for COBRA — I would go ahead and buy the HealthyBlue Platinum plan. But I don’t need insurance, and the plan I’m married to is a bit better than what I can get through the exchange.

So this ends up mostly an exercise in satisfying my own curiosity, but it illustrates both the promise and problem of the Affordable Health Care Act. Up until a couple years ago, if you had told me there was a website I could go to buy good insurance for $400 a month, I would have thought I was being Rick-rolled as a best-case scenario. That would have sounded like a delusional fantasy to me. So the fact that there is such a place, even if it has some bumps, is totally amazeballs. It’s like Candyland for the chronically ill; I can barely believe that with a few more clicks, I would have bought actual, decent health insurance.

That’s the promise of the ACA — and lets be clear, it’s not just the website, but also the fact that I can’t be barred for pre-existing conditions and can’t be charged a million dollars for my premiums. These are all pretty significant accomplishments in health care reform.

Where Candyland gets bitter is that I am still buying insurance from a health insurance company. I am giving Blue Cross a ton of shit in this post, but they are also my current insurer and do a pretty good job. Blue Cross is one of the more responsible companies out there, in my experience, and still their documentation is contradictory, confusing, and difficult. They have a vested interest, as a business model, in not being definite or transparent about the benefits they offer and what they will cover, and that’s probably more true for other insurers as well. And to the extent that the ACA leaves sick people like me dependent on insurers, it still kinda sucks. I wish we had found a way out of that — for example, the public option.

If you do not have health insurance, or are paying too much money for your insurance, you should get started on  (or your state exchange) right this minute. But keep in mind that what you’re buying is health insurance, and keep your eyes open. is a huge step forward for our health care system, but limits and exclusions apply.

*Sex is in no way a benefit of reading this blog, and this blog does nothing to improve your sex life. 

One Response

  1. Mighty Casey December 5 2013 @ 1:06 pm

    Terrific capture of an experience that mirrors most of my own when I enrolled for insurance via – I also live in a “we hate Obamacare, f^ck you” state – in October. My experience is outlined here:

    I was also annoyed/disturbed (enraged?) at the lack of real information available on the plans I was considering. I bought health insurance – individual and company group – for 20 years before winding up on the uninsured Group W bench at the end of Cancer Year in ’08. At least now I’m protected if I get hit by a meteor, and can have an HSA. Only Bronze plans qualify under that heading, which is NUTZ. We should all be able to have HSAs, insurance should be irrelevant in that decision.

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