Healthcare Bizarro World

EDIT 10/9/17 – read the edit at the bottom.  This entire post is suspect.  There are no answers.

EDIT 10/10/17: i’m changing the font to super small because I want to preserve this post even though I think/hope it is completely wrong, but I don’t want to delete it.  I thank my readers for their input which led me to ask another round of questions…

 

Just when I thought the healthcare system couldn’t be more absurd than it already is, I encountered my latest “lesson.”  Let me explain.
My wife and I purchase our own insurance in the individual market.  We have a legacy “grandmothered” plan that doesn’t have all of the mandated features of the Affordable Care Act.  However, our plan has a broad network of doctors and hospitals that we can no longer duplicate with new ACA compliant plans from our provider – Anthem.   There are some other benefits that my wife would like to have without giving up access to our current network of doctors, so we decided to bite the bullet and buy her another plan with another provider that includes these benefits our current plan lacks, and maintain our current provider network optionality.  We figured we’d just pay the premium on the second plan as the cost of this optionality.
Now, in my silly head, I think that my wife has two insurances: 1) our Anthem plan where I am the subscriber and she is the dependent and 2) her Harvard plan where she is the subscriber. As a consumer with two insurances, I would expect that she would get to choose which one she would like to use in any situation.
Before we bought the second plan, I actually checked with both providers just to make sure there wasn’t some absurd rule that prevented consumers from buying multiple plans (there actually are rules preventing multiple ACA Exchange plans, and if you have Medicare/Medicaid there are funky restrictions too).  I didn’t want to get into a situation later where Anthem found out about the other plan and somehow voided coverage.  I was told that of course I could buy multiple plans – and why not? Any insurer should be happy that I have ANOTHER insurer – that’s just – I dunno – math? Logic?   Let’s look at a quick Venn Diagram of what I’m talking about:
multiple health insurance plans

multiple health insurance plans

So “A” is the network of doctors/hospitals which Anthem covers but Harvard Doesn’t.  “B,” which in our real-life healthcare consumption, is a much bigger overlap, is the network that both Anthem and Harvard cover.  “C” is the segment of benefits that Harvard covers but Anthem doesn’t.   We figured we’d pay extra to get extra coverage.
So it turns out that when the providers (hospitals/doctors) find out that my wife has this second plan, they tell her “that’s your primary insurance since it’s in your name.  We will automatically bill that one first.”   Well, you can imagine how that sat with an activist consumer like me: not well.  Both plans have high deductibles, and I’m immediately envisioning the worst case: a year in which both my wife and I require significant medical care – in which case I’m being told that my expenses will of course be billed to the Anthem plan, and hers will be billed to the Harvard plan, while I’d want them consolidated under the same Anthem deductible.  Are you with me so far?  I don’t want to have to eat through BOTH deductibles.  How could it possibly be the case that by paying extra premiums for an extra plan, we could financially screw ourselves ADDITIONALLY with an entirely separate deductible?  That’s absurd.
I, as a sentient, intelligent being, refused to believe that there was a good reason why the consumer can’t choose which of the plans she is paying for she wants to use, so I tried to get answers.  I was guessing that our situation is so unique – there are probably very few people in New Hampshire buying multiple individual plans – that the providers were just confused and giving me standard bullshit.  I managed, through my connections lobbying for balance billing legislation, to get in touch with a senior guy at Anthem who I spoke with for an hour on the phone.  This gentleman was not an idiot, although if you’d listened to our conversation, you might not have realized that.
First, he told me that it was illegal to have two individual plans.  No, it was not in fact illegal, I told him.  It’s not.
Then he told me that I was “double dipping,” by having two plans.  NO – dude – I am literally THE OPPOSITE of double dipping! I am reverse-double-dipping.  I am double-PAYING.  Anthem should, of course, be ecstatic that my wife now has Harvard as essentially the “first loss” tranche on her insurance – it’s great for Anthem.  Nevertheless, I persisted…
He explained that I was taking advantage of subsidies, and I explained that my plans weren’t subsidized – they’re not Exchange plans.  This is why healthcare is so difficult for the average consumer to understand: the System tries to tell you nonsense at every front, hoping you’ll give up or not be knowledgeable enough to argue your case.
After an hour, I think I finally broke through to the Anthem guy, and he seemed to get that I was talking about something he’d never encountered before – this wasn’t dual exchange or Medicare plans – and he’d look into it for me.  I didn’t hear back from him.
Three months later, these theoretical examples of which insurance company to bill became real life examples when my wife went to the doctor, who told her they had to bill Harvard.  I delved into the issue again, asking this Anthem leader to re-address this issue, and also getting in touch with the head guy at the New Hampshire Insurance Department in this regard – I’ll call him NHIDBSD (NH Insurance Department Big Swinging Dick).
First, the Anthem leader put me in touch with one of his subbordinates, who I spoke to on the phone.  I explained that I was guessing that I was getting bad information because my situation was so unique.
“Oh no we have lots of customers who buy individual plans in NH,” she told me.
“You have lots of customers who buy MULTIPLE individual plans?” I asked
“Oh – your wife kept the Anthem plan? No – that’s unusual.” she finally understood.
This Anthem worker (I’ll call her HL – helpful lady) listened to my story, and said “I would think that you would be able to use whichever insurance card you choose to present when you go to the doctor!”
Eureka! That’s what I would think, and that’s what any normal person would think – that’s how insurance works: the consumer buys it, the consumer chooses how to use it. Even in the fucked up world of health insurance, I couldn’t imagine we’d tolerate otherwise.
HL promised me she’d look into it and get me a definitive answer.  I told her that, of course, if it turned out that there was some insane rule that prevented the consumer from choosing which insurance to use, that I would want a premium rebate from Anthem on account of the fact that I had extra insurance “ahead” to them in the risk line.  (Spoiler alert – HL got back to me the same day I talked to NHIDBSD as detailed below – she told me a variety of what he had already told me, with some added inaccurate information mixed in as a bonus.)
In the meantime, I spoke with NHIDBSD, who listened to my story – again, I told him that I thought my situation was unique – and then he told me “this is how it works. If the Harvard plan is in her name, that’s the primary insurance.”
“Ok – you’ve told me what the rule is – now I need you to explain to me any reason WHY that’s the rule,” I pleaded.
“It dates back to when consumers got re-imbursement checks from their insurance companies, so that you couldn’t submit the claim to multiple insurance companies – they have language to deal with which insurance company gets each claim,” he gave me a nonsense excuse.
Nevermind that this isn’t how insurance companies pay claims anymore, which I pointed out to him, I had more questions.  He used the term “primary,” which is the same term that the providers had used – but it’s much worse than that!  For items in segment “B” of the Venn Diagram above, it’s not like my wife has Harvard as her first insurance, and Anthem as her second insurance – in that case, if Anthem had a lower allowed amount that they’d negotiated, we’d be able to at least someone take advantage of the lowest cost option for procedures.  NO – in the “B” group of the diagram, Harvard is her insurance.  There’s no “primary” and “secondary” despite the use of those terms – there’s just one insurance.   So in addition to subjecting ourselves to an entirely separate deductible, we’re also subjecting ourselves to potentially inferior rates, ALL BY PAYING PREMIUMS FOR A SECOND HEALTH INSURANCE PLAN!
On what planet does this make sense?  Why can’t I choose which plan I want to use? I asked the NHDBSD this question, and he said “so if you go for a procedure that has doctors, labs, radiologists, you want to be able to go down the list and say “this one should be billed through Anthem, this one through Harvard?”  He asked me sarcastically.
“YES! OF COURSE! WHY NOT? There is no reason why it can’t or shouldn’t work like that, other than laziness by the providers and refusal to provide the information that the consumer needs in order to choose which insurance options would be best.”  I was relentless.  He knew I was right, and basically verbally nodded over the phone.
Ok – how do we get it fixed?”  I asked him, since there was a senseless rule purportedly solving a “problem” (consumer reimbursement fraud) which doesn’t reflect the current landscape of health insurance reimbursement. I explained that I was the nexus behind the balance billing legislation his department was working hard on – I was the consumer advocate that initiated the whole thing, and that I was willing to fight for all of this.  Give me one of your junior people to tackle legislation on this!  He basically told me that they had bigger fish to fry in healthcare at the moment, with all of the flux around potential changes to the ACA, etc.
I gave him a line that I’d used in my most recent Balance Billing Committee testimony – that the “size” of the problem in dollars doesn’t matter: it’s so obviously wrong in terms of all logic, reason, and “fairness,” and either it’s a big enough dollar amount that it has to be fixed, or it’s small enough that it’s no big deal to fix.  I again proposed that my situation was probably unusual, and he told me that they had many customers with multiple plans – BEFORE the ACA.
“Ummm – yeah – how about now?”  I pressed him… and he admitted that I was probably part of a very small group.
Ironically, this problem is actually going to get worse if the Affordable Care Act is dismantled and plans diverge in the benefits they offer: there will be more reasons for consumers to buy multiple plans, and consumers who do will get completely screwed on multiple levels, as I learned here.
To recap: when my wife was only covered on my Anthem plan, we paid one premium, and had one deductible to meet.  We decided we’d spend extra money to have some extra health insurance coverage options in case we needed them, and as a result
  1. we pay extra premiums
  2. she has a separate deductible that has to be met, where we don’t get to choose how to allocate coverage
  3. we may be subjecting ourselves to higher rates for procedures that are now covered by the new plan, but we don’t get to take advantage of the lowest rate despite paying for both plans
  4. we don’t have overlapping “primary and secondary” coverage – each procedure is only covered by the Harvard plan – or the Anthem plan only if Harvard doesn’t cover it
  5.  are we getting a rebate from Anthem on our premiums? LOLOLOL. of course not.  Why? good luck getting an answer on that.
And so it goes…

EDIT 10/9/17:  so after a reader posted some coordination of benefit docs in the comments (which illustrate why the consumer should be indifferent to which plan is considered “primary”), I revisited this issue with the NHDBSD who said “yeah, that should be how it works.”  I was like “umm DUDE I TALKED TO YOU FOR AN HOUR ABOUT THIS AND YOU TOLD ME SOMETHING COMPLETELY DIFFERENT,” but what I was really worried about was that I have now discovered that both my plan documents and my wife’s plan documents say that we are not eligible for the plans if we have coverage under another plan.  The NHDBSD told me not to worry about that  – lots of people have multiple coverage and that we already have coverage so nothing bad will happen – but now I’m concerned that if I submit Harvard’s EOBs to Anthem, they’ll try to nullify my plan, etc etc… and the beat goes on.

In summary, it’s possible that everything I have written in this post is inaccurate, but I am worried about trying to find out if it’s accurate because I’m afraid that in doing so I will nullify my health insurance.

 

related: my other posts about healthcare

-KD

p.s. – in case it’s not clear from my writeup, both the HL (helpful lady) from Anthem and the NHDBSD (Insurance Department head) patiently listened to all of my rants and made every effort to help me understand what was going on.  I thank them for their time and efforts.