Starting today, Mission and State’s new series, Adventures in Obamacare, will chronicle reporter Kathleen Reddington’s experiences registering for healthcare in California under the Affordable Care Act, which begins in January 2014.
Friday, Oct. 4, 2013
Health-coverage salvation and celebration—or at least a decent beginning—I think.
This morning, a friend forwarded a Barbara Boxer newsletter on Covered California, the state’s new healthcare exchange. Instead of navigating the Internet as instructed, I rang the phone number provided in the newsletter. Delighted to know there is a real person available to answer questions about the Affordable Care Act from Mondays through Fridays, 8 a.m. to 8 p.m., and on Saturdays from 8 a.m. to 6 p.m., except holidays, I hastily dial (888) 975-1142. I get a brief, amateur-sounding recorded introduction. I press prompt No. 4, “all other options.” Four quick rings later, Le Doa answers. I tell her I’m desperately seeking information on the Affordable Care Act, how much will it cost, when can I sign up, what coverage is available. “That’s awesome,” she says. “I think I can get you most all that information here.”
I like Le (pronounced “Lay”) already.
First, she explains there are four tiers of health coverage: Bronze, Silver, Gold and Platinum. As the precious metal hierarchy suggests, the Platinum coverage is the most comprehensive, has the least out-of-pocket costs for medical care and the highest premium. “So much for affordable healthcare. I think my budget can forget the Platinum,” I tell Le, laughing at my own joke.
“Let’s talk about your budget,” she responds. “Do you have your 2012 tax returns handy?” I’ve been through this before. When I lost my job six months ago, my health insurance went away with it. For a couple of months, I paid $1,400 monthly to Cobra to keep the full coverage I had while employed. Then I decided it was breaking my bank and hired an insurance broker. “Of course I have my tax returns handy,” I say, ironically.
Le, who may not get irony, quickly responds, “Please look at your Form 1040, line 37, your adjusted gross income.” I give her the dollar amount, a cruel reminder that I am an over-educated, civic-minded, economic underachiever. We calculate my income, adding line 37 to income earned abroad, savings interest, supplemental security income, alimony and rental income.
She quickly computes the numbers.
“There are two different health-plan packages you can apply to: the Bronze 60 and the Enhanced Silver 87. The number indicates how much ACA will cover after co-pays and deductibles are met.”
So far, this call is amazingly easy compared to the ardor I went through a few months ago with the insurance broker.
“The Bronze 60 deductible is $5,000 for medical and drugs; no prescription drugs until the $5,000 deductible is met,” Le continues. Well, it’s better than the $7,500 deductible I had under my former private healthcare plan.
“There is no co-pay for preventive care, no cost for an annual check-up,” Le says. “The Bronze bundles your primary-care physician co-pays. You pay $60 for three visits, upfront. That’s $20 per visit.”
I breathe a sigh of relief; this is already better than what I have with Health Net, but somehow it doesn’t seem real. Could the government actually release me from the nearly $400 bill every month I pay to avert an economic healthcare catastrophe?
“There’s a $70 co-pay for specialty care—that’s like a dermatologist or an eye doctor. Urgent care visits are a $120 co-pay, X-ray co-pay is at 30 percent, emergency-room co-pay is $300. High-cost infrequent services, hospital care and/or out-patient is 30 percent co-pay.”
Le waits for me to take notes, but so far it’s pretty clear. “The brand-prescription drug co-pay is $50.” Now I’m ready for the punch line: How much?
“The maximum out-of-pocket for one person is $6,350. Your monthly premium for the Bronze 60 plan PPO is $591 and you get a monthly premium assistance payment of $589,” Le says, referring to the subsidy that the government will pitch in toward my premium. Your monthly out-of-pocket cost is $2.”
That seems pretty reasonable.
Now, let’s move onto the Enhanced Silver 87.
“The Enhanced Silver 87 plan is a $500 annual medical deductible; [there’s] a $50 brand-drug deductible; no cost for preventive care, physicals, check-ups; primary care visits are $15 co-pay; specialty-care physician visits are $20; co-pay urgent care is $30; co-pay generic medication, $5; co-pay lab testing, $15; co-pay, x-ray, $20; emergency room, $75; high-cost infrequent services, hospital or out-patient care, 15 percent co-pay; brand-name drugs, $15 co-pay. The maximum out-of-pocket per person is $2,250. After that, 100 percent of all services are paid for,” Le concludes, taking an audible breath.
I look at my watch. Forty-two minutes on the phone and my two ACA options explained. Not bad compared to the hours of rigmarole I spent in bureaucratic hell when I became self-insured. I like the Enhanced Silver 87, but what’s the monthly cost? Le has the figures before I ask.
“The monthly premium for the Silver 87 plan is $763. With a $589 premium assistance payment, you pay $174 a month.”
Cool, much cheaper than the $386 monthly premium I have with Health Net.
O.K., so what carrier am I insured with, under either or both of these plans?
“For your area, Blue Shield of California and Anthem Blue Cross PPO plans are available,” she says. “Please keep in mind these are cost estimates but very close to what each plan will cost you monthly. Can I suggest you call your doctors, the local clinics and hospital where you would seek service and ask if they are contracted with Blue Shield of California and Anthem Blue Cross?”
Thanks, Le. Onto my next mission: seeking contracted doctors, hospitals and clinics. I ask Le if she has an operator number so I can call her back—she’s been great, very informative and clear. ”No, calls are distributed by cue. Any representative can help you. We can even walk you through and fill out an online application, if you like.”
It’s a hot late, Friday afternoon. I’m full of insurance info and the ocean breeze is calling my name.
Saturday, Oct. 5, 2013
Called a few doctors’ offices, including Sansum, which closes at noon on Friday. I get recorded messages advising me to proceed to the hospital or call 911 in case of an emergency. No more healthcare for today. It’s a warm Indian summer day and the waves are calling.
Sunday, Oct. 6, 2013
A friend calls and tells me my daughter, 19, has to sign up for healthcare by March 31, 2014 or face a monthly penalty. She’s my dependent and the obligation lies with me. Where are you, Le? It will have to wait until Monday.
Monday, Oct. 7, 2013
Time to do my homework. I phoned the doctors I see on a regular basis and found they are all contracted and prepared to take both Blue Shield of California PPO and Anthem Blue Cross PPO Affordable Care Act patients. Yes!
Onto Sansum Clinic, where I spoke to Rebecca R. in the customer service department, to see if they’ll take them. “The answer is no. At this point, we don’t accept either carrier as an ACA provider. Right now we are in contract negotiations. It’s a fluid process and we’ll be the first to know when anything happens.”
Thanks, Rebecca, for completely bursting my bubble. So what good is it if my doctors are contracted by the government to accept the ACA coverage but the biggest healthcare service provider in town doesn’t? When might these “fluid” negotiations be over? I ask her, trying not to show my disappointment and frustration.
“That question is for my supervisor. Her name’s Leah M., she’s gone for the day and can be reached at 9 a.m. tomorrow. Unless she has a meeting, then you can leave your questions on her voicemail. She’ll get back to you as soon as she can. Her direct number is (805) 681-1760.” Shut out cold until Tuesday morning.
Next call, Cottage Hospital. The operator referred me to the admitting department, where I speak to a clerk. She was professional and polite, but refused to give her name. “As far as we know, we are taking both Anthem Blue Cross PPO and Blue Shield of California PPO ACA patients. That’s what we have been told.” She referred me to the business office, where I left a message and hope someone will call me back tomorrow.