What a difference a year makes! Last year, I'd written (see my post at http://goo.gl/ST6wtC to read the first on this ongoing saga) about a lengthy delay in getting the blood glucose test strips my doctor prescribed for me. Ultimately, I ended up getting what I needed by calling Executive Office Complaints (e.g. the CEO's office). Yet in spite of Aetna receiving approval from various state insurance regulatory agencies to acquire Humana (including the largest state Humana operates in, Florida), Aetna (like all for-profit insurance companies) decided that saving a few bucks in pharmacy benefits was worth them having to pay a much larger claim for ER assistance to treat a hypoglycemic event I wasn't able to detect, mainly because it impacts another line of business at the company. True, its a new plan year for me, although last year, I'd asked if that my pre-certification for extra testing supplies could be kept in effect permanently since I haven't been cured of autoimmune Type 1 diabetes just yet, therefore the need does not suddenly disappear because its a new plan year, but I was told pre-certifications may only be in effect for one calendar year, and that expired a few weeks ago, so I started again as if all that I went through in 2015 never even happened.
My endocrinologist handled it as requested (he's really good about this), and he had his staff requested a "new" pre-certification request, yet apparently, his request was denied. However, at least in New York State where I live, an insured's right to both an internal appeal and/or an external appeal of a final adverse determination by a health plan exists by law, yet I need a decline letter to dispute it. When I pressed Aetna Rx Home Delivery on this (which is operated by CVS Caremark), I was told that the doctor's pre-certification request was not approved. So I asked why a month had gone by and I still had not received an Explanation of Benefits (or a denial notice of any kind) notifying me that the doctor's request was declined. At that point, the Aetna rep (she may have been a Caremark rep for all I know) got kind of bitchy with me, claiming I was not entitled to an EOB for this. I responded by telling her that New York State Insurance Law § 4910 indicates that I AM entitled to this so that I may appeal the decision (if its decline again, I can re-appeal it again before a neutral third-party). Only at that point did the process of even getting my denial letter begin. Maybe its not an EOB, but a denial letter, but its only fair that I be notified.
Truthfully, I am really so fucking tired of dealing with this shit - endlessly, folks. Every year I deal with this, and spend HOURS on the telephone, writing letters and whatnot. A CHRONIC illness does not disappear simply because a new plan year begins, or because an employer suddenly switches healthcare plans, and yet I am required to spend hours and hours on the telephone just to get what state law requires a health plan (in New York, anyway) to cover if they wish to do business in this state. That's one reason insurance rates here are so much higher in New York than they are in say, Kentucky, but then again, if I were in Kentucky, I'd be completely shit out of luck if this was denied. In New York State, insurance companies have rules they must follow, and that's one reason we pay more for insurance here.
Fortunately, the Executive Office Complaints team has been relatively pleasant enough to work with. They did manage to get Aetna Rx Home Delivery to fulfill 60 days worth of testing supplies so I'm not stuck with nothing, but I still have a few questions:
- Why do insurance companies have rules in place designed to treat people with chronic conditions like second-class citizens? I know they don't want to have to cover us, but try and pretend a little better!
- Why do insurance companies treat people with chronic (uncured) diseases as if their conditions suddenly just disappear?
- What bean counter (accountant/actuary) determined that a denial with pharmacy benefits is the right thing to do when only one trip to the ER would not only erase those savings, but cause the company to pay MORE in benefits than if they had just covered the damn test strips?
I realize I won't get any answers on this, but the math just doesn't add up, and yet I have to keep doing this forever. Sorry, but I can handle a chronic disease, but I cannot handle this endless bickering with insurance companies to get what they're required by law to cover. I'd say that's a major reason why I want a cure. Its not the fingersticks, the insulin injections or the hypos I'm so sick of (and from), its the damn insurance companies that try and cut costs to give their CEOs retirements in Palm Springs or Palm Beach and a platinum healthcare plan so they never deal with the shit ordinary patients have to endure. Whether its Aetna, United Healthcare, Anthem or some other plan, all of them behave like a bunch of fucking idiots.
Whoever claimed the U.S. has the "best" healthcare system in the world has obviously never been to Europe (actually the U.S. rates rather poorly as I reported on in 2008, catch my old post at http://goo.gl/kE59f for more background), but I have, and in spite of complaints from the Swedes, Danes, Finns, Frenchmen and others, they don't seem to have to deal with all of this petty bullshit. Sorry if my language offends anyone, but I've about had it dealing with this stuff. It never goes away.