What To Do… What To Do…

Koan at the barbershop.

Late last spring I did something I had not done in over 19 years: I interviewed for a new job.  While I was really happy working for Prairie, Cedar Rapids Community Schools had created a new position that was just too interesting to me.   I was fortunate enough to be selected for this new role — Executive Director of Digital Literacy and Information Technology — in early May.   This has been a really seismic change for my entire family: a new schedule, different core work, and a change in health insurance.

As I’ve written before, Koan is covered by Iowa Medicaid through the HIPP program — the last vestments of the old (and vastly superior in every sense) fee for service model.  The way HIPP works is that we cover Koan under our private insurance and anything our policy does not cover, Medicaid picks up.  In addition, DHS would send us a check twice a month that re-reimbursed me for Koan’s portion of our coverage plan.  Again, HIPP is so much better than the privatized Managed Care Organizations (MCOs) that place profit over patient needs and are costing tax payers more than the previous, and highly effective, public fee for service model.  With HIPP, we’ve gotten everything we’ve ever needed to care for Koan in a timely fashion.

In order to qualify for HIPP, DHS runs a cost/benefit analysis annually in late June.  As long as our Wellmark Blue Cross Blue Shield policy covers an adequate amount of spending, Koan’s enrollment in HIPP is considered cost-effective.  However, with my new insurance coverage with the new job, I was concerned that we might lose access to HIPP coverage.  And, as I’ll explain in a bit, I did my self no favors to make this process quick and painless.

My new job and health care coverage started on 7/1/2018.  On Friday, 7/6, I was scheduled to have my very first colonoscopy.  Trust me this will all relate back to Koan shortly…  On Tuesday of that week, my second day at CRCSD, I got a call from the gastroenterology team doing my procedure that let me know had no health care insurance.   This was a bit of a shock to say the least.  So, I postponed that procedure for a couple of weeks and started tracking down what had happened.  Of course, to make matters more complex, at the time of this call I was at an off-site executive team retreat.  So, I couldn’t just run to down to HR/payroll and see what had happened.  I did call back to the office during a break and discovered — not all that surprisingly — that the lapse in coverage was my fault.

I had accepted the new position and been on boarded by the HR team in mid-May.  For the last nineteen years at Prairie, all I had to do to select health insurance was circle the coverage plan I wanted on a sheet of yellow paper and return it to benefits.  In my head, I had done that during this mid-May meeting.  I had certainly signed a lot of papers, and I was sure I had done given the benefits team that info.  This was further reinforced by the fact that I had gotten new insurance cards from Wellmark in mid-June.  What I found out during that phone call during the break from the retreat was that CRCSD does things differently.  I needed to go to a Wellmark website and select the plan I wanted and enroll myself.  So, I did technically have coverage, but I had not enrolled in a plan.  The new insurance cards were just an annual refresh of my cards for my Prairie plan.  This was a classic face-palm moment.

The retreat that day was that the Prairie Woods Spiritual Center on Boyson Road.  I had been outside because the cell coverage was so bad in the building.  Once I got this information, I ran back inside to jump on my laptop — while the cell coverage was bad, the wifi was good — to get myself enrolled.  I successfully logged into the Wellmark site and selected PPO Choice — the same plan I had back at Prairie.  Of course, I was a little worried about our HIPP application at this point.  As part to of the application, I would need to send a photocopy of my new insurance cards and a current pay stub.  The application due date was July 13th.  So, I figured I had plenty of time to get these items addressed.  On Thursday, July 5th, I walked down to benefits and had the team member assigned to me fill out the DHS paperwork.  I thought we were all set…

One of the many cool things about working in the CRCSD central office is the building runs a four day work week from early June to the end of July.   Everyone works ten hour days Monday through Thursday.  No one is in the office on Fridays.  At the end of my second week on Thursday, July 12th, I got home around 6:30 PM.  I had worked out at the gym after work and was feeling really great.  It had been a good day at work.  When I got home, Jeri greeted me and in our casual conversation, she mentioned that we got our new insurance card.  She did note that they only send us one card.  We both laughed about that for a minute — joking that Wellmark must be really trying to save money on printing.  Then, Jeri casually remarked,”Are you sure you chose the family plan and not the single plan, right?”  After thinking for a bit and to have some piece of mind before the weekend, I decided to re-check what I had signed up for on the Wellmark enrollment site.

I had indeed enrolled in the wrong plan in my haste to get signed up on 7/3.  I will admit, I lost it at this point.  The HIPP form was due the next day, and the information I had for the application was all wrong.  Worse yet, no one would be in the office on Friday to help.  Jeri was incredible at this point — so calm and collected.  Yet, another concrete proof on why she is my soulmate.  I was in full existential meltdown.  I thought I had not only messed up our family health care, but I thought I had totally screwed up any chance Koan would have to remain in HIPP.  Jeri led us through a very deliberate and reasoned plan to do what we could to remedy the situation on our own that night.  I wrote several rather panicky emails to our HR and benefits team leads as well as left voicemails.  Jeri updated our info on the Wellmark site — selecting the correct family plan.

The next day, the incredibly gracious benefits person called me (on her day off)_ and assured me that she would work with me to get this all sorted out.  She would work with payroll to adjust the amount of insurance from my check — July 13th was my first paycheck.  And, even better, she would write a letter to the DHS team explaining what had happened and describing all the information the State would need for the HIPP application.  This phone call was so awesome and kind.  After talking with benefits, I called DHS and got an extension for our application. Again, I felt like we had everything back on track.

The following Monday I got the letter and all of the other supporting documentation for our HIPP application and emailed it to the DHS team.  On Wednesday, I got a note indicated that DHS needed access to Koan’s claim info from Blue Cross Blue Shield to make a cost-effectiveness eligibility determination.  After going back and forth with the DHS folks a couple of times on Thursday, I was able to get them the right information.  In years past, I had been worried about the cost-effectiveness of our application.  Thankfully, Koan is a pretty healthy guy and we don’t usually need a ton on additional medical help.  This year, we had returned for three appointments to the U of I neurology team and went through two rounds of genetic testing.  I had seen the cost of these test in our EoBs (Explanation of Benefits) from Wellmark.  The Angelman test was about $3,500 and the epileptic panel that had revealed his KCNQ2 diagnosis was a whopping $12,300.  Both tests had been pre-approved by insurance before testing.  So, I had little doubt we would get be deemed as cost effective by HIPP.

The following Monday, July 23rd, the DHS HIPP worker called my cell.  She had reviewed Koan’s records from Wellmark BC/BS and he was coming back as cost ineffective.  She was calling to let me know we would be removed from HIPP and placed (eventually) with an MCO.  I was in shock.  She was really helpful and nice.  But, after looking at the numbers with her, I had to agree.  Koan would not be eligible for HIPP.  Wellmark had spend a total of just under $900 on him for the fiscal year.  Here’s the crazy part.  When I looked at both of the genetic tests, Wellmark had paid a few hundred dollars for the $3,500 Angelman test.  But, they had paid nothing on the $12,000 epilepsy screener.  And here’s the really wild part — Medicaid had paid for none of that test and I didn’t owe anything either.

When I looked at the EoB from Wellmark for that item two things stood out.  The claim had been denied.  The reason for the denial was the procedure was deemed “experimental” or “investigatory”.  Secondly, again, remember according to the EoB, I owed nothing…  All of the cost on these test was covered by “In Network Savings”.  I wasn’t sure what that meant.  So, I called Wellmark to see what it means when cost is absorbed by “In Network Savings”.  What they told me was that terminology in this case means that either the lab that conducted the tests or the University of Iowa Hospitals and Clinics had written off or absorbed all of the cost.  Remember, before both tests were run, we had to wait for approval from insurance.  So, this seems really strange…

I next called Koan’s U of I care team.  I wanted to verify that the epilepsy test was neither “experimental” or “investigatory”.  The genetic counselor agreed as did our neurologist.  So, to be safe I asked them to write a letter I could use to appeal this denial.  I then called DHS and asked if we could get Wellmark to cover some of the cost of the $12K bill if that would swing the cost effectiveness of the HIPP equation.  I was told that it likely would.

As things stand now, I’m still waiting for the letter from UIHC.  But, I’ve been thinking about things a bit more.  I’ve had the unpleasant thought that I might just be able to leverage some payment from Wellmark on this denied claim.  But, I wonder how much of the $12,000+ they will actually pay — $10,000? $7,000? $3,000? $200?  If we actually do get a partial payment, what will happen to the rest of the written off portion?  My concern is that we might get stuck with a $10,000+ bill.  No one can really give me an answer to this question.  So, once we get the letter, I guess well decide what to do.  Should we let Koan roll into the claws of the MCOs or do we risk a huge medical bill that might (at least in the short term) dwarf any cost the MCOs will pass on to us…?  It will be an interesting choice.  It’s never dull having Koan around.


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