Insurance and Mental Health

September 12, 2008 4:23 AM

Please help us navigate the treacherous waters of insurance coverage!

I hope I can boil this all down:

- About two years ago, Mr. A develops severe foot pain after spraining an ankle. After seeing numerous specialists, physical therapists, etc..., one of them declares it to be something called Complex Regional Pain Syndrome, CRPS for short.

- Mr. A's GP, when informed of this, says that Lyrica is an option, but through questions about Mr. A's weight and emotional state, prescribes Cymbalta instead.

- Mr. A was informed that Cymbalta is mainly prescribed as an anti-depressant, but when he brought up side effects to the GP (ex. sexual dysfunction, severe emotional responses) he was basically ignored, and asked "Is the foot pain better? OK then, keep taking it."

- Mr. A taking Cymbalta up until the present time. Left his former position, where he had Anthem insurance, in order to move to a larger city and attend school. Applied to the "Lilly Cares" program to obtain Cymbalta for free, as the short-term health insurance he has now (6 months) does not have full prescription coverage.

Now we come to the interesting part.

- About a week ago, he was prescribed Percocet for an unrelated medical issue. After he took the first one, he was amazed at how his mood changed - he said it felt like he was a different person. Not spaced out, really, but all of the daily feelings like severe depression and anxiety were lessened. They were still there, but he said it was like he realized for the first time in a long time that they were manageable, not crushing. He'd mentioned before that his moods seemed to even out after he started Cymbalta, but when he did get upset, it was over the top. He also felt that his creativity took a huge hit around the same time, which was very frustrating for him. He was able to talk to me about how scared and sad he is a lot of the time, and how he wonders if everyone feels that way. Heartbreaking.

So...IANAD. I don't know if Percocet interferes with Cymbalta, and I don't know how Cymbalta actually affects him, since I met him after he started taking it. What I do know is that reading about Heather's (Dooce) battle with depression through her husband Jon's eyes, is that it's ok to take medication for it, and you need to find someone who will help you find the right one(s), since everyone's chemistry is different. Ideally, we would like to find both a good GP and a psychiatrist, so he can work with them on what's effective for both his physical and mental health.

What we're worried about is this:

1. His current health coverage has a cap of $550 for psychiatric visits, and like I mentioned, prescription coverage is not good.

2. He needs help now, but we're afraid that if we go ahead and open up this can of worms while he's on the short term plan, he'll be turned down when it comes time to apply for more permanent insurance.

Should we:

- Just get him help now and worry about the permanent insurance later?

- Apply for permanent insurance immediately, and then get help?

Or some other option we're not thinking of? We're not asking for advice on how to commit fraud, but how best to handle this.

I would have posted this under my regular username, but we figured it was probably better as anon - so any questions can be directed to my throwaway gmail, [e-mail].

Thanks in advance, everyone...

posted by anonymous to health & fitness (2 comments total)

Percocet (oxycodone) is a serious pain-killer and can be highly addictive. If you aren't used to real pain-killers, your first encounter with it can most certainly be amazing. I don't know why the doc decided to put him on an anti-depressant (which occasionally is used to treat neural pain such as fibromyalgia) rather than opting for a more dedicated neural pain killer like Neurotin. You mention his "emotional state" in connection with the original foot injury. Was he horribly depressed by the pain? If he was presenting as someone who was more depressed than in pain, that could have been the reason for the Cymbalta.

But, of course, IANAD. Certainly, putting someone on an anti-depressant is a roll of the chemical dice. If it doesn't match well with the patient's makeup, throwing a strong opioid like Percocet into the mix could cause issues. I think you guys really need to get your GP to re-evaluate the mix. By your description, it certainly sounds like he's riding a chemical rollercoaster right now.

How long has it been since the two of you had full insurance coverage?
When you say "apply for pemanent insurance", are you saying you will purchase your own, private health coverage?
If you are jumping from an employer-based group plan to a private plan, pre-existing conditions can be excluded by the new insurers. Some private insurers may go ahead and cover pre-existing conditions if you can prove prior coverage, but that isn't required of them.

Since you have SOME coverage right now (as bad as it may be...I've had worse coverage. Try a $3000 lifetime mental health coverage including meds! Thank you Golden Rule), I'd get help for him and work on finding better coverage at the same time. I know, shopping for coverage is a special kind of hell and can take forever, but there really isn't anything one can do to change that.
posted by Thorzdad at 6:33 AM on September 12, 2008

He needs help now, but we're afraid that if we go ahead and open up this can of worms while he's on the short term plan, he'll be turned down when it comes time to apply for more permanent insurance.

I'm presuming you're in the US in the following.

Provided that he has maintained some sort of health insurance coverage with no gaps exceeding 63 days since he was first diagnosed with this he cannot be turned down for insurance because of this pre-existing condition. This is addressed by the "continuous/creditable coverage" aspects of HIPAA.

NOW, what isn't always discussed is the fact that they have to take you, but they can do it at the highest rate window for your classification. So when I was looking to buy health insurance out of my own pocket in 2002 and pressed Kaiser on the matter they quoted me a monthly rate that was just insane. And that was before the sizable increases we have seen in the time since.

So if you're on an employer's health plan and they ask you to pick up a percentage share of cost that's averaged across the entire pool then they are going to suffer the big brunt. If it's a percentage of HIS cost it could be worse. If it's all out of his pocket... well, in that case the portability is useful to some people but not always reasonable.

So, there are potential impacts but being overtly turned down is not one of them. Honestly, if he's suffering from diabetic neuropathy (which is what they'd be using cymbalta to treat) and there are weight issues (from what you say above) then this is not the only thing that's going to impact his insurability/cost of insurance.

Let me also make my standard comment whenever someone says they got poor consultations from their doctor: there are a lot of doctors out there and odds are you do not have to go to one who isn't servicing your needs. If his doc didn't spend the time with him that he wanted he should have (a) demanded more from his doc and (2) gone elsewhere if the doc wouldn't step up. Be more forceful in future dealings. You are the customer and you're paying someone to help you with the only body you get. It's worth pushing your comfort zone.
posted by phearlez at 9:08 AM on September 12, 2008