My dept is becoming part of the National Division (home office in Georgia) rather than the Regional Division (where I now work at Regional Division Home Office in PA). I am not physically moving anywhere. My employer is now National Div, even though it is just the parent/umbrella of Regional Div. My insurance carrier will now be BCBS of GA instead of Highmark BS of PA. ADHD is covered by Highmark. It is not by BCBS of GA. I will end up paying about $4000 in out of pocket expenses due to this. Is this legal? What are my options? Supplemental insurance for MH does not exist. I make too much for any state aid and am ineligible for other state MH programs. (there is a TL;DR summary marked as such at the bottom)
posted by sio42 to work & money (16 answers total) 1 user marked this as a favorite
tl;dr marked near end if you don't feel like reading all this:
Currently, I work for the PA State Division of a nonprofit which has GREAT insurance (Highmark Blue Sheild PPO) - unlimited counseling visits, reasonable co-pays, the whole 9 yards of a cadillac plan (I’m all for reform, but I take the best that I can get right now.) After the middle of this month my dept is being “nationalized” – instead of working for the State division (SD), we will be working for the national division (ND). We were told about this change about a month ago, but no one was able to provide with me any information about the insurance change. ND people came to our office on Weds March 31 to finally provide this info and have an “informative session” with just our dept, little more than ONE FULL BUSINESS WEEK before the change takes place, considering that Good Friday is apparently an unofficial holiday for a lot places.
When I am a national employee, I will no longer be able to be on the same carrier because the ND home office is in a different state than where I am now. I do not understand how this works, but that’s what we’re being told. I will be with Blue Cross Blue Shield of Georgia (BCBS of GA). I am staying in the same office, same desk, same everything. Everyone else in the office, with the exception of my boss and the rest of the department, will still be working for the state division.
Having worked dealt with insurance in HR in a previous job, I knew that mental health is often different from plan to plan, I got a hold of the plan book after the 3 hour meeting. (Only the summary was given at meeting, I had to email someone at ND to get the plan details book). I discovered the following (I have bracketed my editing, parenthesis are in the original, anything with … is just referring to like 80 other conditions or something. I have tried to include all the relevant info but will happy to be post more detail if you need to know.)
Limitations and Exclusions [excerpted for brevity here][anything under this heading is an EXCLUDED service]
Behavioral Disorders: [bunch of stuff about learning disabilities] This includes services, treatment, or educational testing and training related to behavioral problems, developmental delay (when it is less than two standard deviations from the norm…), including but not limited to services for conditions related to autistic disease of childhood (except to the extent that the contract provides for neurological disorders), hyperkinetic syndromes, including attention deficit disorder and attention deficit hyperactivity disorder,...
Outpatient Therapy or Rehabilitation: Services for outpatient therapy or rehabilitation other than those specifically listed in this Certificate Booklet. Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, psychodrama, cognitive therapy,...
I'm like, weird - I mean on the benefit summary it says “Outpatient Mental Health and Substance Abuse Treatment” is covered. But what are they covering if all this is excluded? The contract that I have does not provide for other neurological conditions, and in fact has does not have ANY language about what IS covered for Outpatient Mental Health. Considering how much they exclude, I have to wonder what’s left, except for Substance Abuse Treatment.
So I had a conversation with a health ins rep that went something like this: (I was calm the whole time, no yelling at the poor rep doing her job.)
me: So i see ADHD is an excluded condition. does that mean my prescriptions are not covered for ADHD?
her: as long as they are on the formulary. [i didn't find out until later that no one can give me the official formulary yet so i can find out if Adderall is covered or not]
me: but if I go to my dr about my ADHD meds, then that is not a covered office visit?
her: if the billing code states it was for ADD or ADHD, then it is not covered.
[me - wondering how I am going to pay for that titration specialist that was recommended by my last Ask.Me]
me: so the Outpatient Mental Health Therapy exclusion page says that cognitive therapy is excluded. I know what cognitive therapy is. what does BlueCross/BlueShield think cognitive therapy is?
her: hold on, let me look that up. [pause] hmm, ok. it says therapy for anxiety, depression, things like that
me: so....the things that people normally go to a therapist about?
her: [pause, then quietly] um, yeah. well, it depends on the billing codes.
me: ok. hey, I have my EOBs here for my therapist handy. [tell her billing code, which reads "Individual Therapy 90806"]
her: [she looks it up on the computer] no - we wouldn't cover that. that comes up as behavioral health, and , well, um, that's not covered.
me: right. ok thanks.
After this I got more info about the codes. The billing lady at my GP's office was really nice. Office visits to my GP to discuss my ADHD meds are coded using 99212/99213/99214 (these show up on the Explanation of Benefits). These codes mean "medication management" which is under behavioral health. If I was going to the dr to discuss migraine medication (which I don't have, just an example) that would be "medical management".
Further, there is a diagnosis code that is on the actual bill that most of us never see. I had her fax me one so I could have it for reference for my employer. 314.01 is for "ADHD combined". You can actually Google DSM diagnosis codes and see all the categories.
My therapist also has been using the 314.01 code with the 90806 code mentioned in my OP.
When I talked to the new HR guy by phone (he is in GA) on Thursday, I emailed him my spreadsheet where I calculated that I was essentially taking a $4000 pay cut since none of my therapy or medication management visits will be covered as of April 12. (Therapy is $100 a visit, dr - $114 for a quick visit, specialist - $231 and up) I am not eligible for sliding scale because of my gross income. I really don’t want to change all my providers just to find someone cheaper because I feel they provide me a good service.
HR Guy in GA was contacting their BCBS of GA rep to get more answers but of course Friday was an unofficial holiday most places so no one got back to me. I did not think to ask the rep when I talked to her what codes WERE covered, but my guess is for things that are traumatic or situational, like bereavement or witnessing a horrible car accident or something.
The State Division HR person is trying to see if there any other options for me, such as staying with the Division rather than going to ND so I can keep my current benefits. I would have to take a different position, possibly PT, but at least then I could finish up a master’s degree in 2 years instead of 4. No one really foresaw this AFAIK w/r/t mental health coverage, but even if they did, there was nothing they could do, as this is coming from above – they can’t just NOT allow us to go to ND. (SD is not happy about losing us to ND).
I was able to reschedule my appt to get my refill prescriptions before the change so I won't be without meds for the time being.
Not to be all litigious, but I am seriously curious about the legality of this. Even though I am staying with the same company but just changing divisions due to restructuring, how can they make me take insurance that no longer covers a condition that is currently covered? It’s not like I applied to be part of ND and knew about this. I started asking for the Plan Book and other details about a month ago when this was all initially announced. My current HR person did try to get the new info for me but they wouldn’t provide it to her until they came in person on March 31, the same day we all got the info.
The overall premiums are cheaper at ND, but when nothing is covered for me, I am spending so much more out of pocket. I’m not getting a pay raise, but I have to work more hours. (we all have to work 37.5 hours to be full time at ND instead of the 35 we all work now. PLUS we have two less company holidays, less vacation time, and a crappy sick time policy.) I spent pretty much from about 3 pm (when the meeting let out) until midnight going over the plan book and having that convo with the BCBS of GA rep and making my spreadsheet. Did they really expect us to just make sure our providers and conditions were covered in the span of a week? And no one can get me a copy of the formulary for the Rx coverage, so I have no idea if that pays for Adderall or not. They won’t know until they get the new cards, SOMETIME NEXT WEEK, mere days before the new plan takes effect. ( I say that’s BS but what can I do?)
And I discovered via AskMe that mental health supplemental plans don’t exist. I have been thru the individual health insurance/state programs eligibility already after I was laid off from a previous job and before insurance kicked in at new job. (in 2008, so it wasn’t so long ago that things have changed and I make even more now than I did then.)
What can I do? What should I ask of any parties involved? What am I not seeing?