Blarrrgghhhhhhhhh.......

April 3, 2010 12:53 PM

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)

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.)
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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.

TL;DR
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?

posted by sio42 to work & money (16 answers total)

You can start looking for a new job that has insurance that has coverage of what you'd like.
posted by Geckwoistmeinauto at 1:01 PM on April 3, 2010

sorry - i forgot to mention that i really like my job. i really didn't want that to be my only option.

but i know - it's in the not-too-far-back part of my mind.
posted by sio42 at 1:10 PM on April 3, 2010

This could be a long shot, but is there a way you could talk to other employees in the ND and find out what they do about ADHD or even mental health treatment generally? Maybe ask the HR person whether anyone would be able to share their experiences with you?

If you're stuck with this coverage, I would definitely ask for a raise.

My other inclination is that you could consult with an employment lawyer but I'm honestly not sure whether you would have any legal remedies here.
posted by sallybrown at 1:12 PM on April 3, 2010

Oh and the Mental Health Parity and Addiction Equality Act of 2008 might be involved in some way; as the article says The effective date of the final rules will be on April 5, 2010, and apply to insurance plan years that start on or after July 1, 2010, so perhaps that will help you in the future? (IANYL, TINLA, just a thought.)
posted by sallybrown at 1:23 PM on April 3, 2010

Do you think it's possible the change is taking place mainly to save money on the contribution they have to make to employee insurance benefits?

If so, and you make too much noise about it, you could be identified as a Problem.
posted by jamjam at 1:51 PM on April 3, 2010

Can you COBRA your old insurance? Might not end up cheaper, of course.
posted by stevis23 at 2:10 PM on April 3, 2010

Is it possible that the outpatient mental health and substance abuse parts of your benefits are covered by something that is not the main medical plan?

I had an employer at one point that did this. Our mental health/substance abuse stuff did not go through the same company.

So the first thing I'd do is contact HR. "The benefits summary says outpatient mental health. The details here say they exclude mental health. So where does the outpatient mental health benefit come from?"

They're the ones who can answer that. The health insurance rep can only tell you about your health insurance; if your mental health benefit comes from elsewhere, they wouldn't be able to answer those questions.
posted by gracedissolved at 2:12 PM on April 3, 2010

Which Adderall are you on? The IR is generic. Not sure about the sustained release.
posted by elsietheeel at 2:30 PM on April 3, 2010

Have you tried the generic? Or calling around to check prices? I've found a huge difference between pharmacies on how much they charge for generic amphetamines (Costco has the best price in my area).
posted by Jacqueline at 2:53 PM on April 3, 2010

i already talked to my new hr guy about this. there's not a separate plan for mental health or he probably would have mentioned that. i will ask specifically when he calls me back.

our current benefits are not paid by the national group. If it was a cost savings measure they'd be consolidating a much bigger departmentthan ours.

I am the extended release right now but I don't know if that will continue to be my med or not. When I start seeing the titration specialist that might change.

I'm not eligible for cobra and you're right. It is expensive.

I'll have to look more into the parity act.

I appreciate all responses and am not trying to shut down anyone, but just to answer what's being brought up
posted by sio42 at 3:03 PM on April 3, 2010

Have you talked to your supervisor? Would this be something they'd be sympathetic to? As in "I'm excited for our move to blah blah blah, but the insurance change is going to hit me hard out of pocket, is it possible to get some sort of adjustment?"
posted by Oktober at 7:09 PM on April 3, 2010

Check your memail. I think you need to ask specifically whether mental health is under a different thing, because when I was on BCBS of GA, I'm pretty sure it was.
posted by ishotjr at 7:51 PM on April 3, 2010

Poor man's extended release: Break your dosage up and take it with food. That's what I do -- every 2-3 hours, half a regular dose with a snack. (I can tell when it's time for another dose because I start wondering what's going on on the internet. :))
posted by Jacqueline at 11:56 PM on April 3, 2010

i did indeed check my memail - just posting a little here by way of update.

ishotjr had been given an option of a separate plan that handled MH, much like most Rx plans are someone else other than your main medical provider (like ExpressScripts or Medco).

i was not given any information about such a plan from either the State or National HR person, nor was such info included in the quasi-newhire packet we received.

i will however specifically ask about it on Monday.



and thanks for the tip Jacqueline - i have an appt on Tues to get my Rx refill. I will be explaining my situation and see if they can xfer it all to IR instead of the XR and possibly post-date a 2nd Rx.
posted by sio42 at 9:04 AM on April 4, 2010

i received word from on high that anything with a diagnostic code for ADHD, ADD, anxiety, depression, etc is NOT COVERED. no way, no how.

there is not a separate MH plan.

in fact, they are still trying to figure out if my Adderall will be covered.
luckily, my GP was awesome and gave me a larger Rx so it would last longer and said i just can call in next month for a refill to skip the office visit cost. so at least that's good for now.

the HR people are "working on it" my boss tells me. he is trying to explain to them that a lot of my expenses are due to the fact that i just got diagnosed a few months ago and i am still in the stage where i need frequent visits to get the right meds/dosage, and that after this year, my costs won't be as much. this in hopes that the "one time payment to make us whole" they told us about might be higher for me.

in the mean time, i'm taking the civil service test tomorrow. i can't take a $4000 paycut.
posted by sio42 at 7:40 AM on April 7, 2010

just another follow up in case someone finds this in the future and health care reform is still not realized.

i got nothing. all i got was the previously stated one-time payout they were giving to everyone. this was apparently not negotiable as i never signed anything agreeing to it or not. we were not given any numbers on how that figure was arrived at. it just appeared in our direct deposit one day.

i am not getting a raise, i am not getting compensated in any way for extra costs. i am told that if i incur a cost that was unexpected i can submit it to HR and "maybe" something would happen. i said that i was afraid to go to the doctor now for fear that i would not be covered since i can't "refund" my visit. i was told that my providers need to call a day before to verify the diagnosis codes are covered. at least any diagnostic visits are covered, just not treatment. (which to me is like saying, hey you have cancer but we aren't going to pay for the chemo, just the test that said you had cancer. mental health parity? BS.)

all i know is that i am a fairly good advocate for myself. i feel bad for the first parent who doesn't realize the difference and keeps taking their kids to therapy for ADD and then gets a $1000 bill after a while. oops!

someone had memailed and correctly guessed where i worked, having also worked there but on the other side of the country.

i am so incredibly disappointed with my job right now. and very upset that i have no recourse. i also cannot get private insurance because all of the goods plans require that you either a) have exhausted cobra or b) aren't OFFERED ins thru your employer.

so i have no choice if i want insurance. none. at. all.

thank you for everyone who offered your cost savings tips but i think the first answer is indeed the best. i am trying like hell to find another job and/or go to grad school (where oddly enough, the crappy student ins costs about the same and is BETTER. go figure.)


i hate when posts like this don't have a resolution so i just wanted to give the final word/rant on the whole thing. i just hope that one day this kind of post is culled for a book about the horrors of healthcare in times gone by.
posted by sio42 at 10:50 AM on May 3, 2010 [1 favorite]