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Aetna: you only THINK you're insured

DCblogger's picture

Caught by a Change in Health Care

She needs these machines and others because she has spinal muscular atrophy type 2, a disease that weakens muscles throughout her body. She also needs nursing care 12 hours a day.

Without the nurses, her parents, Philomena (aka Phil) and John Rogers, who is the chief information officer at the Commodity Futures Trading Commission, would be in a very tough spot. The outside assistance, covered by their federal Aetna health insurance policy, means better care for Shelby and a more normal life for her parents and three sisters.

But that assistance will not last long. Private duty nursing care will not be covered after Jan. 1, although Aetna is allowing a transition period to March 31. "Please be advised that these changes have been approved by the U.S. Office of Personnel Management," reads a letter from Christopher L. Weinrich, Aetna's director of federal operations. ...

... The Rogerses have used open season to look, without success, for other insurance companies that will cover private duty nurses.

The fact that other companies do not provide the coverage is one reason Aetna decided to dump that benefit, too. "If no one else is offering that benefit, then what you end up getting is adverse selection," Weinrich said during an interview. That occurs when people with a particular health need are drawn to the one company that covers it, which results in that company paying out more than its competitors.

It also means that our nation's health-care system, even for those with coverage, is fraught with holes big enough to push a wheelchair through. Much attention has focused on the 45 million people without health insurance and rightly so. But in the process, the many shortcomings of our market-based insurance system slip by.

This is a top level federal bureaucrat, with premium coverage, but it is not there when he needs it. We need healthcare, NOT health insurance.

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dupager's picture
Submitted by dupager on

As someone who has had 3 employers in the last 18 months, i have also had 3 diferent health insurance plans, 3 different dental plans, 3 different life plans etc..

the ridiculousness of employer sponsored healthcare really hits you when you must complete paperwork applications for insurance giving the same information 3 times over the course of a year.. obviously entails a cost to the employer and a cost to the insurance company for paperwork that no other developed nation requires from workers.

fortunately i am not sick or have any chronic condition because every "plan" has a pre-existing period.. so it's 6 months or a year in some cases.

And with every claim with the new plan within this "pre-existing period" the following scenario occurs:

several weeks pass between the doctor visit and the arrival of a EOB from the plan: this is a copy of a letter the plan has mailed to the provider asking whether this is a pre-existing condition or not. This is for routine things like, an annual physical exam coded that way on the medical form. More paper processing by me, the provider, and the insurer.

Back and forth and this isn't even to the point where they are able to tell me how much i owe..

And this is just the health insurer.. the same thing happens with the new dentalcare insurer.. complete waste of time and paper..

Gee.. sarcasm.. It's almost as if they want to hold onto premium money as long as possible before actually paying the doctor who performed the service.. as if they are making money off not paying claims incurred.

splashy9's picture
Submitted by splashy9 on

Seems so strange to me. Would you go buy a car, a television, or whatever without knowing how much it's going to cost you?

Our "system" is the weirdest thing. There are no prices posted for treatments. You have no idea how much it's going to cost when you go, which keeps those of us without health insurance away from the doctor for fear it's going to run into the tens of thousands or more if there IS something wrong.

Weird...

carissa's picture
Submitted by carissa on

I had foot surgery four weeks ago, and while the surgeon, who is out of network, will accept the out of network reimbursement and write off the rest, I still think I'm going to owe something, but have no idea how much. Don't know either if the anesthesiologist will do the same.

Biding my time...