I recently saw a study that said that when people actually use their policies their attitude toward the ACA becomes more favorable.  This has certainly been the case for me.

Things did get rocky for a while though.  At one point, I came close to publishing a diary stating that we had been paying premiums for nothing as it appeared that no doctor would accept my plan.

This New Years was particularly special, as, when that clock stuck midnight, I finally had real insurance.

In order to choose a plan I went to the exchange to see what was available.  Since I did not qualify for a subsidy, I thought it would be easier to purchase the plan directly through Humana.

The first real hurdle was getting through the Humana application process. Their website was very glitchy.  But I got through and selected an HMO with a $1500 deductible, $500 prescription deductible and, my favorite part, a maximum of $2500 out of pocket.  Keeping my doctor was not an issue, as my favorite primary care doctor, who was beyond wonderful, had become fed up with insurance companies several years ago and  left her practice to lead a Hanley Hazelton center. So I researched the list of primary care doctors available for my plan and made a selection which was than noted on my insurance card.  Dr. Carl Spirraza, with Bethesda Medical Associates was to be my new doctor.

Having purchased the plan outside the exchanges, I was not sure if it even qualified as Obamacare.  I would later learn that for some providers the "x" in my policy was not just another letter.

I went with the HMO because I do not really mind them. I like knowing there will not be any surprise bills, and I was content with the specialists that were included in the plan. I also knew that the worst case scenario of $2500 was something that we could come up with even though it would hurt.  But the deductible had prevented me from going to the doctor as soon as I should have.  

I was born with a rare mild form of Spina Bifida.  The main lingering effects are areas of Neuropathy.  Like a diabetic, I have to be very careful if I get wounds, lest they become infected.  It also means that my feet sustain stress fractures that go undetected. About twelve years ago I did have to have a toe amputated due to a bone infection - Osteomyelitis.

I did know that I was entitled to a free wellness check along with a pap smear and mammogram.  But my concern was that since I had other conditions that the doctor would want to monitor the intended "wellness" visit could end up costing a bundle. I will also admit that I was not looking forward to the pap smear and mammogram.

So for seven months I walked around carrying my insurance card, confident that if I had any problems I just needed to call a doctor named Carl Spirazza.

Last Sunday night, several hours after working out, I had unexplained chills and then spiked a fever.  By the wee hours of Tuesday morning it became obvious that an area I had been monitoring on my foot was infected.  I figured that in order to ensure I was covered I should call Humana before heading to the hospital emergency room.  Humana has a wonderful 24 hour ask a nurse hotline.  The nurse agreed that it had to be looked at immediately, and  said that since I had not yet had contact with my primary he would probably not get me in right away. Her suggestion was the local urgent care center which would be quicker and cheaper than a hospital.

When I walked into the clinic, I expected that since I had a $1500 deductible I would be treated as an uninsured person.  I also anticipated being asked to pay some huge fee up front before I was treated.  I was wrong.

When I handed over my insurance card, I was only asked for the $35 specialist co-pay. Moreover, since Humana had negotiated a rate with the clinic the most I would be billed was an additional $100. At that moment I realized that having a deductible is far different from being uninsured.

The doctor took one look at my foot, backed up, and, made it clear that he did not want to touch it.  He did not even clean out the infected area. Instead he wrote on my discharge papers that a visit to "Podiatry was mandatory ASAP."  He also prescribed a cocktail of antibiotics, consisting of three prescriptions.  They had two of the prescriptions available at the clinic for twenty dollars each, but since I had to go to the pharmacy anyway I would see what their price was first.  

When I told the doctor I needed a referral from my primary to see a specialist, he nonchalantly stated that once my primary saw his recommendation he would not require an office visit before issuing the necessary referral.

When I arrived at the pharmacy, I informed the clerk that I would be paying out of pocket due to my deductible but was still giving her my insurance card "so I would get credit." I asked her how much the total would be and was shocked when she said $21 for all three.  What I discovered was that once again, I would benefit from a rate that Humana had negotiated.  My receipt showed that had I been a "cash" customer the total would have been  been $146.97. One of the prescriptions would have been $4 regardless.

I should note that my policy requires that I fill my prescription at one of only three pharmacy chains.  Thus the pharmacies agreed to low rates in exchange for relative exclusivity.

Once I got home, I confidently called Dr. Spirazza's office.  I explained to the testy woman who answered the phone, that although he was my primary I had not yet been to the office and would be happy to schedule a wellness check, but, in the meantime there was an urgent need for a referral.  She quickly put me in my place, ignoring the urgency of the matter and said  I would get no referral without an examination by Dr. Spirazza.  Then she asked me what kind of insurance I had.  When she heard the policy had an 'x" in it her response was "that is Obamacare we do not accept that."  She could not explain why I was allowed to linger on their rolls for 7 months.  She was just insistent that Obamacare was not welcome in their office.

So I called Humana and let them know what was going on.  I was told right away that Humana had a procedure in place to bypass the primary referral and get one issued by a a nurse from a special unit.  I was also sent a list of other primaries and told to schedule a wellness exam when I got the chance.  Of course I spent some time in insurance company telephone purgatory getting shifted from department to department in search of the correct one.

Finally I got the correct department and they were very understanding.  Obviously it was in Humana's interest to get me in to see a doctor at no cost to them instead of letting the situation fester and risking an expensive hospitalization for which they would be responsible for most of the bills. Things were looking up.

Then Brittany entered the picture.  Brittany did not seem to have a clue.  She relayed what she thought was good news. She had worked really hard and found me a new primary who agreed to  see me Friday afternoon.  I explained that would mean I could not get into a podiatrist until Monday which would mean that almost a week would pass, and the urgent care center had put in writing that I must be seen within two days.  Brittany would not budge, she claimed Humana could not issue direct referrals and told me the name of the medical practice that would see me Friday.  

Unfortunately I did not immediately write down the name of the practice.  Since so many practices have similar names I actually called the wrong one  when I went tried to see if they could issue a referral prior to a Friday visit.  When I told the practice my policy I was once again informed that they did not accept "Obamacare."

At that point panic and anger set in.  I recalled hearing about people on the west coast who claimed no doctor would accept their plan, and I thought I was in the same boat.   That was when I started to write a diary mostly for the purpose of getting suggestions on what to do next.  It was looking like an emergency room was the best option after all.

I decided to try and go over Brittany's head but was once again connected with Brittany.  This time however, I uttered the magic word - "amputation."  When I explained that a similar situation had led to an amputation in the past, Brittany said she would not make any promises but there was one phone call she would make.

When Brittany called back, it was hard for her to get the words out through the egg that must have been all over her face.  She informed me that as it turned out, I did not even need a referral since my plan entitled me to five podiatrist visits a year.  I knew referrals were not necessary for gynecologists but apparently they were not necessary for podiatrists either.

So I called the podiatrist from my list and a very nice lady gave me an appointment for first thing in the morning. She also assured me that if I needed any procedures that required a referral, they would take care of it, and I need not worry.  I was actually glad that the antibiotics had some time to kick in before treatment, since they were very effective and the procedure went much easier.  

Once again I expected to be asked to pay a significant amount up front, but instead was asked for my $35 specialist co-pay and told all billing would go through the insurance company who would then decide what I owed based on previously negotiated rates.

The doctor recommended an MRI and I awaited the bad news about how much that would cost. The answer $195. I remember years ago being billed a $100 co-pay for an MRI when I did not have a deductible so that seemed more than reasonable.    

When I got home I researched the actual primary care doctor that Brittany had found for me.  I was not pleased. The doctor was not board certified and more importantly did not have hospital privileges. While hospital privileges are not necessary for abortion providers, having your own  primary keep track of you during a hospital stay does make a huge difference. I feared that this woman represented the kind of primary care doctors available on my plan. However I decided to do some research.

My research turned up one doctor who seem ideal. Board certified, hospital privileges, excellent reviews and feedback. And I liked her picture. Unfortunately she  also belonged to the same large medical group as Dr. Spirazza.  But I figured it was worth checking.  I called the office and the person who answered the phone had a lovely demeanor and assured me that they did take my plan.  Following up with Brittany, I discovered that Dr. Spirazza's office seemed to be the only member of Bethesda Associates that was prejudiced against Obamacare.

All in all, despite outside hurdles, my plan has proven excellent.  I am able to get the treatment I need and the doctors and their office personnel have been great. If anything, I suspect that in some cases a doctor's unwillingness to take my plan may be a self-screening method to rule out assholes.

Your Email has been sent.