“I had no choice but to do my 3x more expensive COBRA option. AARRRGGHHH!!”

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Photo by PoPville flickr user Lindsey Robinett

“Dear PoPville,

I recently lost my job, so checked the healthcare.gov/DC healthlink options available as an alternative to a COBRA plan– Pretty expensive at $360 per month. I have multiple sclerosis but am in otherwise good health, so when choosing plans, the only two considerations were that my doctor and drug were covered. Here’s what I found:

1. There are only two individual plan carriers in DC: Carefirst and Kaiser Permanente.
2. Carefirst covers my doctor, but not my drug.
3. KP covers my drug, but not my doctor.

So, instead of having any of those more affordable, $115-150 plans available, I had no choice but to do my 3x more expensive COBRA option. AARRRGGHHH!!

Do you/anyone out there know of any resources to help me out, or advocacy groups? I’ve no doubt I’ll be gainfully employed again soon, but what if someone with less means found themselves in this situation?”

30 Comment

  • binntp

    If your MS medication is put out by one of the major pharmaceutical companies, you should look into whether you qualify for their Patient Assistance Program – look it up at rxassist.org. Then you can enroll in the Marketplace plan that covers your doctor, and get help paying for the drug.

  • Kaiser is an HMO model so it makes sense why the doctor would be in-network for Carefirst, but not Kaiser. You could petition Carefirst to provide an exception to include the drug on-formulary, but this is going to be an uphill battle to climb. Easiest option would be to find a new doctor within the Kaiser network or see if there is an alternative NDC you can substitute to that is on-formulary for Carefirst. Not ideal, I know, but that is the nature of the medical insurance market.

  • You could find out how much your doctor visits are without insurance – if you don’t go that often it could be cheaper to go with the one that covers the drug. Alternatively, you could do some research into how much the drug is without insurance (maybe discount drug cards would cut the cost – I discovered the magic of them recently because my prescription insurance is nonexistent until I meet my full $7000 deductible – or the Patient Assistance Programs binpetworth mentions above?)

    • MS drugs are INSANELY expensive out-of-pocket. My partner’s is easily ~$200/dose, 4x per week.

      • Yeah I don’t mean 100% out of pocket – discount drug cards often cut the cost by 70-90% and the patient assistance programs are also a great option to look into. I just know that I personally found that sometimes, it’s cheaper to go with one of those options than through your insurance, if you find yourself with insurance that doesn’t cover anything (like mine).

  • anonymouse_dianne

    You should be able to use Cobra to buy your old insurance through your former employer. I was laid off while being treated for breast cancer and was able to keep my Kaiser coverage. After I got a new job with a small contracting company, I was also able to keep my Kaiser coverage through my former employer. They can’t charge you more than what they were paying for it for you.

    • I’m guessing the OP was paying less than the $360/month (likely employer-subsidized) but I wouldn’t be surprised if that’s what the employer was paying. Regardless OP definitely check that that’s what they were paying!

    • Yes, but they charge you at their rate from the insurer without the employer contribution I thought.
      .
      So if your employer insurance was $400 a month and they aphid $150 of it and you $250–with COBRA, you have to pay the full $400.

  • Sorry you lost your job first of all, that’s a bummer.
    .
    FYI – 360$ is pretty much what a good health care plan costs. That’s actually very reasonable. You were likely paying less before because your employer was subsidizing the cost.

    Source: person who buys healthcare plans.

  • A friend with a similar chronic condition was very happy with Kaiser. I know what it’s like to get attached to a doctor, but it might be worth your time to ask around about KP doctors who specialize in autoimmune disorders.
    I used KP for a while, and I really liked their model. I had to try a couple different doctors– they’re not all great– but eventually found ones I liked, and their integrated system was very convenient.

    • anonymouse_dianne

      The new KP facility at Union Station is fantastic! I can get everything done there, where as before I had to go to Rockville for bone density scan, etc.

      What I paid for KP was a whole lot less than $400 while unemployed.

      Also to the OP, get signed up for unemployment benefits. You’ve been paying for it, its not much, but every little bit helps.

    • I have several friends who have Kaiser through federal plans and are *very* happy with it. HMO’s get a bad rap, but these are educated people who can weigh their choices properly and know whether they’re getting good service, so if they’re saying they love it, it must be good. Personally, I have the federal BCBS (same provider, basically, as Carefirst), and also love it, though they can be stingy with approving things they don’t cover/cover differently when random exceptions arise (I fought a long, hard, but at least ultimately winning battle with them when I had an emergency dental procedure which they covered (so my dental insurance said *BCBS* had to pay first), but there was a minor discrepancy in how BCBS would have liked it to be done (they wanted a specialist, but IT WAS AN EMERGENCY and the DDS who did it was PERFECTLY QUALIFIED to do it!)). It’s half dozen of one and six of another when faced with a situation’s like OP’s, but I suggest she keep trying to find a way, and it looks like there’s some good advice in the comments.
      .
      Also, just have to comment that $360/month for two VERY good providers is a mark that the DC marketplace is doing it right. I just did one of the comparison tools in case I decide to leave my fed job sometime in the future but stay in DC, and end up with a job that pays (a lot) more but doesn’t provide benefits (due to my field, that’s a possibility), and I could get the exact same plan I have now for just under $500/month. Zero deductible, low to moderate co-pays, no referral needed for specialists, $5000 max OOP yearly, covers nearly everything. I actually think that’s less than my + employer contributions right now! That’s the platinum plan…I was doing an apples to apples comparison (“you’d have to pay me X dollars more than I make now to make it a good offer”), so I didn’t look at the gold and silver, but they are offered, so I could theoretically spend less and still have *very* good coverage.

  • There are subsidies on premiums that are available for lower-income individuals (up to 400% of the federal poverty level) through DC healthlink. They are based on the lower-cost plans, though, so if someone ended up in your situation, they would likely need to choose whether their doctor or medication took priority.

    Also, if you end up buying insurance on the individual market again, another consideration is the deductible. The lower-cost plans you were finding on DC healthlink could also have high deductibles that you would need to pay out-of-pocket before insurance coverage kicks in. I’m not sure what your employer’s plan/ COBRA plan looks like, but the extra ~$200/month could be worth it if your medication is expensive and you’re only unemployed for a few months.

  • MS drugs are super expensive but Novartis has really good patient assistance. If Gilenya is an option for you it is a great drug and ended up costing me just $25/month.

  • Switch to a Kaiser doctor.

  • DC Healthlink is a bit of a nightmare, mainly for the reason the OP states: There are only 2 choices, Kaiser and Carefirst. In addition, like most DC bureaucracies, is poorly run, almost impossible to get in touch with someone who can actually help you, and people there give the impression that they don’t care too much about you. Last year, they enrolled me in the wrong plan and it took almost the entire year to get it fixed. This year, they lost my application altogether. They blamed Carefirst, Carefirst blamed DC Healthlink (it was DC Healthlink). DC doesn’t fit very well into the ACA scheme–the idea works much better with the larger and more diverse population of a state. It was not intended as a self-contained system for an urban area alone. We’d be much better off on the Federal exchange, or if Maryland would allow DC to piggyback on its plan. I’d be interested to hear any suggestions about how to approach this politically.

    • An FYI response to just one part of your comment: The federal exchange isn’t one giant marketplace. Each state that uses the federal exchange’s infrastructure still has its own carriers and plans–they aren’t lumped together with other federally-run exchange states in terms of the market size. The federal infrastructure might work better than DC Healthlink’s does from a technological perspective (though I doubt that–my dad had a similar experience to yours in WI, via the federal platform and United), but other than that, I don’t think using the federal platform would likely change much.

  • Ask a health insurance broker for advice, they don’t cost the consumer (you) anything

    • This – they’ll also act as advocate if you have billing issues (at least that’s what mine told me, I haven’t actually had to take him up on it).
      Also, as someone who has had to pay her own health insurance for the last 13 years, and who’s individual coverage basically just went up to almost $360, I can’t sympathize too much with your situation. One reason I stayed on my grandfathered plan was the high deductibles on the ACA plans (which BTW, my options were much higher than $150 – you must be younger than me). So while you may pay more monthly, especially if you will be using your health coverage, you may end up ahead of the game on the COBRA plan. But again, a broker can look at your options for you, and offer you some solid advice.

  • I just recently saw a national news story about blinkhealth.com. It’s a way to get discounts on prescription drugs using your own pharmacy. You need a script. Haven’t used it yet but it’s apparently getting good reviews and I’m keeping it for future reference. May be worth checking it out.

  • You probably qualify for Medicaid if you lost your job. In D.C., the program is called D.C. Healthy Families. Prescriptions would be free out of pocket. D.C. Healthy Families is actually better than most plans that people had with their doctors. One of the options is Medstar’s plan with D.C. Healthy Families. Some of the best doctors in the area belong to Medstar and most are located at Washington Hospital Center or Georgetown. Very good plan and you probably will qualify if you qualify for unemployment.

  • Why not apply for the state insurance? Since you lost your job, maybe you can qualify and get a better coverage that works for you.

  • northeazy

    “If you like your doctor, you can keep your doctor.” Barack Obama 2009

  • Get both. Still cheaper than COBRA.

  • Switch doctors. IME, much easier to switch doctors than medications. Get a doctor that’s on the new plan and be done with it.

    • Definitely agree. I’m sure your doctor is great, but people really have an irrational attachment to their current doctor(s). As layperson consumers of medicine we have very little ability to judge the quality of our doctors, we might like the bed side manner, but that really isn’t why you go to a doctor. You need a lot of specialized medical knowledge to have a valid opinion about a doctor.

  • Echo many things, but would like to emphasize that $360 is a reasonable premium. My mother, who is 61, pays $700 a month for a “gold” (good, but not ‘platinum’) plan because she has a chronic illness and expensive medication. The rates are based on gender, age and maybe where you live. I know it’s expensive but I hope you’re able to find something you’re happy with.

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