How What County You Live in Could Affect Your Healthcare Coverage – A Healthcare Story from Benton County WA

In 2010 I suffered a hemorrhagic stroke at the age of 40, due to an incredibly rare type of benign brain tumor that the neurosurgeon said had probably been there since birth (they could tell it had been there a very long time because of the way blood vessels had grown around it). I was incredibly fortunate that when this completely unexpected major health emergency occurred, I was covered by my then-husband’s health insurance through PSEW (Puget Sound Electrical Workers).

Unfortunately, the marriage was not destined to last, and we separated. However, I asked my now-ex if he would be willing to technically stay married until I hit the lifetime maximum on his work insurance policy that had covered my 11-week hospitalization. Many, many people during that time assumed that because Obama was president and had enacted the ACA, that lifetime maximums had been eliminated, but that was not the case. The policy I was under had a $1 million lifetime maximum (it may be that some companies were able to get grandfather clauses allowing them to keep lifetime maximums).

As Explanation of Benefits (EOB) statements began arriving in bundles in the mail, we started referring to me as “Million Dollar Baby.” The amount that is shown as what was paid for any service or provider on an EOB statement is the highest amount a provider could receive. However, the insurance companies always negotiate that price down. So what shows on an EOB statement is not usually what the insurance company actually paid. Most likely, they paid less, but the health consumer is not privy to that information! The only information we had were the numbers showing on the EOBs, and I was inching my way up to that $1 million. At that point I had weekly check-in calls with the woman who was the insurance case manager, to ask how close to the cap I was.

My then-husband did agree to technically stay married so I could keep that insurance coverage until I hit the million dollar limit. However, being an electrician is feast or famine, and he got laid off with no new work – a routine we had sadly become incredibly familiar with. He needs a certain number of work hours accumulated to keep his benefits instated, and with no work, he lost his benefits. The last time I checked in with the insurance case manager, I was up in the $600 thousands somewhere.

I was then forced to find a private health insurance policy until I qualified for Medicare. Anyone under 65 who becomes disabled has a two year waiting period before eligibility for Medicare kicks in. During that interim two year period, after my husband’s benefits ended, I was lucky to find a non-profit org that helped me navigate the process of finding a private policy without getting booted to the high-risk pool, which would have been insanely expensive. They helped me answer questions truthfully on applications. I believe that organization was called the Washington Health Foundation. At the time in 2011, they actually had an office space (somewhere in Seattle I think – no idea exactly where) and like three employees. I don’t think they exist anymore, but with their help, I secured a policy with Assurant until I finally got Medicare in 2012. I also learned that the key is to never have a lag period in which you are not covered. If you do, THAT is when insurance companies can pounce and charge you outrageous premium prices.

Disability does not make you rich (cue bitter laughter), and after getting divorced I was forced to do a short sale of my house because of the housing crash. I moved my young daughter and myself into an apartment in Bothell, WA. Rent prices skyrocketed, and I was then forced to move to a more affordable area. I chose the Tri-Cities (West Richland) because I have family and friends here and it is close enough to the west side that my daughter can see her father and his family on a regular basis.

When we lived in Snohomish County I had a Medicare Advantage plan (part C) for my supplemental policy. What Medicare does and does not cover can be lengthy and convoluted. However, as a general rule of thumb, Medicare part A covers hospital stays (although people need to be sure their stay qualifies – there are minute details that are best read in an article I’ll post at the bottom, if you’re interested), and Medicare Part B is the part that covers outpatient services. However, Medicare only covers 80% of outpatient visits. So most people pay for a private, supplemental policy, in addition to their Medicare coverage (which each person also pays for). Medicare Part C refers to Medicare Advantage plans, which are supplemental policies offered by private insurance companies. While we lived in Snohomish County, I had a Medicare Advantage plan (Part C) through Regence.

When we moved to West Richland, which is in Benton County, I just assumed I would be able to stay on my Medicare Advantage plan since we were moving within the same state. I assumed it all went by state; but it does not. It goes by county. After the move was complete and my daughter had already started 4th grade, I discovered that I was NOT eligible to stay on the Regence plan.

My only choice in Benton County, as a person on Medicare who is under 65, is a Medicare Supplement Plan F, offered by Premera. If I was 65 or older, I would have plenty of different Medicare Advantage plans to choose from in Benton County. However, because I am under 65, it is either the Supplement F plan or nothing. I assume this is because Benton County is much less populated than Snohomish, and there may be too few people under 65 to make it worth the insurance companies’ while to offer Medicare Advantage plans to the disabled here. Apparently I am lucky that there is a supplemental plan available to me at all in Benton County!

Trust me, I have thought many times about risking it and going without the supplemental. My monthly premium doubled, compared to what I had been paying for the Advantage plan, but I now have zero copays. So instead of paying $175 a month, which was what I paid for the supplemental in Snohomish County (Part C), I now pay $356 a month for the Supplement F plan, which covers the 20% gap that Medicare Part B does not – but I never have a copay.

I also pay approximately $130 per month for Medicare (it is deducted from my SSDI before it hits my account, which is why I am never exactly sure how much it costs me). I have also opted to pay for Medicare Part D, which is the prescription drug coverage. That also comes out of the SSDI before it hits my account, so I am not exactly sure how much I pay on that each month.

After the dust had settled and I figured out my only supplemental plan option in Benton County, I begrudgingly purchased the Supplement F plan. I then decided I would have to MAKE it worth it. As mentioned, I had only paid $175 per month for the supplemental on the west side, but over there I had co-pays. As a stroke survivor, PT and OT are now part of my regular routine. Since both PTs and OTs are considered specialists (as opposed to someone like a primary care provider), there was a $45 copay for each appointment. As rent prices increased on the west side, I was only able to go to PT and OT once a month each. I used to go to a place in Seattle one Saturday per month. If I had both PT and OT that day, the combined copays were $90. Factoring in gas to get me there and back, I started referring to those Saturdays as my “hundred dollar days.” Eventually, I stopped going to PT and OT altogether because I had to make rent. However, now that I don’t have copays (although double the monthly premium), I have been going to PT and OT regularly here on the east side.

Finally, Medicare does not cover vision or dental, so I have two separate policies for each of those, as well. All told, I have six insurance policies (Medicare A, Medicare B, Medicare D, the supplement F Premera plan, VSP for vision and Cigna for dental) for a total of approximately $520 a month, just for me. My daughter is currently covered by her father’s health insurance through PSEW, however, there have been times throughout the past 10 years when she had to be transitioned to Apple Health (WA state Medicaid) because my ex lost his benefits. Because of the current shutdown, he has been laid off again. So I do not know how long his benefits will cover him and our daughter. She will just go back to Apple Health, if necessary.

Does your brain hurt yet??? Is it complicated enough? Sometimes I envision how someone from a different country would react to this tale. I’m sure it would blow people’s minds, and I know that it is only ONE story. There are millions of similarly messed up narratives out there!

This is a website that spells out the details of what Medicare covers for hospital stays (Medicare Part A): https://www.healthline.com/health/what-medicare-covers

This one talks about what Medicare Part B covers (outpatient): https://www.healthline.com/health/what-medicare-covers

LET’S STOP THIS MADNESS!!!!! Go Whole Washington!!!!

-Kim H., Benton County WA

Posted in Healthcare Stories.

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