I worked for Empire BCBS when the Medicare D drug program was first released. I’m not exaggerating when I tell you at least 20 phone calls in my day from members were elderly people on Medicare barely scraping by with their SS check, and they were in tears because they couldn’t afford their medicines. Medicare cut the list of covered medications in half with this new drug program. So, they buy a supplement policy with Empire, which runs off Medicare mandates. Either way Medicare is saying what will/will not be paid for. With Empire they pay a normal HMO based copay amount, instead of the 80/20 Medicare copay, and still get no help with prescription coverage. So now, we turn them to Social Security drug assistance programs that deny their application because they make $30 too much a month. No I’m not exaggerating there either. Explain to me how an “extra” $30 a month covers a prescription that costs $150 a fill. Now the 83 year old woman who has to choose between paying for her heat or medicine is paying for her Empire HMO as well, and still can’t afford her drugs because Medicare allows no other drug program to be purchased as a “rider” or “secondary” so to speak or they will drop your benefits completely.
Not that the private insurance companies are all sunshine and roses. I got just as many calls from members wondering why their cancer treatment at Sloan Kettering wasn’t covered for example. We’re sorry you want to live and see the best doctors in your area for your condition Mrs. Jones, but you’re under an HMO with Empire and do not have the same network benefits as you did previously when you were covered by Medicare only. Sloan Kettering is not a covered facility under your policy, you are liable for the $7,000 bill you received from them. So now the same 83 year old who purchased an Empire HMO to try and reduce her copays, so she can have left over money from her SS check for her drugs that aren’t covered by Medicare, has to appeal to our claims department and go through red tape to have her treatment approved. We actually had members drop us to receive their cancer treatment covered under Medicare only, paid their 20% of their $7,000 for example, and signed back up with us the next enrollment period.
You can take this post however you want, these are just the things I’ve seen first hand with insurance whether it be government run/private company.
Sorry it got so long.
/rant