The insurance trap

The Insurance Trap

December brings a lot of milestones including the Christmas and Hanukah holidays, the Winter Solstice, and New Year’s Eve with its endless “Best Of” lists and unrealistic resolutions for the coming year. Equally ubiquitous are deadlines for making commitments for the coming year’s health insurance. Whether you’re covered by your company’s insurance (I’m not), purchasing health insurance on your own (that’s me), or by Medicare, you have to make important decisions that will impact both your health and your pocketbook for the next 12 months.

I’m in a weird place with insurance at the moment and will be for the foreseeable future. I am self-employed and while I have a lot of flexibility while still being able to work what is essentially part-time, it means that I’m not covered by an employer’s health insurance plan. For reasons that are immaterial to this article, I’m also not eligible to be covered by my husband’s company plan. This means that I have to purchase a private plan. I make too much money to get a rebate on the government plans, so I purchase my health insurance directly from the insurance company. Given the fact that I have RA and take expensive biologic drugs, have frequent specialists visits, usually have multiple joint injections or other procedures, and am probably looking at some type of surgery in 2015, I need a very robust plan. My already-expensive insurance premium for 2015 went up 15% to more than $1000/month. And while there are less-expensive policies, by the time you factor in the high deductibles and the co-pays, I’m better off paying the high monthly premium.

The good news is that under the current legal landscape I cannot be denied health insurance, otherwise I would fall into the high-risk insurance pool with minimal coverage offered by the state.

The bad news is I have to keep working in order to keep making insurance payments. My schedule is very light by anyone’s standards but, even so, there are periods of 12-14 hour days and intense stress. Stress increases RA’s effects. Given the choice, I would retire completely and be able to better manage my health. But then I wouldn’t be able to afford the health insurance I need.

I’m trapped into working by need to pay for insurance.

But there are also other hidden traps. For example, after a year of experience in the new marketplace, the insurance companies are learning how to manage their costs. Among other things, they’re reclassifying some of the more expensive drugs into different tiers or taking them off their formulary lists altogether. Drugs that used to cost RA patients a small copay may cost them thousands of dollars a month in 2015.

I am in the unenviable position of change drug therapies (again). My old drug was covered by my insurance. I don’t know whether my new drug will be covered or not. The specialty pharmacy is currently processing the paperwork with the insurance company. Checking the insurance company website is not encouraging, but the information is limited and it may be that there is a step-therapy or other conditions required. Hopefully I will find out this week what the situation is.

If I wasn’t too big to sit on Santa’s knee, I would have told him that all I want for Christmas is a new RA drug (that works and is covered by insurance). Is that too much to ask?

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This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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