The ACA and My Obstetrician and Me

So as previously mentioned I am growing increasingly pregnant with each passing day, and today I had a my monthly prenatal appointment with my OB-GYN.

On the agenda for this morning was first, my gestational diabetes screening, which meant chugging 10 oz. of a drink called Glucola™ (verdict: kind of into it). Second on the agenda — aside from the usual peeing in a cup and hearing baby’s heartbeat — was for me to corner my OB about some brewing insurance woes I’ve been doing the “panic, avoid, make a fruitless phone call, Do 1 Thing” dance about for weeks now.

To back up: I signed up for individual insurance in the marketplace post-ACA which went into effect 1/1/14, right? Platinum plan, y’all, because I’m having a baby. My OB showed up in the database of the plan I liked, which was through a co-op which seemed great, and it had the lowest premiums of its level, along with no deductible, no co-pays for prenatal care, $500 for delivery. Perfect, done.

“Oh I should call the doctor’s office to confirm they take it.”

“Yes you definitely should.”

“But, ehhh, it’s the weekend. And it says they take it on their site, and on the insurance site. Oh it’s fine, I hate the phone, let’s do this.”

“Okayyyy, but…”

*cue ominous music*

I go into my first appointment after the New Year, so excited to finally have real insurance, like it’s some kind of special club or something.

“Okay what’s the name of your new insurance?”

“Well, they use the Magnacare network.”

Nurses for miles shake their heads, click their tongues. “Oh we don’t take that.”

“What? Yes you do. It says so on the website.”

“DID YOU CALL?”

“No.” I turned bright red at the counter. “No I didn’t call because it said you took it on your website and on the insurance’s website.”

“You’re supposed to call.”

“Okayyyyyy, so. I didn’t call. And this is my insurance. It’s already paid for. What do I do?”

They had me talk to someone higher up on the admin side and she let me know that actually, my OB does take Magnacare, but that the other doctors in the practice don’t, and they are trying to drop it. She made a grim face at me. I looked at her and then all the nurses and admins, still standing around listening and shaking their heads.

Someone asked me how far along I was. Twenty-one weeks. More head shaking. I didn’t call.

“Well you can see the doctor now,” the woman said, “But we are trying to drop it. It could be any time now.”

I wasn’t sure what to say. “Um, please don’t drop it?” “Can you give me a warning before you drop it?” “Can you update your godforsaken website?” Instead I just shrugged, said, “Um, okay, so I’m good for today?” then sat down and waited for my name to be called.

A week or so later I worked up the nerve and the energy and called the billing office to ask if and when they’d be dropping Magnacare, and what kind of lead time I would have — should I find a new doctor now? The woman I spoke to had no idea, and said to call the doctor’s office.

“Yeah you should definitely find out. Giving birth is very expensive without insurance. At least seven thousand dollars. You don’t want to get there and be surprised.”

Yeah no kidding, thank you.

I called my insurance — the co-op — and the woman on the phone was genuinely helpful. “Okay,” she said, “I think there is a policy about continuing care when pregnant. Let me find it.” She put me on hold and then came back to say she was going to read me the policy word for word. I typed notes as she spoke but the general policy is that, should your health care provider drop your insurance when you are in the second or third trimester of pregnancy, or in the middle of a terminal illness, the insurance company will agree to essentially pretend the provider is still “in-network” and everyone keeps paying what they were paying. The doctor’s office or hospital has to sign off on this, too. If they do, everyone fills out a form, I keep paying my insurance premiums and co-pays, and the insurance keeps paying the doctor what they were when the doctor accepted the insurance.

So today when the doctor asked me how I was feeling I decided it was time to stop avoiding the subject and living in coverage limbo and debating finding a new doctor at 28 weeks pregnant (all the while paying $515 a month for this coverage, I might add!).

“You might not be the person to talk to about this,” I started off, “But I mean, I don’t know how this works and I don’t know who to ask.”

Now I should say here that I like this doctor, but I like her less in a “she is the nurturing, relatable Mother Earth type I always imagined working with” way and more in a “I find her fascinating and compelling more as a character than anything else, and perhaps she is not the ideal candidate for delivering my baby, but she is very competent and oddly reassuring so I’ll take it rather than going through the trouble to find someone else,” way.

She raised her hand to cut me off and talk but then stopped herself, “Okay, well, let me know your question and then I can see if I can answer it.” LOL, okay Doctor, thank you for tolerating my preamble.

First I let her know that while she took my insurance, the other OB’s in the practice didn’t. I asked her if for some reason she wasn’t on-call that night and I delivered with someone else, would I have to pay out-of-pocket? FYI: No, the doctor would essentially be covering for her and it’s all billed as an entity anyway so coverage overlaps. Great.

“So we just have to hope you don’t drop our insurance, then,” Dustin says. And there he goes, I think (he is the bad-cop and I am the ‘please like me’ cop in these type of exchanges), then wonder if he is on the brink of a rant about how we should all be on a single-payer system.

I explain to her my situation, that some mysterious office worker told me they were ‘trying’ to drop Magnacare, but that they hadn’t yet. Then she very candidly, perhaps disturbingly so, explained to me what was going on. What is going on, apparently, is these new ACA plans do not pay doctors as much cash money as they would like.

She refers to the ACA marketplace plans as a “parallel universe” and a “gray area” where, basically, providers/practices/hospitals/entities won’t be reimbursed by the insurance companies at as high of rates as the non-marketplace plans. So there is regular Blue Cross Blue Shield and then ACA Blue Cross Blue Shield, the latter of which will only reimburse the provider X amount, whereas the former would have said, “$600 ultrasound? Okay fine.”

Having seen what the providers bill to insurance companies, vs. what they bill to individuals, I can see why the insurance companies would refuse to pay at the full rate. I do not say this.

She goes on, not quite mentioning the bottom line but she does use the phrase, ‘balancing the books’ so that’s where we’re at: “The hospital hasn’t decided yet whether to accept these plans or not,” she says, “They haven’t figured out what’s more advantageous,” (FINANCIALLY) “If they do accept those plans, more patients will be able to get medical care, but the hospital will be reimbursed at lower rates. If we say to patients, ‘No that plan is out-of-network and you have to make up the difference,’ we will lose patients but we’ll keep the ones with the ‘good’ insurance plans. They’re not sure yet how it will all shake out.” (FINANCIALLY.)

I nodded and tried to pretend that I was truly concerned about the hospital balancing its books.

She went on to tell me that since I was pregnant they will accept me and my insurance as in-network until I give birth (thank god), after which I will probably get kicked to the curb with my affordable insurance that reimburses healthcare providers at reasonable rates.

“We won’t leave you out in the cold,” she said, and I laughed nervously. “And we don’t want you to go broke.”

“Well,” I said, “I don’t know if anyone cares if I go broke, the insurance or the hospital.” Dustin and I laugh and he echoes what I said just a little bit harsher.

“Oh we care,” she says. “We care because if you go broke, then you won’t be able to pay your medical bills!”

We all laugh together as if this is the funniest thing in the world.

“Oh great, glad we’re all on the same page then,” I say.

“You know, this was supposed to make everything better for everyone, but I’m not so sure it has,” she looks off into the distance wistfully and I’m like, “Hmmm,” and Dustin shakes his head, and then she gave me the TDAP vaccine and ranted about parents not immunizing their children.

She offered to give us a list of places where “Dad” could go get the vaccination, too, and for a minute I was like, “Dad? Whose dad / who’s Dad?” Then I realized she meant dad as in the dad-to-be sitting right next to me, who was probably waiting to get on the train back to work with me and rant about her rant about the Affordable Care Act, and then to suggest for the hundredth time that we switch to a midwife.

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