Only The Essentials

The real cost of being sick when you’re part of the working poor

When I received my new insurance card in January, I was excited. In a standard set by “Friends,” I could start catching on fire again! Then I saw the giant book full of rules about how and when and where and why I may use my insurance. As awesome as it sounded when I clicked “buy plan” back in December, there was, as always, a catch.

Under The Affordable Care Act, New York has established what it calls “The Essentials Plan.” From my experience, this insurance is designed to fill the gap between qualifying for Medicaid and qualifying for standard Marketplace subsidized rates. In other words, this is the insurance New York offers to members of the Working Poor.

New York hosts its own exchange web site. Enrolling follows a similar path to the one you would follow at identity questions, income questions, etc., until you eventually reach the point where you’re told, roughly, that because you make X money, you qualify for Y options and they cost Z. On the site, when you qualify for a federal subsidy, this is where you would be able to choose between metallic-color-coded levels of coverage: bronze, silver, gold.

Because my income was estimated at $21,400 for 2015, I qualified for The Essentials Plan and I was presented with two coverage options. They provided identical coverage ($15–125 copay; no deductible), they had identical premiums ($46.48 per month), both included vision and dental, and it looked like I was just choosing to which business to send my check. After a quick peek around both insurance company’s sites to make sure there were in-network doctors near me for everything I could possibly want, I chose the plan sold by WellCare because I liked their name.

Things started to sound a little weird when I got sick the week before the New Year. My insurance was effective as of January 1, 2016, so I called my company to see if I would be able to get in to see a doctor on January 1, if that pesky head cold turned into the ear infection it was threatening to. No dice. The person I spoke to at WellCare told me they didn’t even have my information yet. It wouldn’t be released to them until the first, which also happened to be a Friday. Even then, they wouldn’t be open on the first, so I would have to wait until the following Monday to call back and make sure they received my payment, verify I had coverage, and ask for my plan ID number so I could maybe go to the doctor.

My detailed plan information arrived about a week later, and about a week after that my insurance card followed. I was a little confused when I saw there was a primary care physician (PCP) named on my card, since I had never been asked whether I already had a PCP nor if I had a preference for who my doctor should be. But I wasn’t alarmed. I’d figure it out later, no big deal.

Twenty to twenty-five days later, when I developed food poisoning in the early hours of Monday after the Super Bowl, it became a big deal. I’m the kind of person who actually reads legal materials when they’re handed to me, so when I opened the giant packet of guidelines for how to use my health insurance, I read it. I remembered reading something about not using the Emergency Room unless it was an actual emergency.

Checking later, for this essay, I found my memory did not fail me. On page 30 of The Essential Plan Contract, it says, “Emergency Department Care does not require preauthorization. However, only Emergency Services for the treatment of an Emergency Condition are Covered in an emergency department” (emphasis theirs). The part I did not remember continues, “If You are uncertain whether a Hospital emergency department is the most appropriate place to receive care, You can call Us before You seek treatment. Our Medical Management Coordinators are available 24 hours a day, 7 days a week.”

I did call my insurance while I was sick, at approximately 7:30 a.m. on a Monday, and I listened to a recorded message which said, “Thank you for calling WellCare. If this is a medical emergency, hang up and dial 911. We are currently closed and live assistance is not available at this time.” I hung up.

I spent the next several hours violently ill, unable to be away from my bathroom long enough to buy water from the convenience store that’s one mile from my home. I should have taken myself to the emergency room, or called an ambulance, or called a friend for a ride to the emergency room. My doctor asked me several days later why I did not. The answer was simple: I was terrified my insurance would refuse to pay for it.

Here’s what being sick cost me without an emergency room visit:

  • 12.5 hours of work at $9.25 per hour
  • $15 copay for a standard doctor visit
  • 4 days of per diem employment at $80 per day
  • $3.00 in bridge tolls
  • Approximately $6.00 in gas

The grand total: $459.63, or approximately 2% of my annual income.

The cost of an emergency room or urgent care facility if the visit is not covered could have been more than triple that amount.

Complicating matters further, one of my jobs has a very strict policy regarding absence due to illness. It’s a minimum wage job for a corporate chain; it’s the kind of job some of my friends have quit without notice simply because it was a beautiful day and they didn’t feel like going in. So, if a person misses two days due to illness, that person must provide a note from a doctor before returning to work — not as proof of health, but, instead, as proof of illness.

Two days into my illness, my symptoms were sporadic, but I had a headache from dehydration and could stand for only a few minutes at a time. My stomach would allow me only a few sips of water at a time, and hydrating myself would take a few more days. My assigned PCP was new to me, so I had no idea whether they would squeeze me in for a same-day appointment. I wasn’t ready to go back to work, but I was worried what might happen if I didn’t. I didn’t sound sick. I knew no one would believe me if they didn’t see my face.

So, on Tuesday evening, I drove the half hour to my job, and walked up to my supervisor expecting exactly the reaction I received. She asked, “Wow, are you okay?” I told her I wasn’t, really. She asked me why I came to work if I was sick. I lied, and said that I thought I was fine. She called a manager over, and the manager said, “You look like I’m going to have to pick you up off the floor in a few minutes.” I told him I agreed. They sent me home.

The next day, I started making phone calls. I wanted to see a doctor because I was still very lightheaded, and my symptoms were shifting into what now felt like the flu. Besides, I thought, it wouldn’t hurt to have a note, just in case I still needed one.

A woman at my PCP’s office told me the earliest appointment they could offer was more than a month away because I was a new patient. “But I’m sick now,” I said. They said it didn’t matter. “But I need a note for work,” I said. They told me I would need an appointment if I wanted a note. I told them that yes, I knew that. That was why I called. And so we went, around in circles, until we were both screaming into the phone. I asked to speak to someone else.

The new person suggested I call my insurance and request a new PCP, someone who had an appointment available within the next 48 hours because they were actively accepting new patients.

I called my insurance. The representative I spoke with at my insurance told me she must first verify my assigned PCP wasn’t accepting patients. She asked me to hold. I said, “Sure. I’ll hold.” The representative returned to inform me that I would need to call my PCP and schedule an appointment, but they had nothing available until the middle of March.

“Yes,” I said. “That’s the problem.”

I reminded her that I am sick now. I explained again that I needed a note for work. She repeated the line from her script. I asked to speak to someone else.

Her supervisor got on the phone and asked for my problem. I explained I was sick, that I needed a note for work, and that my PCP would not help me. I explained I did not request that doctor, and that I would very much like a new PCP. “Any doctor will do,” I said. “I just need a doctor who is accepting new patients.”

He assigned me a new doctor. He promised she was accepting new patients. My new insurance card was on its way, and here was her contact information in the meantime.

I called my new doctor. A human being answered the phone. This woman was helpful. I might even say she was kind. But as for the PCP I was just assigned: “She’s not accepting new patients.”

“Please,” I begged. I explained the situation all over again. She sympathized and offered to speak to her office manager. Other doctors in that practice were accepting patients, so perhaps I could have an appointment with one of them. I told her that would be perfect, but, “Will my insurance cover another doctor?”

Almost 24 hours later, after a sit-com-worthy interaction with an after-hours message center rep, and a morning of pestering, I was told that my insurance would allow me to see a different physician within that same practice.

By the time I walked through the door for my appointment, I was healthy. The doctor was confused why I was there. Every member of the staff emphasized how irregular this was, seeing me without a new-patient intake first. They thought I was crazy and all needed an explanation that my insurance is an HMO. It didn’t matter; I needed that note.

In the end, I got it. For now, I’m alive, and the approximately $10,000 per year I make at my second job is safe. So, yeah, I have the essentials.

Amy Lynn Tompkins is a writer and photographer who sometimes moonlights as a freelance waitress, cashier, and substitute teacher. She worked as a staff reporter at InYourSpeakers and her essays have been published by Living City Magazine. She has a bachelor of arts in liberal studies with concentrations in English, business, and psychology.

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