Contracted Cost

It has been a very trying journey to get the insurance.   Healthcare.gov was not my friend for 2 months.   I spent untold hours trying to purchase health insurance through healthcare.gov starting on October 6 and for the next 6 weeks.  Finally I called the 800 number and after 20 minutes I had an accepted application.  The very kind woman, Lisa, explained my eligibility and started discussing plans.  After 30 minutes I told her I just had to stop for the day.  My brain was truly overloaded.

Figuring out the benefits and terms was nightmarish for a person who had not had insurance for almost 20 years.   The terminology alone is confusing – deductible, co-pay, premium, coinsurance, out-of-pocket, inpatient, habilitative, diagnostic – what is covered, what isn't, what counts, what doesn't?  I asked many questions and I kept researching. 

Lots of jargon I had to decipher, so I made an appointment with a navigator, Eunice, from Insure Central Texas.  She was kind and helpful.  She defined terms, showed me several plans that would meet my needs, and printed everything out for me.  I was able to make a decision and get enrolled by December 23.  I am still waiting for documentation in the mail, but I have a temporary card and it's working. 

So, I went to get a prescription filled the other day.  I have had this same prescription for many years.  Up until the beginning of 2014, I had not had insurance for 20 years, so I was always paying full cash price for it.  I would scout around all the pharmacies and find the best price which could vary from $114 to $44.  I had checked the price of this prescription in December because in my limited understanding of my new insurance plan, I thought that I would be paying that price until the deductible was met and then I would be paying zero. 

When I went to get the prescription filled, I expected it would be $101 as that was the price quoted in December.  The Tech told me it would be $12.87.  I was shocked and confused.  I called my insurance company and asked if I understood the plan properly and a lovely man named Frank from Cigna explained it to me.  He said that the $12.87 is the price that that pharmacy has "contracted" with the insurance company and yes it does go toward the deductible.  Just learning what the terms mean in general doesn't explain what they mean in the particular. 

An gift with purchase is that the pharmacy called me and they don't have enough of the medicine to fill the prescription and they have no idea if they ever will.  They are doing a partial fill and I guess I will have to transfer it.  So now, I get to go to other pharmacies and do what I did before I had insurance – compare the "contracted" price instead of the cash price.   I had a similar experience with my physical therapy.  The cash price was $125 a session and with insurance it is $100. 

I knew that there was no price transparency with health care vis a vis cash pay patients but I am seeing it is even more convoluted and secretive.   It's complicated.  I makes me even more convinced that a single-payer system would be so much more cost effective and I don't mean because doctors and providers would get paid less but because the costs would be clear and you could really compare.  In the meantime, I'm glad I have insurance and I look forward to finding out what the prescription will cost at a different pharmacy.

I am also seeing that my decision to make this first year of insurance be a learning experience was a wise one.  I never foresaw that I would pay less for some prescriptions before the deductible.  And when I talked to Frank, he gave me a whole list of preventative care that would be covered.  I was aware of a few, but there are many more than I realized and I need them.  He also told me I am covered for an eye exam.  What???  That's great and I didn't even know. 

All I can say is that so far my experience with health insurance has been positive.  I am sure there will be hiccups and some bureaucratic bs, but that's nothing new or exclusive.  I know it will get easier.  I know that as I get used to how the insurance works and what the costs are I will not have to call the insurance company all the time.  I know that once I find a gp, a gyn, and get my preventative care started, it will all start to fall into place.  I will have set my medical roots in Austin.  I feel like I am part of the system now. 

Thank you President Obama and Nancy Pelosi for the Affordable Care Act.