Topic: I have entered the Insurance Twilight Zone!

Forum: Employment, Insurance, and Other Financial Issues — Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: Dec 27, 2016 11:32PM

Posted on: Dec 27, 2016 11:32PM

siciliana wrote:

I found out my diagnosis of BC on 12/21/16--just a few days before the deadline for signing up with the Affordable Care Act. The insurance I have had for the past year is Premera, but it is no longer available in my county for 2017. So that left only two options: Group Health and Bridgespan. I used a broker to help me select the best plan for my income and circumstances. Unfortunately, the plan I chose (Bridgespan) looks rather good on paper, but that is far from the reality. Even though the search function shows that numerous hospitals are "in network", I am unable to find any doctors who are in network at those same hospitals. Can't go to Seattle Cancer Care Alliance, not contracted. Can't go to University of Washington Medical Center (which is in network) because all of their cancer specialists are contracted with Seattle Cancer Care Alliance which is not contracted with Bridgespan. So what is a person to do? So I can find an in-network hospital, or I can find an in-network doctor, but can't find a combination where the in-network doctor has privileges at the in-network hospital. I can't have surgery without a surgeon.

In my depressed state after spending days on the phone trying to find some combination that will allow me to get treatment covered, I am visualizing a Scrooge-like entity, hunched over his computer, punching numbers into his calculator, devising the ultimate fail-safe system to keep his company from having to pay out.

This is the new reality, I guess. When my husband was going through his treatment for brain cancer seven years ago (a losing battle), at least we did not have to worry about finding a hospital that would treat him. We had many worries, but insurance was not one of them.

Please forgive my "poor me" attitude tonight. I realize there are others on this forum who have a much harder time of it than I have.



Dx 12/19/2016, ILC, Right, 1cm, Stage IIA, Grade 2, 1/3 nodes, ER+/PR+, HER2- Surgery 2/23/2017 Lumpectomy; Lumpectomy (Right); Lymph node removal Hormonal Therapy 6/3/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy Whole breast: Breast, Lymph nodes
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Dec 28, 2016 11:25AM Zillsnot4me wrote:

insurance is a nightmare for healthy people. You are still trying to wrap your head around your diagnosis. Most hospitals will have some kind of assistance. Good luck.

8/6/21 Gemzar 1/7/2021 Axabrane 10/29/2020 Taxol 7/22/2020 A/A combo, 11 cm liver spots! piqray, zometa, faslodex 6/11/2020 rads to liver 12/2020 3 cm liver 10/2019, Liver spots 1/ 2016, Xgeva 9/2015, Bones 4/2015, Lungs 4/2013 Dx 4/2013, 4cm, mets, ER+/PR+, HER2- Surgery 4/29/2013 Lymph node removal: Right; Mastectomy: Right; Prophylactic mastectomy: Left Chemotherapy 5/23/2013 AC Hormonal Therapy 10/2/2013 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy 11/6/2013 Breast, Lymph nodes Surgery 9/25/2015 Prophylactic ovary removal Hormonal Therapy 1/7/2016 Femara (letrozole) Targeted Therapy 1/7/2016 Ibrance (palbociclib) Hormonal Therapy 2/4/2016 Arimidex (anastrozole) Hormonal Therapy 4/24/2017 Faslodex (fulvestrant) Chemotherapy 11/16/2017 Xeloda (capecitabine) Dx 10/2019, metastasized to liver, ER+/PR+, HER2- Radiation Therapy Liver
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Dec 28, 2016 11:46AM luckynumber47 wrote:

Is Swedish in your network? I received excellent care from Dr Hendershot ther

My avatar is a Blue Footed Boobie. Cracked me up. Dx 2/15/2016, IDC, Left, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2- Dx 3/16/2016, DCIS, Right, <1cm, Stage 0, Grade 3, 0/1 nodes, ER-/PR- Surgery 4/6/2016 Mastectomy; Mastectomy (Left); Mastectomy (Right) Hormonal Therapy 5/16/2016 Femara (letrozole)
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Dec 29, 2016 03:27AM ShetlandPony wrote:

Siciliana, I'm afraid I don't know much about the kind of insurance you have, but it seems to me that there must be a way to contact the company and say, "Look, I bought this insurance, and I haven't been able to figure out where I can get treatment. Please tell me how to proceed." Be succinct, unemotional, and firm. They need to give you a workable solution. Otherwise, can you call your state's insurance commissioner for help? Another idea would be to ask the hospital social worker for help in solving this problem. Please tell us what happens. I'm sorry you have to deal with this on top of everything else.

2011 Stage I ITCs sn, premenopausal, Oncotype 16. 2014 Stage IV mets breast,liver. TaxolNEAD. Ibrance+letrozole 2yrs. Fas+afinitor nope. XelodaNEAD 2yrs. Eribulin,Doxil nope. SUMMIT FaslodexHerceptinNeratinib for Her2mut NEAD 1 1/2yrs. GI/perit mets Dx 2011, ILC, 1cm, Stage IA, Grade 1, 0/1 nodes, ER+/PR+, HER2- Dx 2014, ILC, 2cm, Stage IV, metastasized to liver/other, Grade 2, ER+/PR+, HER2- Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy Whole breast: Breast Surgery Lumpectomy
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Dec 29, 2016 10:03AM rainnyc wrote:

Siciliana, I am so sorry you have to go through this on top of your recent diagnosis. I'm also on an ACA plan, and it's definitely a challenge. A couple of things: while you're trying to find care providers on the Bridgespan plan, you might also continue to ask about providers on the Group Health plan. There is still time to switch: If you do so by January 15, that will get you February 1 coverage.

As others have said, get on the phone with the plan. You can say, "I am a cancer patient, and I would like to ask for a care coordinator (sometimes called a nurse navigator)." This is someone the health plan hires for people with complex, chronic conditions, not only cancer but diabetes, for instance. Being able to get this person on the phone will help you eliminate long waits on the insurance company's main help line, and at the minimum may give you someone who can help find care providers.

And yes, if you can't find a doctor who can see you, definitely call the hospital's insurance coordinator or patient advocate and explain the situation and get their help. Go up the chain of command. If it's not working, get in touch with your state's insurance commission. Be a very, very squeaky wheel....

It really stinks that you have to do this. Good luck, and let us know how you're coming along with it!

Dx 4/2015, IDC, ER-/PR-, HER2+ Chemotherapy 5/12/2015 Taxol (paclitaxel) Targeted Therapy 5/12/2015 Herceptin (trastuzumab) Surgery 9/22/2015 Mastectomy: Left, Right Radiation Therapy 11/1/2015 Lymph nodes, Chest wall Targeted Therapy Perjeta (pertuzumab)
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Dec 29, 2016 02:29PM NoUGo-CA wrote:

Hi Sicilliana,

You could try asking Bridgespan for a Case Manager to help you figure this out.  If you've already received member info, log-in to the Bridgespan site and check the 'USE' dropdown.  Select 'Case Manager'. It explains what a Case Manager does and how to request one.

I'm so sorry that you have to worry about all of this at this time.  You'll get it figured out and receive the care you need.

Vicki

Dx 3/9/2016, IDC, Right, 1cm, Stage IA, Grade 3, 0/4 nodes, ER+/PR+, HER2+, Surgery 3/25/2016 Lumpectomy: Right; Lymph node removal: Sentinel Targeted Therapy 5/2/2016 Herceptin (trastuzumab) Chemotherapy 5/2/2016 Carboplatin (Paraplatin), Taxotere (docetaxel) Radiation Therapy 8/24/2016 Whole breast: Breast, Lymph nodes Hormonal Therapy 11/2/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Dec 29, 2016 04:11PM siciliana wrote:

Thanks, everyone! I finally found a breast cancer surgeon in Bellevue, affiliated with Overlake Medical Center, who is contracted with my insurance. I have an appointment scheduled for January 3rd. Feeling a little bit better right now. I love the idea of getting connected with a patient advocate.

Dx 12/19/2016, ILC, Right, 1cm, Stage IIA, Grade 2, 1/3 nodes, ER+/PR+, HER2- Surgery 2/23/2017 Lumpectomy; Lumpectomy (Right); Lymph node removal Hormonal Therapy 6/3/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy Whole breast: Breast, Lymph nodes

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