Hi terukun01-ga, and thanks for your question. I sympathize with you
and your girlfriend's plight, having gone through some rocky uninsured
times myself.
Probably the most reliable data on procedure costs comes from the
government H-CUPnet (Healthcare Cost and Utilization Project)
database:
http://hcup.ahrq.gov/HCUPnet.asp
Data is aggregated at the state (not city) level, but can be broken
down by metropolitan vs. other regions. The most recent data for the
state of California is from 2002. Here are the results for partial or
complete thyroidectomies:
Uninsured, metropolitan: $18,246
Medicare, metropolitan: $16,885
Medicaid, metropolitan: $17,996
Commercial insurance, metro: $15,379
The overall average for all payer types for metropolitan patients was
$16,008. There were a total of 6,192 procedures performed in
California in 2002. There were only 62 thyroidectomies performed on
uninsured patients in 2002.
_________
Much more information is available through the above database. Here's
how to obtain this or similar information on your own:
Visit the H-CUPnet site:
http://hcup.ahrq.gov/HCUPnet.asp
Select "State Statistics"
Select "Medical Professional"
Select "Statistics on specific diagnoses or procedures"
Select the symbol for California, 2002 (or any other year)
Select " Procedures grouped by Clinical Classifications Software (CCS)?"
Select "Principal Procedure:
Type in "thyroidectomy"
Click "Search"
Select "Next"
On the next page, you can select the information you're interested in,
for example, hospital charges, mean, etc.
Select "Next"
Select "All patients in all hospitals," "Payer," and "Hospital
Location" Feel free to select other options, such as "Hospital bed
size: small, medium, large."
Select "Next"
On this page, select how you'd like the data displayed. The first
choice is simpler to understand, but the second gives more
information. I chose the second to see a more detailed breakdown of
the data. (Two-way tables)
Select "Next" and you will be presented with multiple tables of data
broken down as specified.
========================================================
As you state, once the thyroid is removed, a person must take thyroid
replacement medication. Synthroid (levothyroxine) is one of the most
popular hormone replacements. You can find information about it here
at RxList.com:
http://www.rxlist.com/cgi/generic/levothy.htm
The typical dose is 1.6 mcg/kg/day. For a typical woman, this works
out to about 125 micrograms once per day. The dosage needs to be
adjusted for each individual based on their response. Based on this
dose, you can compare prices at multiple pharmacies via
PharmacyChecker.com:
http://www.pharmacychecker.com/Pricing.asp?DrugId=19334&DrugStrengthId=68148
The best price in the US is $17.79 for 30 pills ($0.59 per pill) at
CVS. The total cost over a lifetime would depend on many things, such
as how old your girlfriend is now, any other medical problems, family
history, life expectancy, any possible dose adjustments, and the
possibility that the price of Synthroid will go up or down over the
course of treatment.
========================================================
The specifics of pre-existing conditions within the context of your
girlfriend's health insurance policy are difficult to comment on,
since each employer can negotiate individual contracts with health
insurance providers with their own terms and conditions.
If your girlfriend had had previous health insurance, then code AB
1672 may apply, which requires that individuals who switch insurance
coverage (excluding Medi-Cal) still be covered for this condition
under their new insurance. You can read more about AB 1672 here:
http://www.disabilitybenefits101.org/ca/programs/your_rights/hipaa_ab1672/ab1672/faqs.htm#_q519
More relevant to your girlfriend's plight is this California
Consumer's Guide for California Health Insurance:
http://www.healthinsuranceinfo.net/ca01.html
This document describes the state and federal limitations on what
health insurance companies can exclude as pre-existing conditions.
Section 2 of this document states the following:
"When you first enroll in a group health plan, the employer or
insurance company may ask if you have any pre-existing conditions.
Or, if you make a claim during the first year of coverage, the plan
may look back to see whether it was for such a condition. If so, it
may try to exclude coverage for services related to that condition for
a certain length of time. However, federal and state laws protect you
by placing limits on these pre-existing condition exclusion periods
under group health plans. In some cases your protections will vary,
depending on the type of group health plan you belong to.
* Group health plans can count as pre-existing conditions only those
for which you actually received (or were recommended to receive) a
diagnosis, treatment or medical advice within the 6 months immediately
before you joined that plan. This period is known as the look back
period.
* Group health plans cannot apply a pre-existing condition exclusion
period for genetic information. Also, these plans cannot apply a
pre-existing exclusion period for pregnancy, newborns, newly adopted
children, children placed for adoption, provided they are enrolled
within 30 days.
* Group health plans can exclude coverage for pre-existing conditions
for a limited time. The maximum exclusion period depends on the type
of group health plan you are joining. If you are joining a fully
insured group health plan in California, the maximum exclusion period
is 6 months. If you are joining a self insured group health plan, the
maximum exclusion period is 12 months. You will receive credit toward
your pre-existing condition exclusion period for any previous
continuous coverage.
* If you enroll late in your group health plan (after you are hired
and not during a regular or special enrollment period), you may have a
longer pre-existing condition exclusion period. If you are a late
enrollee, you may have a 12-month, pre-existing condition exclusion
period.
* Group health plans that impose pre-existing condition exclusion
periods must give you credit for any previous continuous creditable
coverage that you?ve had. Most types of private and government
sponsored health coverage are considered creditable coverage."
http://www.healthinsuranceinfo.net/ca02.html
Your specific situation may be somewhat more complicated because
certain entities in California have opted to exempt their covered
employees from some of the health insurance protections. These are
listed in Section 2 above. Employees of Orange County are on this
list, as are some school districts and other counties.
_________
Section 5 of the above Consumer's Guide also details possible
financial assistance for health related expenditures:
http://www.healthinsuranceinfo.net/ca05.html
Unfortunately, few of these options are viable unless she is pregnant
and making less than 200% of the poverty wage, which is $9,310 (so
total of $18,620). In this case, she would qualify for Medi-Cal.
Here's a printable version of the Consumer's Guide referenced above:
http://www.healthinsuranceinfo.net/ca.pdf
I would recommend speaking with the Human Resources director at your
girlfriend's place of employment and explaining the situation. They
may be able to help. There are also multiple resources in the state
of California who deal with health insurance issues. Here is a good
list of the main agencies:
http://www.healthinsuranceinfo.net/ca06.html
The Cancer Center at UCSF has a very good page for their patients in
need of health insurance, with a section focussing on pre-existing
conditions:
http://cc.ucsf.edu/crc/insurance_overview.html#pre-existing
Some of the options they discuss may work for her as short-term solutions.
Also, if you're interested, you can read more about multi-nodular
goiter at these sites:
UpToDate:
http://patients.uptodate.com/topic.asp?file=thyroid/4861
Endocrine Web:
http://www.endocrineweb.com/goiter.html
eMedicine.com:
http://www.emedicine.com/MED/topic916.htm
========================
I hope this information is helpful. I wish you and your girlfriend
the best in getting through this stressful time. Please feel free to
request any clarification prior to rating.
-welte-ga |
Request for Answer Clarification by
terukun01-ga
on
10 Nov 2005 09:00 PST
Welte-ga,
Thank you for the wealth of information that you have provided. YOu
have answered part 1 to the fullest and I am completely satisfied with
that answer.
As far as part 2 is concerned, you have provided great information
here too, but I would like some clarification.
I read through the information regarding the look-back period, and
that was 6 months for people with group health insurance ( which is
what she has ). So in more simple terms, can I understand this to mean
that if she was currently employed at her job for 4 months, and she
received some procedures / recommendations for surgery at the 2 month
mark of her employment, does this mean that if she waits another 6
months, the health insurance company cannot invoke the pre-existing
exclusion clause on her?
I ask this because earlier in your analysis, you stated that it would
be difficult to assess the situation as every employer can negotiate
different terms. Does the negotiation include terms regarding
look-back periods? As in, can they extend these look back periods? or
is that something that as a citizen, we are protected under federal
law, and that the look back period is regulated to be 6 months, and is
a non-negotiable item? Is this something you could tell me, or is
this something only the health insurance company in question can tell
me?
Im hoping that the look-back period is mandataed by federal law, and
cannot be changed, as my girlfriends case of her goiter is relatively
minor, and she is willing to wait a few months if it means less cost
for her in the future.
I appreciate your suggestions about free health care, but she makes
much more than the poverty line, so free care would pretty much be out
of the question. HOwever, $20k out of ones pocket is quite a bit of
money.
|
Clarification of Answer by
welte-ga
on
10 Nov 2005 10:31 PST
Hi again, I believe you are on the right track... To re-quote a
section from the HealthInsuranceInfo.net site:
"Group health plans can exclude coverage for pre-existing conditions
for a limited time. The maximum exclusion period depends on the type
of group health plan you are joining. If you are joining a fully
insured group health plan in California, the maximum exclusion period
is 6 months. If you are joining a self insured group health plan, the
maximum exclusion period is 12 months. You will receive credit toward
your pre-existing condition exclusion period for any previous
continuous coverage."
This means that each group health plan can decide to exclude
pre-existing conditions for insured employees, but they can only
exclude the condition for 6-12 months, depending on the type of
insurance. Since your girlfriend falls in the fully insured group
health category, the maximum exclusion period should be 6 months. If
she were paying for the insurance herself, the maximum exclusion
period would be 12 months.
So, this means that Guardian can exclude her condition for a total of
6 months from the time at which she became insured. After that point,
they should cover it. A good example may be someone with a chronic
disease, such as diabetes. The insurance company could exclude this
condition and all of the subsequent complications forever if there
weren't some type of clause such as that above be useless (but very
profitable) for all but the most healthy.
As usual, this is not a substitute for medical or legal advice. I
would recommend talking with the Human Resource office, since they
certainly deal with this type of situation frequently and may be able
to help with navigating the specifics of the policy that has been
established between your girlfriend's employer and Guardian. There
may be some specific forms, etc., for notifying them of the date of
onset of a pre-existing condition, etc., and you would want to have
everything in order to minimize the chance that her claim will be
denied after the look-back period has expired.
Best,
-welte-ga
|
