Earlier today, I was reminded once again why Celiac Disease and health care reform in the United States is such a timely topic. Sitting in my email inbox was the October newsletter of the National Foundation for Celiac Awareness, and the last article in the newsletter was a link to a Wall Street Journal Health Blog from mid-September.
The WSJ post of a 17-year old girl from the Chicago area who was dropped from her health plan after being diagnosed with Celiac. In a heavily criticized tactic known as recission, her health insurance provider – upon learning of her diagnosis – went back and reviewed three months worth of medical records. Then, looking solely at her symptomology prior to diagnosis, declared that if they had known about those symptoms, they would not have offered her coverage. Seriously? We all experience symptoms leading to the diagnosis of anything… that’s how doctors do their job. The more I delve into this topic, the more disgusted I become with the health care system in the United States, and the more I feel like I come across questionable ethical practices on the part of insurance companies that appear to be motivated solely by corporate greed.
I feel like it’s not that much a satirical leap of faith to foreshadow a time in the not too distant future when an unregulated health insurance company would turn to a patient and say: “We went back and reviewed your records, and we couldn’t but notice that you were born. Your being born constitutes an implied acceptance of the terms of life. Unfortunately, those terms guarantee that you will get sick at some point over the course of your life. Based on those factors, we’re declining coverage.”
But again, I digress…
As I got my hands dirtier and dirtier with this topic, I wanted to do more than write about it. I didn’t want to do a series of posts dealing only in hypotheticals, theories, anecdotal stories, and ideology. I wanted to do a concrete case study about the gauntlet of health insurance coverage faced by someone with Celiac, and who better to be the guinea pig than me?
And so I called four of the most prominent health insurance providers in Colorado (HumanaOne, Cigna, Aetna, and Anthem Blue Cross / Blue Shield), posing as a prospective customer. To each I gave the same set of circumstances: I was a self-employed sole proprietor exploring my options for health insurance coverage. Oh, and I had Celiac Disease. Was that considered a pre-existing condition that would exclude me from being able to obtain coverage? (These were all true statements.) Here’s how each customer service department responded:
HumanaOne – Told me that I was not eligible for any of their plans, but recommended I look into Cover Colorado (a state-based health insurance plan offered specifically for people who’ve been turned away from other health insurance because of pre-existing conditions). The customer service rep also said that “not all companies are the same, and you might find another company that will offer a plan.” And so I called other companies…
Aetna – The customer service rep was utterly unhelpful, and when she didn’t find Celiac Disease in the underwriting guidelines, recommended I “apply online and see what they say.” Basically, it was a crap shoot, and I wouldn’t know the outcome unless I formally applied for acceptance to a health insurance plan.
Cigna – Here, too, the customer service rep didn’t find any information about Celiac Disease in the underwriting guidelines. But this gentleman was more helpful, asking me to send him an email with my age, height, weight, and a description of the condition, and he’d pass it along to the underwriting team to get an answer.
Anthem BC/BS – The customer service rep told me, with regard to Celiac Disease, “I’m thinking it’s not declinable.” This was tentative good news. But I wanted a more definitive answer than that, I told him. And so he invited me to submit an application in order to get an official disposition from the underwriters.
In each of the cases where a company asked me to jump through an additional hoop in order to get a decision or answer, I began to follow those leads. But eventually, they all began asking for far more personal information than I was prepared to fork over. Instead, I switched gears and – wearing my investigative journalist hat – called the media relations rep for each company to get an official stance on the subject. Then the plot thickens…
I asked each media rep the same three questions: 1) Was Celiac Disease considered a pre-existing condition that would exclude someone from obtaining health insurance? 2) If so, what was the rationale behind the underwriters’ disposition in that regard? And 3) Was that true across all insurance plans offered, or did it differ from plan to plan? (For example, would someone be excluded from one plan, but invited to join another that had higher rates?)
HumanaOne’s media rep told me he’d have an answer for me in 1 to 2 days. 4 days later, not a word.
At Aetna, I left both a voicemail and sent an email. I just received word this afternoon that they’re working on it.
Cigna was more helpful. The media rep there did some digging, and while she couldn’t get an answer on the exclusion question, she was able to confirm that testing for Celiac Disease is covered under the company’s insurance policies. (Which raises an interesting question – Do their insurance plans cover a test which, if it comes back positive, would then get you dropped from those plans?) She also recommended I call the Colorado Association of Health Plans to get an industry-wide sort of perspective. I have a message in to CAHP, but haven’t yet received a response.
And lastly, there was Anthem BC/BS. Their media rep was by far the most knowledgeable, and the only one to point out several nuances of the health insurance structure in Colorado. (I’ll get to that in a minute.)
Before I use Anthem BC/BS as a jumping off point, I wanted to share two other interesting tidbits related to the prior to companies (Cigna and Aetna):
First, when I did a search for “Aetna Celiac” on the Internet, Google returned four consecutive search results that seemed to offer conflicting information. #1 cited that Aetna deems a Celiac screen/test “medically necessary” for people suffering from symptoms of Celiac, and therefor covers the test under its insurance policies. #2 cites donations Aetna has made to the National Foundation for Celiac Awareness. #3 points to Intellihealth, an Aetna website with an extensive information page about Celiac Disease. All three seem to point to Aetna being kind toward people with Celiac. But then you come to #4 – the story of a parent whose 4-year old son was denied coverage by Aetna because he had Celiac Disease.
Second, when I did some digging on Cigna’s website, I similarly found an extensive fact page about Celiac Disease. Couple this with the media rep’s comment that they cover testing for Celiac, and you feel like you start to get a rosy picture. But then you hear Cigna’s notorious reputation for denying coverage on the basis of pre-existing or diagnosed conditions. What does it all mean?
And so, returning to Anthem, the BC/BS media rep was the only one to point out the distinction between individual and group insurance options in Colorado. Here’s where things really get interesting:
Colorado law stipulates that coverage cannot be denied to an employee (or their spouse or dependents) who is offered group health insurance through an employer. This is irrespective of pre-existing conditions. Further, Colorado law also ensures that group health insurance is “guaranteed renewable,” which means your policy can’t be cancelled if you’re diagnosed with Celiac (or something else). (Colorado has also enacted other recent legislation, including the Health Insurance Portability and Accountability Act, which offers additional protections.) This is all good news for Celiacs in Colorado seeking to obtain health insurance, and many other states (though not all) have put in place similar legislation to varying degrees.
But what about the nearly 800,000 non-elderly adult individuals in Colorado (1 in 5 in the state for that age bracket!) who don’t have health insurance, and who would need to obtain an individual policy? Well, I’m afraid they’re largely out of luck. Individual health plans don’t have the same state protections as group plans. As a result, a patient could be denied coverage on the basis of a pre-existing condition such as Celiac, which is why HumanaOne told me “no” when I called them.
However, there’s even more to this story. The case isn’t closed for individuals with pre-existing conditions in Colorado seeking health insurance. Certain self-employed people (such as me) would qualify for state status as a Business Group of One. Officially becoming a BGO in Colorado makes me a company from a health insurance standpoint. In essence, I’d be both the employer, and the only employee. And since I’d then be obtaining health insurance through my employer, I qualify for group health insurance plans, which are protected by state law, and under which I can’t be denied coverage, even for a pre-existing condition like Celiac.
And wait…there’s even more! Colorado law further states that group health insurance plans may not be underwritten. That’s part of the reason why those plans are inclusive of people with pre-existing conditions. But, because they’re not underwritten, and because they include all people, they inherently cost more… up to double or triple insurance plans that have underwriters. On the flip side of the coin, individual health plans with underwriters have lower costs, precisely because underwriters exclude people with pre-existing conditions whose heightened medical expenses would cause the overall costs of the plan to rise.
And so in the end, here is what the decision making process would look like for someone in my shoes pursuing health insurance coverage in Colorado, in light of a pre-existing diagnosis with Celiac Disease:
1. Am I employed, and is health insurance offered through my employer? If so, it’s a group plan, and I can’t be denied. I’ll have health insurance, case closed.
2. If I am not employed, do any of the private health insurance companies offer individual plans, or am I excluded from them all on the basis of my pre-existing condition? If I’m excluded from all options, then I pursue Cover Colorado. (Other states have similar plans, such as the Oregon Medical Insurance Pool.) If I’m not excluded from all options, how do the individual plan costs compared to my only other option: Cover Colorado?
3. If I’m self-employed, do I qualify as a Business Group of One? If so, I qualify for group health plans, and I can’t be denied. However, because group plans are significantly more expensive than individual plans, do I also qualify for individual plans, or would I be denied from them all? If some would accept me, how do their costs compare to a group plan, and how do either one of those costs compare to the state-based option?
It’s enough to really get your head spinning. But as you can see, there are options. The private insurance companies, in my opinion, have some deplorable practices. But some do offer coverage to people with Celiac, and a combination of state-based legislation and a state-based health insurance option offer further protections and choice for consumers like you and me. But if I’ve made any case over the course of the three posts this week, it’s that nationwide health care reform is badly needed.
I can’t predict what that reform will look like in the end, but if we (people with Celiac Disease and gluten intolerance and wheat allergy and a long list of other pre-existing conditions) don’t speak up and advocate, then that reform may not – or likely, will not – meet our needs. And that’s who the reform is most meant to help…we the people. Not we the people without pre-existing conditions. All people. Ensuring health coverage for someone with Celiac Disease shouldn’t be this difficult, or this labrynthine. And so raise your gluten-free voice, and be part of making that desperately needed reform happen.