May 25, 2006

Of nickels and NIPs

First, my thanks to the commenters who offered feedback below on the Naomi Berrie Diabetes Center. I really appreciate the input. I'm looking at other options, though in the meantime I may end up there for a maintenance appointment. Foggy, Peculiar Violet also entertains a vague hope that her doctor there will be Miraculously Different.

Meanwhile, my company has changed insurance providers. A very strong plus is that I now have a network here in NY, whereas previously all my medical stuff was out of network and had to be paid up front, then reimbursed. (Ow.) Some of the other changes are more complex:

1. The highly-recommended-by-multiple-trustworthy-persons Dr. Carol Levy is not in the network. Rats. I could pay her up front, but I'll only get 60% back from the New Insurance Punks (NIPs). Multiply by 4x a year, and you see why I may end up at Naomi Berrie (whose providers are NIPpers).

2. I have a deductible now of $300. (Previously, I paid a higher premium to avoid a deductible, but that option is no longer available.) It doesn't apply to office visits or prescriptions, but it does apply to test strips and pump supplies. That means my first batch of strips, normally $90, will cost around $330, every year. After that, though, I will have 80% coverage, same as I previously did.

3. My current test strips aren't on the formulary. So I need to change to a different brand. That's okay; my meter is a piece of crap anyway. But now I need a new prescription. Maybe Dr. Reassurance will give me one. Hopefully this will be okay even though Dr. Reassurance is not (you guessed it) in the NIP network.

4. Luck of the diabetic: my current insulin, Novolog, IS on the formulary. Woo hoo! If I were still on Humalog, I'd have to change. It's not the end of the world, for me, to change between those insulins, but I do need more H than N, so I'd have to rework all my ratios, using many of the precious $330 test strips.

5. Lab work is 100% covered if conducted within the doctor's office. If not, it is 80% covered. Huh? What difference does it make where it happens, as long as the doc has ordered it? To NIP, the difference is apparently critical. (I think this is a ploy to get patients to come to the all-in-one NIP clinics, which adorn the city and suburbs of Minneapolis much as Starbucks coffee shops adorn Manhattan.) Of course, there are no NIP clinics in New York, and as noted below, it seems to be rather unusual to have blood work done in a doc's office here. Maybe they will do it at Naomi Berrie. Otherwise, I'll be paying 20% for my A1C, thyroid, cholesterol, etc. etc.

6. That said, if I keep my diabetic butt properly NIPped by remaining in the network, my annual out-of-pocket max is $1500 (plus my premiums, of course). Hey, that's not bad! And easier to attain with the jumpstart offered by the $330 test strips! Throw in some pump supplies and a few prescriptions (plus some lab work), and I should hit the max around September or so--not this year, when I'm starting at $0 on June 1, but in the future. Then it will be freebies through New Year's, huzzah.

My quiet ranting aside, this is good coverage based on what I know so far. I don't think I have much to complain about, assuming (major assumption) that I can get acceptable care from the NIPpers. One of the first experiments will occur next month, when I will visit a gynecologist whom I chose based on her office location, gender, and the fact that we have the same first name. (I had to draw the line somehow...)

All this makes me terribly curious about the diabetes costs incurred by the OC. How does your insurance treat you? And if you don't have insurance, how (the hell) do you manage?

6 comments:

  1. Oh Violet, I hear you.

    I saw Levy and always paid for her out of pocket (i.e., she wasn't on my plan either) and while she gave me a bit of a cut rate, it was still plenty o' money out of my pocket. I also paid, mostly out of pocket, for mental health visits.

    Frankly, I don't know how people without insurance pay for great diabetes care. I have had multiple insurances through the years, including HMOs, PPOs, COBRA plans, plans as a longtime freelancer, and now something called an indemnity plan. Paying for health insurance has always been one of my top concerns, and I pay thousands of dollars every year, even with insurance, on deductibles and certain things that my insurance doesn't cover (like, inexplicably, the batteries for my pump, even though they cover everything else).

    I don't know what to say--insurance and health is where I spend a lot of my dollars. I read books from the library (i.e., rarely buy new), generally buy clothes on sale, and the husband and I save a lot. We don't travel a lot, or drink alcohol (which makes things expensive when people eat out), and we don't have super expensive tastes.

    It is what it is. My health and insurance (and now, the husband's health and insurance) is where a large part of our income goes. Thank God s1955 didn't pass.

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  2. Violet,

    I consider our family very lucky-- at least for now (Ryan works for a smaller company, and every year they send out a call for bids for a new plan... for this reason, I'm always extra tense toward year end).

    Anyhow, currently we spend (after premiums) just under $1500 per year out of pocket on Joseph's pump supplies, insulin & visits with the endo, eye doc...

    Our insurance pays 80% of pump supplies, with a $25 co-pay on all scripts & visits to the doc (labs are covered 100%). No deductible.

    Also, we live in a university town with some of the best pediatric endos in the midwest, and (thankfully) all of these endos are in our HMO network.

    Now, if only they'd cover a CGMS...

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  3. Hi Violet --

    I'll weigh in. God, I hate diabetes and insurance and healthcare in general.

    I'm paying more for healthcare at my current job than I ever have before.

    I pay $190 a month for my premium, 25% of my pump supplies = about $45/month, $25 for each prescription X 4 = $100/month, another $25 for each PCP visit and $30 for each specialist visit (translates to about $400 per year or $35/month). Lab work is $10 each time - not matter where it's drawn. So total healthcare costs equal about $4500 a year - including premiums. That doesn't include the daily vitamins and aspirin that I take at my doc's recommendation.

    Irritating. That's a big chunk of money -- but not quite enough for me to qualify for a tax deduction.

    Grrrr....

    And when I need a new pump -- only 75% coverage.

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  4. my insurance is pretty good ... i have:
    -100% coverage on ALL pump supplies (not batteries lol)
    -15 dollar copay on all doctors visits ...
    -insulin (3 bottles for one month) is 15 dollars ...
    -test strips (250 strips for one month) is 15 dollars
    -generic birth control is 100% covered
    -all other prescriptions are either
    5, 15, or 25 dollars a month ...

    So pretty much I can't complain but let me tell you ... I'm never leaving college or turing 26 cause as soon as one of those hits - I'm off my parents insurance ... so I've pretty much decided that they need to come up with a cure with in the next couple of years ...

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  5. Violet--you should look into creating a medical expense account, esp. since you know the exact amount of your max out-of-pocket expense. The expense account is pre-tax, so you don't have to pay income tax on it, but the killer is that you lose the money if you don't use it by the end of the year (but again, shouldn't be a problem when you know your out-of-pocket-max). Sorry I don't know the details (can't remember exactly the account is called) cuz my mom (I'm a college student) currently does this for me. But it seems like a really good idea.

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  6. Thanks for the comments, folks.

    I do have a medical expense account through my employer, and it saves a ton of money. Highly recommended.

    I'm intrigued by the variations in costs & coverage among just the 4 people who posted details on theirs. From profiles, it looks like all are U.S. residents. Isn't it incredible that we're paying extremely different amounts of money to manage the same disease with the same methodology?

    Oh, capitalism...

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