Advice pls! - spouse has unexpected health issue

[Nanny]

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I'm a 4th year planning to go into pediatrics. I just recently found out that my partner has a rare and serious medical problem whose treatment probably won't be covered by the insurance I get at my #1 choice for residency. Strangely enough, it looks like the procedure that's needed would be covered if I went to one of the programs I interviewed at that I wasn't crazy about (and my partner hated too, btw). Complicating things even further, my partner might be eligible for disability and Medicaid (which would cover the procedure), and we're in the process of applying, but I won't know if my partner qualifies until after I have to submit my match list.

Ok, so obviously the health of my partner is the absolute most important thing to me, and if there are no other options I will choose the program that covers that procedure. But ARE there other options? I was thinking I might apply for a transitional year at that not-so-wonderful institution -- because that way I wouldn't be stuck there for my whole residency, but my partner could get that treatment in the meantime. But is it too late to put in an app for a transitional year at this point? Or is there some other thing people do in this situation? I'm thinking that I can't be the first person in the history of the match for whom this situation has arisen. But I pretty much feel like I'm stuck between a rock and a hard place right now, and I'd really appreciate any information about viable options other than just biting the bullet and going for that program that I didn't like.

Thanks in advance.

 

[NotAProgDirector]

1. If your partner has a major medical issue that needs an expensive treatment, I find it surprising that your future insurance won't pay for it. there are a couple of reasons this could be that I can think of:

A. It's experimental.
B. It's not a main stream therapy (such as extended Abx for "chronic lyme disease")
C. Since this person is your "partner" and presumably not a spouse, they may not qualify for benefits under your plan.
D. The insurance plan does not cover "Pre-existing conditions"

If it's A or B, then I'd really need to know what the problem was, and we get close to the "no clinical advice on SDN" rule.

If it's C, that sucks.

D is very uncommon today, and would also suck, but might be waived.

2. Regardless of #1, perhaps you want to take the year off to deal with this. Your medical school might let you split your fourth year (no extra tuition), and continue your same health plan. Or, you could do a research year. My point is that if your partner is that sick, perhaps your focus should be on helping them rather than a PGY-1 year. Will you really be able to focus on your education?

3. Remember that Medicaid is state specific. If your partner get's medicaid approved, and you move to a new state, you start all over.

Feel free to PM me, if you'd rather continue this privately.

 

[Nanny]

1. If your partner has a major medical issue that needs an expensive treatment, I find it surprising that your future insurance won't pay for it. there are a couple of reasons this could be that I can think of:

A. It's experimental.
B. It's not a main stream therapy (such as extended Abx for "chronic lyme disease")
C. Since this person is your "partner" and presumably not a spouse, they may not qualify for benefits under your plan.
D. The insurance plan does not cover "Pre-existing conditions"

If it's A or B, then I'd really need to know what the problem was, and we get close to the "no clinical advice on SDN" rule.

If it's C, that sucks.

D is very uncommon today, and would also suck, but might be waived.

2. Regardless of #1, perhaps you want to take the year off to deal with this. Your medical school might let you split your fourth year (no extra tuition), and continue your same health plan. Or, you could do a research year. My point is that if your partner is that sick, perhaps your focus should be on helping them rather than a PGY-1 year. Will you really be able to focus on your education?

3. Remember that Medicaid is state specific. If your partner get's medicaid approved, and you move to a new state, you start all over.

Feel free to PM me, if you'd rather continue this privately.

Hey, thanks for the response. It is B, but I'd rather not get into the specifics of it.

#2 is a really good suggestion. Unfortunately, my student insurance plan is a complete joke, and, though I admit I haven't specifically looked into it, I'm almost positive it would not cover what my partner needs. But it was a good thought that I hadn't considered, so thanks for the feedback.

If anyone else has other ideas, please share.

 

[Nanny]

1. If your partner has a major medical issue that needs an expensive treatment, I find it surprising that your future insurance won't pay for it. there are a couple of reasons this could be that I can think of:

A. It's experimental.
B. It's not a main stream therapy (such as extended Abx for "chronic lyme disease")
C. Since this person is your "partner" and presumably not a spouse, they may not qualify for benefits under your plan.
D. The insurance plan does not cover "Pre-existing conditions"

If it's A or B, then I'd really need to know what the problem was, and we get close to the "no clinical advice on SDN" rule.

If it's C, that sucks.

D is very uncommon today, and would also suck, but might be waived.

2. Regardless of #1, perhaps you want to take the year off to deal with this. Your medical school might let you split your fourth year (no extra tuition), and continue your same health plan. Or, you could do a research year. My point is that if your partner is that sick, perhaps your focus should be on helping them rather than a PGY-1 year. Will you really be able to focus on your education?

3. Remember that Medicaid is state specific. If your partner get's medicaid approved, and you move to a new state, you start all over.

Feel free to PM me, if you'd rather continue this privately.

Hi, a progdirector. Thanks again for your advice. After a good nights sleep, I thought I should add a few more things to make my situation a little more clear.

I need to talk more in detail with human resources from the residency program that I am most interested in to make absolutely sure, unfortunately they were closed today due to it being MLK day. But it states clearly in the plan that "out of network" inpatient treatment is not covered. This is in contrast to the other residency programs I have applied to, whose plans state they cover anywhere from 40-80% after paying a deductible (anywhere from $3,500 to 8,000 for a family). What I wonder (and need to find out) is if there is a "maximum out of pocket" at which point the insurance picks up the rest. Because we are looking at (I'm making an educated guess) somewhere in the neighborhood of $500,000.

I should have clarified; currently my husband has no insurance. He was self-employed prior to this. He has been able to get on a county plan since falling ill (it is not really an insurance program but covers some generic prescriptions, radiological studies, and local physician visits). We have filled out a medicaid application, but I will most likely not find out whether or not he is accepted before I have to submit my rank order list. So, although I would like to take a year off and agree that would be the best thing, I don't feel I can take the gamble of him having no insurance should he be rejected for medicaid. My student health insurance will not cover the condition until he has been on the plan for at least 6 months, and to add to that, it has really poor coverage. And...taking a year off means no income for our family, as my husband is not capable of working. So I don't really see a way of paying medical debts unless I plow forward with residency.

Thank you for providing the information regarding medicaid and having to reapply when you move to a different state. I did not know that, and it certainly adds another dimension to consider.

 

[Miami_med]

For me, it's a sick child, but the concept is the same. I'm also currently the sole breadwinner, as my wife isn't able to work due to childcare constraints. I've had to take three of my top five programs down the list over an insurance issue. Most programs don't really understand the basics of their insurance, because people like us (with sick dependents) are relatively rare in the medical school senior applicant pool. I think that time off is generally the wrong choice. Is there only one program on your rank list that covers out of network procedures? More importantly, do you need to get approval for out of network procedures with the program that you think covers whatever the problem is?

 

[Nanny]

For me, it's a sick child, but the concept is the same. I'm also currently the sole breadwinner, as my wife isn't able to work due to childcare constraints. I've had to take three of my top five programs down the list over an insurance issue. Most programs don't really understand the basics of their insurance, because people like us (with sick dependents) are relatively rare in the medical school senior applicant pool. I think that time off is generally the wrong choice. Is there only one program on your rank list that covers out of network procedures? More importantly, do you need to get approval for out of network procedures with the program that you think covers whatever the problem is?

Hi, Miamimed. I am sorry to hear of your predicament as well.

I have also had the experience that other residents and even program directors seem to be fairly unknowledgeable of the details of the program's health insurance plan. Worse, I worry about asking too much or appearing too needy for the possibility of it ruining my chances, you know? If I were a program director, I couldn't help but worry about accepting a resident with a very sick family member who might not be able to perform up to snuff. I had been very reluctant to start going down this path, but I did talk with several of the program directors about this issue, without going into too much detail. I suppose the thing I have on my side is that relatively few people seem to know much about the disease, etc... The program directors were sympathetic but not much help. One said "i am sure we can find you a good specialist when you get here" (i doubt it, and besides affordability is the point). The other just kind of gave his sympathies and didn't say much else.

Yes, there are several more programs on my list that "cover" out of network care (after deductibles they cover between 40-80%). Honestly I don't know how I'm even going to swing that. It seems impossible unless there is some cap/out of pocket maximum. I'm guesstimating a possible half mil when all is said and done.

Yes, I do need to get approval for using out of network, however I am 100% positive that will not be a problem as there are really only two places in the U.S. (that I am aware of) which do the procedure he needs. It is not experimental, it is totally evidence based. It is simply rare.

 

[NotAProgDirector]

It is B, but I'd rather not get into the specifics of it.

I completely understand.

What I wonder (and need to find out) is if there is a "maximum out of pocket" at which point the insurance picks up the rest. Because we are looking at (I'm making an educated guess) somewhere in the neighborhood of $500,000.

It's much more complicated than this, unfortunately.

On the good side, there almost always is a maximum out of pocket expense in any given year, usually expressed as both an individual and family maximum. For example, at my institution, if you go out of network there is an individual deductible of $300, and then a 30/70 split (pt/plan) for the next $5000. So, an individual would only be responsible for the first $1800. Many plans have individual maxima, usually annually and lifetime of $500K and $1M respectively -- interestingly, our housestaff plan has no maximum. And, if you stay in network here, everything is waived -- no copays, no deductible. I think you pay small fees per prescription only.

In addition, if the care you need is not available in network, then you can be "pre auth'ed" for out of network services, which will pay 100% (not exactly, see below)

Remember that this is usually per calendar year, so if treatment were to start in the fall, you'd likely have to pay double -- one deductible/copay for 2009 and one for 2010.

BUT, there are possible problems. First, the plan specifically excludes experimental treatments. Although you claim this is not experiemental, when only 2 institutions in the whole US provide the service you are looking for, some insurance companies may try to claim it's experimental.

Second, they limit payment to out of network providers to the "Maximum Allowable Benefit". basically, for each procedure they decide how much they are willing to pay. Perhaps taking a gallbladder out is worth $2000. If you decide to go out of network to see some "famous surgeon" and he/she charges you $3000, you get billed (by the surgeon) for the $1000 difference and this does not count towards your copays or co-insurance.

Third, they might require some sort of pre-auth to pay anything, and could easily refuse to pay if what he is looking for is not mainstream.

Last, there could be exclusions for pre-existing problems, or a waiting period. If he gets worse, he might not be able to wait.

So, much hinges on whether this procedure your spouse needs is truly considered "mainstream" and is simply limited to a small number of hospitals (like separating conjoined twins), or whether it's not mainstream because most people don't believe it works (like Morgellans). If that's the case, insurances are unlikely to cover it even if they have out of network coverage, no matter how "evidence based" it might be.

Of note, $500K is a lot. I had a patient willing to pay cash for bariatric surgery, and that bill was $30K. $500K will pay for a transplant of some sort.

We have filled out a medicaid application, but I will most likely not find out whether or not he is accepted before I have to submit my rank order list.

Remember that Medicaid is state specific. If the treatment he needs is in another state, it will not be covered by medicaid in your state. And, you can only get Medicaid in the state in which you live. In addition, there are many treatments not covered by medicaid at all. Bariatric surgery (in my state) is one of them. The more expensive the treatment, the less likely it is to be covered. Or, Medicaid may simply say "we are only paying $50K for this, take it or leave it" to your physician. They may be unwilling to proceed.

And...taking a year off means no income for our family, as my husband is not capable of working. So I don't really see a way of paying medical debts unless I plow forward with residency.

I understand your dilemma. Just be aware that I have seen others in a similar situation fall apart in residency. Make sure to take care of yourself, it's easy to get caught up in a loved one's medical issues.

 

[Law2Doc]

...
D. The insurance plan does not cover "Pre-existing conditions"
...

This is going to be pretty much the end of the discussion under any insurance policy. When you sign up, any conditions that already exist generally will impact whether, and to what extent a person is covered. Meaning if your spouse had a heart issue, or cancer, or an upcoming major surgical procedure or something else big, then most insurers wouldn't cover them without an extremely high premium that you likely could not afford on a resident's salary. Generally you can't just sign up for insurance when you have a need for it. You sign up when you have no need, so that it covers you when you do. Once you have a need, the company knows it can't just rake in premiums for doing nothing, so it has to adjust your premium rate accordingly or not take on such coverage. So don't expect that you will get much benefit taking a policy offered by a program lower on your rank list. No insurance company plays to lose.

 

[Miami_med]

LTD,

I've seen plenty of employer-sponsored health plans that do cover pre-existing conditions. This is of course because the contract for all employees within an organization is worth a few financial losers. The majority of plans at residencies at which I've looked DO cover pre-existing conditions if you elect employer based coverage. On the private market, you're absolutely right.

 

[Law2Doc]

LTD,

I've seen plenty of employer-sponsored health plans that do cover pre-existing conditions. This is of course because the contract for all employees within an organization is worth a few financial losers. The majority of plans at residencies at which I've looked DO cover pre-existing conditions if you elect employer based coverage. On the private market, you're absolutely right.

I assure you that if you are a resident trying to add a spouse with a pre-existing medical condition of the type that requires $500,000 in procedures in the short term, every employer-sponsored health plan is going to have a host of exceptions that don't require them to take this pre-existing condition.

So too the spouse with the severe heart condition or malignancy. These people who are not insurable aren't going to get out of this status thanks to an employer sponsored health plan of a spouse. Minor things, sure, they won't balk at. The usual hypertension, high cholesterol kinds of stuff. But for the big ticket things you'd better believe these companies have a lawyer somewhere who thought this through and gave them an out. They are in business to make money, even if it's employer sponsored.

 

[error404]

My thoughts are with you both.

 

[DonStracci]

I have also had the experience that other residents and even program directors seem to be fairly unknowledgeable of the details of the program's health insurance plan. Worse, I worry about asking too much or appearing too needy for the possibility of it ruining my chances, you know?

I have the same feelings. For me, benefits are very important, as my spouse might not even be employed if we move and therefore I'll be the sole breadwinner, foraging for income and health benefits. My top programs at this point have great training and I'd be thrilled to work at either of them. However, upon looking at the benefits information from each, some things are very unclear. When I contact the programs for clarification, I am sometimes made to feel as if I shouldn't even care about these things (health insurance, FSA/HSA, 403b, etc). I ask very tactful, general questions so as not to seem nit-picky, but evidently most candidates don't ask about this stuff.

If it comes down to a few programs that are quite similar to each other, benefits will be one of my deciding factors.

And Nanny, best wishes for resolutions to these issues.

 

[Nanny]

Hi Miami Med and Aprogdirector; I tried to pm you both, but I'm not sure if it worked. My "sent mail" folder is empty. Let me know if you don't get the pm's.




Thanks everyone else for your comments.

I could not find out much today due to the holiday, but I did manage to set up an appointment with an insurance specialist tomorrow here at my home institution so hopefully I will learn more soon. I will update as I learn more.

 

[Habeed]

I really hope that whatever it is can be treated succesfully. $500k is a stupendous amount of money, implying a very severe illness.

 

[Blade28]

Out of curiosity, will your partner be able to relocate and find a new job that provides the necessary insurance coverage?

 

[Doowai]

Wow, I am sorry to hear of the delimma's. Residency often seems suited only for 20 somethings with no relationship attachments other than having healthy parents. The single residents often have no idea how hard having SO's or dependants makes residency.

I trust you will be able to work things out. Often there is not a "best" choice, just choices we make the best of.

 

[Nanny]

What I have learned after talking with the health insurance specialist:

1) "Out of network" seems to refer to conditions where the patient says that even though the specific service is offered within their network, they would prefer to have that service provided by a doctor or hospital outside of the network. In my husband's case, the service is only provided in several places in the United States.

2) In general, if the service is the accepted medical treatment by the medical community (not experimental, etc...) but NOT offered anywhere within the network, insurance companies will help to pay for it.

3) At one of the residency programs (my residency program of choice), my husband's insurance would be considered "expanded network" and at another program, it would be considered "in network." This means that at the most I would be paying around $8,000 at my program of choice (including deductible and maximum out of pocket cost but not including the monthly premium for the plan), which I can swing. However, BOTH insurance programs would require "prior authorization" before I could get my husband's treatment covered. This could possibly be a hassle; I can't receive a guarantee on this until I actually try to get it covered. I imagine there could be as yet unforeseen legal quandaries as Law2doc suggests. I have talked with human resources and the program directors at both programs who seem to feel it will not be a problem, but until I actually try and press the prior authorization through the insurance company, I won't truly know.

4) None of the programs I have applied to exclude preexisting medical conditions.



I did talk candidly with the program director at my top choice program yesterday. I let him know how highly I regarded his program and that it was my top choice, but that I felt it was important that he be aware of my situation, how it could affect my abilities to perform as an intern, and how it would require them being flexible with my schedule. I let him know that I hoped that I could get my husband's care covered on medicaid and that he could receive the treatment prior to my starting residency, but that it was more likely I would be dealing with all this during intern year. To my relief, he was extremely helpful. He let me know that they were very happy to have me, to not worry at all about how we would work it out, and that they had dealt with similar problems in the past with other residents. I feel very lucky in this regard...


I thank everyone again for their comments and I wish anyone going through similar situation either now or in the future the very best.

 

[Miami_med]

Best of luck in the match this year. I can say from personal experience that you'll come out on the better side of adversity a better person and a better physician.