June, 2005
For the last couple of weeks I have had the pleasure of introducing my mother to life in Santa Cruz. Believe me, it is very different from life in South Florida, especially the weather. In addition, we spent a few days in Phoenix so she could get caught up on the grandkids. That can be a challenge in itself, but try doing it in 108-degree weather. For four days it felt like you could hardly breathe, car air conditioning hardly made a difference and playing games with the kids was next to impossible. I guess all this climate change got the best of her because she is now a little under the weather and may need to see a doctor. This makes me wonder, how does one insure access to their medical coverage when they are on a trip. Just how do you know you are getting the coverage provided by your insurance company? Are the charges being paid in a reasonable manner?
All of us at times reminisce about our youth. It seems we were capable of doing everything, or at least that's what our memories tell us, and we are surprised when we can't do the same things today. Looking back at my youth I recall the ability to leap tall fences in a single bound, run faster than speeding rubber ball, and the uncanny ability to hit a baseball a mile from either side of the plate. Well, those days are gone. I now face the reality that I am no longer the young and agile man I used to be. My leap is now a hop, my grandchildren run circles around me, and the only thing I can hit from either side is the pillow as I lay down for a nap. My joints pop, my stamina is gone, my muscles get sore and I find myself at my doctor's office each month for some injury or ailment that could have been prevented, had I acted my age. I remember when the only time I saw a doctor was for my annual physical. And how I hate it when he says those five words that shakes the very foundation of my denial..."you're not getting any younger". Ouch. That hurts.
I don't mind getting older, but adjusting my lifestyle to accommodate for some of the changes aging naturally brings about can prove difficult at times. This means visiting the doctor's office regularly, not only when injured or completely sick. This, in turn, meant having to deal with my health insurance company. I hate that because I have no idea what I'm doing. I walk into the doctor's office with my insurance card in hand like it is a shield of protection only to find out it's full of invisible holes. I will admit I did not read the epic novel the insurance company sent me that describes my benefits and the steps I need to take to get medical services. Instead, I took the easy route ...I played pin the tail on the doctor. I called to ask what physician I could see, they gave me some names and I went. That's the easy part. The hard part is trying to figure out the letters I receive from my doctor's office three months after I've seen them. By that time I can't even remember why I went to see the doctor in the first place. Now, I don't claim to know everything about insurance companies but I do know what CLAIM DENIED means. That means I have to pay, and that is the extent of my knowledge of the health insurance process. I walk in to the examining room believing that I'm covered by my insurance company, then discover, several months later, that I'm not.
What really annoys me is going to a doctor listed within the network, and the insurance company doesn't pay him for the treatment I received, or they say that I had this condition before I was insured with them. So I try to work with them. I jump through their hoops trying to get a straight answer and, in the end, give up and pay the bill.
Don't get me wrong, I know I am lucky to have health insurance and I know there are a lot of people that don't have any health insurance. What I am trying to say is that insured people (HMO, PPO, Medi-Cal through the Central Coast Alliance for Health) need to understand their health insurance. And I have found out there are places we can go for assistance in understanding the insurance maze. One of these is the California Department of Managed Health Care and the Office of the Patient Advocate (OPA).
Created in 2000, the Department of Managed Health Care regulates and licenses HMO's and the Office of the Patient Advocate helps protect the health care rights of people enrolled in them. So if you feel that your health insurance company is not providing you the care that they should be in accordance with your policy, the first thing you should do is file a grievance in accordance with their grievance procedures. If you are still not happy then you may have need for OPA assistance. Call the HMO Help Center toll free at 1-888-HMO-2299 (TDD 1-877-688-9891) or use their website www.hmohelp.ca.gov to get advice and assistance. Only by making our voices heard can we insure our rights are protected.
Remember - Disability is a random event that can occur in any life, at any moment.
- Michael Bradshaw, Central Coast Center for Independent Living