Enter the Social Worker from Stage Left; What’s My Insurance?

It’s Monday, four days after The News.

Enter the Social Worker

I was awoken bright and early by a call from a social worker. The nurse navigator had mentioned that a social worker was part of the team at PAMF who would help me along but I wasn’t expecting a call so soon! From what I can tell, while the nurse navigator assists with coordinating the medical aspects of my care, the social worker will help in other aspects of living through the journey.

Things she seemed to be interested in were my living situation (single, live alone, no family close by) and whether I needed any psychological or emotional help. In trying to determine what her role was I asked if, further down the road, I needed assisted living was that the kind of thing she dealt with? Yes, she’d be involved if I needed some sort of special home care or a visit to a care home and there were various services for meal prep, etc. which she could hook me up with.

What’s My Insurance?

After the call I started on the one item I had planned for today. The nurse navigator suggested I call my insurance provider and ask to speak to a customer service representative. Explain to the rep that I had a recent cancer diagnosis and was starting on that journey, and wanted to understand my benefits.

Sounds straightforward. In preparation for that I rummaged through my files and found the plan document. It was from 2009. There were a number of addendums, which grew thicker as the ACA provisions took effect. I didn’t have all of them, but there was no way I could make sense of my benefits given a 12 year old plan with annual updates. Hopefully Anthem has one that’s up to date.

So called Anthem and explained the journey I was on. Asked if I there was an up to date plan document. The CSR dug up my records and said yes, let me see….we have a plan document and 16(!) updates. You’ve got to be kidding! Not quite what I was hoping for.

So proceeded with Plan B. Explained I wanted to know what process to follow to ensure that claims are processed as smoothly as possible, since the last thing I want is to get into an argument with Anthem. So…who’s responsible for making sure that the diagnostic tests and treatments are covered under my plan and that getting any necessary pre-approvals? Answer: As long as I’m in-network (e.g. PAMF) then the provider does that. If I’m out-of-network then I may need to ensure the pre-approvals happen to ensure its covered under the PPO aspect of my plan.

How do OTC and prescription drug coverage work if I pay out of pocket at the pharmacy? CSR: I’m sorry I’m not sure since we contracted that out to Ingenio. I can give you their number and you can follow up with them. The Anthem CSR was very friendly and I will say as helpful as he could be, but I’m not impressed with Anthem. How is anyone someone supposed to figure out what a plan with 16 amendments covers? And I don’t really care if Anthem subcontracts out certain items, but I do expect to be dealing with Anthem and not the subcontractor. Sigh. Such appears to be the state of American private health insurance however.

At the moment I’m glad that PAMF is in-network and based on what the nurse navigator said I shouldn’t be facing out of pocket costs too much greater than my deductible. Knock on wood that holds true!

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