Affaire du coeur, Part 4

We were finally contacted by The Seattle-Times, which began knocking on a few doors themselves. They started rallying to our cause by rattling Regence’s cage, and working closely with the Insurance Commissioner’s office. I talked to Shelby Gilje at the Times, and went over what I had been doing.

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Friday, January 08, 1999
State Wants Insurers To Provide Details On Prescription Coverage
Shelby Gilje

Seattle Times Staff Reporter

The state is investigating a complaint from a consumer with a life-threatening illness who says her insurance carrier stopped paying for her drugs in mid-treatment with little notice.

Insurance Commissioner Deborah Senn did not disclose details of the complaint but cited it as an example of why consumers need more information on the prescription coverage their health plans provide.

Yesterday Senn filed proposed rules for health plans on what insurance carriers would be required to disclose up front to consumers. A public hearing on the proposal is set for Feb. 23. The rules could become effective in mid-March.

Senn is seeking comments from consumers and the insurance, health-care and pharmaceutical industries on about 10 recommended disclosures.

Among them, Senn has proposed that health-insurance carriers provide the following information to consumers:

— Whether the plan limits or excludes certain drugs that may be prescribed by a doctor, and whether substitutions will be encouraged for some drugs.

— When the plan can change the approved drug list or formulary.

— If a change occurs, whether the consumer will have to pay more or could be “grandfathered” to continue with a drug already in use.

— What phone number consumers can call to request a change in coverage or make an appeal.

— What consumers must pay to get a prescription filled.

— Whether their plan requires consumers to use specific pharmacies, and their locations, to pay the least out-of-pocket expenses.

— How many days of medication a consumer gets per co-payment.

Senn’s staff and industry representatives were involved in a year-long task force that studied consumers’ complaints about prescription and mental-health benefits.

Representatives of Premera Blue Cross and Regence Blue Shield were part of the task force and said it was a positive, collaborative approach.

But while Premera wants to support the disclosure recommendations, officials at the insurer said, they’re concerned about the cost of providing information on dozens of prescription plans and whether that detailed information might confuse consumers.

Regence already provides most of the information, said spokesman Chris Bruzzo.

“We are in strong agreement with the commissioner that more information, and direct, clear communications can go a long way to avoid confusion and mixed expectations,” Bruzzo said.

Regarding mental-health treatments, Senn’s proposal also would require insurance carriers to tell consumers what information about them would be disclosed to entities other than medical providers, how many mental-health visits the plan covers and how that coverage can be used.

For more information, see the insurance commissioner’s Web site at or call the agency at 800-562-6900.

Copyright (c) 1999 Seattle Times Company, All Rights Reserved.

Still, it looked like no solution was close at hand, so I began working on Plan B. I had just read Through A Distant Mirror, about the 100 Year War which finally ended by a political marriage. It gave me an idea. If no one could come through for us, I would marry her to get her covered by my insurance policy, which was through an excellent company, with good coverage. I contacted the insurance company to see how soon they could cover a new spouse. They told me immediately.

I started talking to Tory about this plan. She thought it was a workable solution. We set a deadline to get the resolution solved, otherwise, Plan B it was. I contacted the Marriage License department and a local judge and set a date based on this backup plan. She would fly out on the deadline date, and we’d immediately get married, and I’d get her onto my insurance policy. Her only question was if her mom could come to the wedding.

Don’t forget, I was still faxing and mailing and calling everyone I could to resolve the situation without having to go through the backup plan.

Finally, 7 days from Plan B, Regence blinked. The pressure from the Insurance Commissioner’s office and The Seattle-Times, became intense, and they realized they were about to be dragged into the spotlight. Tory told me this on a Friday, I think. We were relieved that Regence finally capitulated, although they covered their ass by saying it was a “clerical error.”

On Monday, as I was getting ready to leave for work, I got a call from Shelby. She told me to sit down, and proceeded to tell me what I had already known, that Regence had agreed to continue Tory’s coverage. She asked me how I felt about this finally happening and I told her I couldn’t be happier. I started checking my watch to see how much time I had left before I had to get to work. We chatted for a while, and then she asked me, “So what’s this about a Plan B.

I told her what my backup plan had been, and she must’ve been paying more attention than I thought.   This is the article as written by Shelby for the Times. They didn’t get everything quite right, but the important parts are there.

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Sunday, January 10, 1999
Health-Insurance Gaffe Nearly Fatal — Life-Dependent Drugs Not Covered, Woman Told
Shelby Gilje

Seattle Times Troubleshooter Columnist

Life looked bleak for Victoria Doyle, 41, a heart-transplant survivor, until just a few days ago. But now Doyle’s got insurance.

Just before Christmas, she was told that Regence BlueShield insurance no longer would pay for anti-rejection prescriptions because her policy has a $500-a-year cap on prescription drugs.

Because the drugs that keep her alive cost about $2,000 a month, the news was like a death sentence.

“I’m surprised I didn’t pass out right there in the hospital,” Doyle said.

Over the holidays, Doyle wrote a friend via e-mail that she felt as if she were “standing on a melting ice floe” because of the news that her drugs would not be covered.

On Thursday, Doyle got some good news from the state Insurance Commissioner’s Office. Don Sloma, a deputy commissioner, called Doyle and said Regence would cover her medication under the $200,000 lifetime-transplant benefits in her policy. Regence discovered a billing error, Sloma said.

Waltraut Lehmann, manager of regulatory affairs for Regence, said the carrier has only two other subscribers who are transplant patients, so “it’s a pretty unusual circumstance.” The confusion apparently arose over whether Doyle’s medication should be under the transplant-benefits category or the prescription-drugs category on the policy she bought in late 1996.

Representatives of Regence are working out details with Doyle’s doctors and pharmacists at the University of Washington, where she had the transplant July 4, 1991.

Doyle’s dilemma surfaced Thursday after state Insurance Commissioner Deborah Senn filed proposed rules requiring detailed, upfront disclosures on prescription coverage before consumers buy insurance policies. Senn will have a public hearing on the proposed rules Feb. 23 in Olympia.

“I’m glad for Victoria that we got this resolved, and I commend Regence for fixing it,” Senn said.

Among those Doyle told about her insurance problems was Jack Huster of Fort Wayne, Ind., whom she met through an online chat room about two years ago.

Huster, 35, a U.S. Postal Service data-entry worker, e-mailed the story of Doyle’s dilemma to Washington’s governor, the insurance commissioner, members of the congressional delegation, and local and national media.

“I wasn’t going to stand by and see her die,” Huster said.

Twelve years ago, Huster said, he spent New Year’s Eve with “somebody very special, and she was gone in three months because of a heart condition.” That was his wife, Kathy.

When he heard that Doyle was facing death if she couldn’t get her medication, he came up with a plan: If Doyle’s insurance wouldn’t pay for her drugs, he would marry her so his insurance would cover her.

Huster sent Doyle papers to apply for a marriage license and reserved a date with a judge for a wedding this month.

Doyle was touched by his proposal and caring. “It’s something wonderful from something terrible,” she said.

Copyright (c) 1999 Seattle Times Company, All Rights Reserved.

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