Several weeks ago, my husband and I learned that our daughterOlivia had developed a rare condition brought on by juvenilerheumatoid arthritis.
Our 7-year-old could die if her physicians can't stop cells knownas macrophages from attacking and destroying her red and white bloodcells. Essentially, Olivia's immune system is attacking her own body.
It wasn't until that moment in a staff room at Children's NationalMedical Center in Washington, when I found out the gravity ofOlivia's condition, that I fully appreciated how fortunate I was tohave a good job. Without my job, I wouldn't have access to the kindof health insurance it is going to take to treat my daughter'sillness.
Olivia has now been in the hospital for six weeks. Already we havea stack of billing notices as thick as the yellow pages.
When I sit by Olivia's bed and watch her breathe through an oxygenmask and moan in her sleep from all the drugs she has to take, Ican't help wondering how much more scared and stressed I would be ifI didn't have adequate medical coverage.
I chose my plan, Kaiser Permanente, the way I picked my bank. TheHMO was convenient. It had a large medical center near my home.
Sure, I had looked at the type of coverage the plan offered andhow much the co-payment was compared with other plans availablethrough my company. But there was so much I didn't check out. Youshould want to know which hospitals are affiliated with your plan.Yet I didn't know that Children's, one of the nation's top pediatrichospitals, was where we would, luckily, be referred for specialtycare for our children.
'Which health plan you choose can have important consequences forthe quality of health care you get, the convenience of getting thatcare, the ease and pleasantness of dealing with the plan, and yourtotal health care costs,' say the editors of Consumers' Checkbook, anindependent, nonprofit information service.
About the same time Olivia was admitted to the hospital, Ireceived Consumers' Checkbook's Guide to Health Plans. The $14.95publication is full of important and potentially life-saving advice.It can be ordered with a major credit card at 800-213-7283 or on theWeb at www.checkbook.org.
This medical crisis my daughter is going through has taught methat if you want good care in any plan, it often comes down to reallyknowing the rules and enlisting the help of the care providers whoare part of the plan. Here are some key things to do or ask,according to Consumers' Checkbook and other experts:
Find a good primary-care physician. This 'is essential to gettinggood care in any type of plan but especially critical in an HMO,where this doctor will be the gatekeeper controlling access to allother services,' according to the health plan guide.
Understand how to get a referral for specialty services. This iswhy you want to select not just a good doctor but also one who isgood at navigating your plan's referral system. I don't think mydaughter would be alive today had it not been for our pediatrician.She put in a request for a referral to a specialist the moment itappeared that Olivia's condition was unusual. When a referral didn'tcome through fast enough, she ran interference. It was a specialistat Children's who diagnosed Olivia's rare syndrome.
Find out who authorizes what treatment you will need during ahospitalization. By far the best thing I think Kaiser has done isstation one of its own physicians at Children's. That doctor has beena godsend. He coordinates daily with the wonderful team of physiciansassigned to Olivia. He works for Kaiser, but he's become our doctor,our advocate -- and now our friend. Not once have we had to fightwith some bureaucrat about paying for a procedure or drug, no matterhow experimental or expensive.
Find out which services are covered and what limitations andexclusions there are. You may be surprised to find out that yourpolicy has what is called a lifetime limit, which is sort of like acredit card limit. It establishes a monetary ceiling for how muchwill be covered for the life of your policy. Data from the KaiserFamily Foundation show that the lifetime limit often depends on thesize of the company you work for. The larger the company, generallythe higher the lifetime limit. Overall, says the foundation, 63percent of employer-based health insurance plans carry a lifetimelimit of $1 million or more; 21 percent carry no maximum value and 6percent carry a limit of $1 million or less.
If your policy has a low lifetime limit and you're married,consider carrying insurance through both of your jobs. It may bepossible to use one health-care plan until it is maxed out and thenswitch to the second. Having a lifetime benefit of $1 million mayseem sufficient, but keep in mind that the limit takes into accountall previous treatments for various illnesses per individual coveredunder the plan. With the cost of medical care, you could hit thatlifetime limit sooner than you think. But with two policies, once youmax out on the primary plan, you can submit the additional charges tothe secondary policy, says Joe Luchok, communications manager for theHealth Insurance Association of America. Here again, check the secondplan to find out what it will cover.
If you follow the basic tips I've outlined, maybe you won't havetrouble with your medical coverage. Maybe you still will. At the veryleast become an informed consumer before a medical crisis hits. Godig out your health benefits book and read it cover to cover. Asklots of questions even before you think you need the answers.
I'm grateful that at a time like this, I don't have to worry aboutthe cost and quality of the medical care my precious and precociouslittle girl is getting. But I'm also aware and still troubled by theway insurance worries could have made things work out differently.
Researcher Raymond Lee contributed to this column.
While Michelle Singletary welcomes comments and column ideas, shecannot offer specific personal financial advice. Readers can write toher at The Washington Post, 1150 15th St. NW, Washington, D.C. 20071,or by e-mail at firstname.lastname@example.org.