Monday, August 20, 2012

TennCare (Medicaid) and The Taxpayer Money (WASTE) Part One

So I see a lot of people whining about 'Obamacare' and how its going to bankrupt our country, like Medicaid (insurance for the poor and disabled) and Medicare( for the disabled and elderly)  already have.

I am slightly inclined to agree.
I am a liberal independent. I do not side entirely with either democrats or republicans,  I am pro legalization of marijuana (especially for medical reasons) pro universal health care and pro choice. I am against immigration amnesty and fining people for not having health insurance.

Let me tell you about a few things I have noticed as a recipient of Medicaid. 
As a disabled person actively receiving social security benefits, I am qualify for Medical Assistance, which I do utilize.

Here in Tennessee its called TennCare. Tenncare is a joint funded 'project' by the state and Feds. 

TennCare is one of the WORST Medicaid providers in the country.

This is what my benefits look like (which is standard)

5 Presciptions a month, unless on the 'exempt list' (Which comprises of mostly retrovirals for AIDS drugs) 3 generic and 2 Brand Name, with a 3$ copay. Certain medicines such as Benzodiazapines, Pain Killers, Controlled Substances (narcotics usually) and certain sleeping pills, amongst others are NOT covered.

Weight Management program IF qualified (must be over weight or have a comorbitiy like diabetes, high blood pressure.. so on) which can include, nutrition classes, a gym membership to the YMCA, counseling, and weight loss surgery.

12 visits to a Primary Doctor a year, unless you have a medical exemption (I do)

Limited in-patient hospital care

No dental
No vision
No chiropractic care

Pre-authorization required for most testing, such as CT scans, MRI's, and so on. Basics like blood work, EKGs and xrays are usually covered with just doctors orders.

Emergency Room Care

Thats about it. Now that seems like A LOT to someone without any insurance, and by all means it is.

Personally, I am grateful I have any insurance at all.

However, I have MANY MANY MANY issues with TennCare.

First and foremost the prescription benefit limit, as run by SXC. 

I am on disability. Don't you think I need more than 5 prescriptions a month? I usually blow through that in antibiotics a month. Yes, they have something called an exemption waiver, where a doctor tells the insurance company why that medicine is medically necessary and should not be counted towards your prescription limit. Out of the 23 current practitioners that I have, not a single one knows what I am talking about or how to do this. The insurance company insists that the doctors should and will not tell me how to have them go about this.

So each month, I regularly choose between antibiotics, heart medications, lung medications (asthma, allergies, so on) kidney medications, skin creams (usually for skin infections) auto immune suppressants, allergy medicines (like an EpiPen, or a cream for hives) GI drugs (for my stomach/intestinal issues) ear medicines (for whatever) and birth control.

Usually the antibiotics win. Sometimes a mental health medication may win a spot, but rarely.
I was told by the pharmacy and by SXC that they do not consider an EpiPen to be an emergency drug and thus it counts towards my benefit.
So if I got stung by a bee, used my EpiPen (and saved my life) received medical care and a prescription for a new one, and I had already used my 5 for the month (or 2 brand names) then I could NOT get another life saving EpiPen until the next month.

Thats some bullshit.

I find it ludicrous that not a single practitioner knows how to fill out these forms, or jump through the right hoops, and I completely believe each practitioner when they say they cant figure out HOW to do them, or that they ALWAYS get denied.

Second, perhaps I was more spoiled by Medicaid in the north (Access, in Pennsylvania, where I hail from) where I had somewhat limited dental and limited vision care, as well as unlimited prescriptions each month. (Some did require prior auths, which were easy to get) However, I find that as a disabled person, that Access actually met my needs 98% of the time, versus TennCare which meets them about 40%, if that.

In Pennsylvania (not saying they are perfect, they are not) there were different 'classes' of Medicaid, and Medicaid eligibility, just as there are here. You could be:
On cash assistance (welfare, TANF)
Under 21
or other, which usually meant waiting for disability
OR a cancer patient 

Each category usually had its own rules and benefits. 
I can only really speak to unider 21 and disabled, since I have received both.

Medicaid for disability is supposed to be life sustaining, health sustaining. They put these lovely little provisions in 'appeals' (Ill get to that later) where if it could cause damage, death or hospitalization, its considered an emergency.

Well, usually if you are on disability a lack of care or medication could cause any of the above to happen.
Benefits in all states are far better for CHILDREN on Medicaid. Usually those on disability have something similar to that, as again, its expected to be health/life sustaining.
Not so here in great old Tennessee.

I get the SAME exact insurance pregnant moms get, welfare recipents get and so on.

Mom who lost her job or had to flee domestic violence and lives on Cash Assistance, probably does not need to see 23 doctors and take 18 prescriptions a month.

I do. I am not alone.

So, instead of say, TennCare covering a 2x a year dental cleaning at 40$ a piece, I dont get it done. In turn I get abcesses and infections and need antibiotics, at about 40$ a pop per antibiotic. Surgical removal of the abcess is quite expensive I'm sure, however I dont have the money to get that done so I dont know.

Another dental example: My wisdom teeth are coming in, at nearly 25 years old. (I turn 25 on Wednesday)
My jawbone is currently exposed, and will likely cause all kinds of problems, from infections of the bone to abcesses and distorment of my jaw and teeth.

So instead of paying 300$ to remove my two wisdom teeth (Medicaid pays WAY WAY WAY less than standard private insurance, in case you are wondering why my figures are so low) Medicaid will pay to have my jaw surgically fixed, and bone removed, in addition to the antibiotics, hospitalization and care required, as well as prescriptions, at about 30-40,000.

That makes sense right?

Heres an example:

ABout a month ago I started randomly passing out. I was seeing colors, had a headache to bad I wanted to die, was vomiting non stop, slurring my speech and had lost my appetite and had severe sensory hallucinations (smelling, tasting things that were not there)

I went to my primary who suspected a migraine, but wanted to make sure by ordering a head CT and called in a migraine prescription.  Well, dont you know I reached my benefit limit, so no migraine medicine.
At 6 pm on a friday I had no other choice.. I wanted to die. So after I passed out, I went to the local ER.

That bill was probably about $2000 that the state PAID.

Well the ER here sucks and they gave me more prescriptions I couldn't fill.. so I had to go back when I passed out again. 

Probably another 3k in work done, at the er.

Well three days later it still hadnt gone away, I had just stopped going to the ER, and I went one last time, this time in Nashville. That probably cost about 300$, since they did NOTHING.

So, instead of covering a 50$ prescription that *might* have solve the issue, thy just paid at minimum $6000 for medical care for me, and still didnt treat or solve the problem.

it took two weeks and five antibiotic prescriptions (and a bag of antibiotics in the ER the second time) to get rid of that. I still dont know what caused it.

They denied the head CT saying it was medically unnecessary. So... those symptoms that scream STROKE or TUMOR mean nothing, I guess.

This is just one example.
This post is already getting too long so I will have to do a part 2.

1 comment:

  1. Oh sweetheart I know exactly how you feel. I lived in NYC and lost everything during hurricane sandy. I had family in TN so I moved down there with just the clothes on my back. I am disabled and have a ton of medications per month which I have or die. In NYC they paid for all my medications except for needing a prior auth. every once in a blue moon. I needed tests prior auth. done in a day.
    I came to TN changed over here and I can't get any help. Most of my medications are not covered by tenncare even if I am within my limit. Also coming from NY I noticed that not only do they not cover the medications but that the medicines cost more. I had a lapse at one point in time in nymedicaid. I had to pay cash for a medication that I have been taking for years, in which the doctor said never come off of because it could kill me. It's an antidepressant. So I bought it in ny for 19.99 then because I didn't have any insurance in TN yet I tried to refill and pay cash expecting a $20 price tag. No problem, no wrong it was $279.00 after a discount provided by the pharmacy. I was sick for days and wanted to kill myself because of the withdrawls of that medication but lucky for me my acceptance letter came in the mail and I ran to the pharmacy to get the medicine.
    I have only come across one theory that can explain this problem in TN, because it is a problem. It hurts the people which really do need help. I for one need help and do not abuse the system and I cannot afford private insurance and copays. My theory is this, that NY is a liberal state which seems to mean better benefits. TN is a conservative state of the worse kind therefore they don't give a s*** about the poor. If the rich get richer then they are fine but god forbid you pay for a disabled persons life saving prescription drug because the next thing you know they start raising hell.
    See what people don't understand is that not all disabled persons receive medicare. Only people that have worked enough to receive it can. Some people were disabled young. They couldn't pay in enough so they are in an insurance gap where they don't receive medicare but state medicaid. These people need medications which can't be afforded to them and they don't have enough money to pay for them.
    Thank you for writing this because I don't think many people understand what is really going on out there.