No one thinks America’s health care system is perfect. People argue on every side of every issue about the flaws in the system. Personally, our family has benefited from the Affordable Care Act, and I am very grateful we have its protections. Without the ACA, Gracie’s insurance would have dropped her years ago and we would have been forced to add her to one of our employer-sponsored group plans for an outrageous expense (it’s $600-700 per month to add a child to either my plan or Chad’s).

Back in the day, before the ACA, we made a choice to enroll our children in their own health insurance plans. Each child has a child-only plan (through separate insurers) that is not tied to any other person. We have never had any problems with Jackson’s plan, but then again he’s a healthy kid so we’ve never really tested it. We haven’t had too many problems with Gracie’s, either, but we were paying huge dollar amounts out-of-pocket each year between her yearly deductible, hospital stay deductibles, prescription drug costs, etc. Last year, we finally got her enrolled in secondary Medicaid to defray our out-of-pocket expenses, and it’s been a lifesaver. We would have lost our house if not for the secondary insurance; we are not out of the financial woods but things are a lot less scary now.

Ever since we’ve added the secondary plan, Grace’s primary insurer has been refusing to pay for things left and right. We ordered a wheelchair for Grace because she tires very easily and long walks are too much for her. Anthem denied it. Medicaid paid the full cost. We ordered new gloves for her—Grace wears special gloves to protect her fingers from her teeth and from accidental injuries—and Anthem denied them. Medicaid paid the full cost. We ordered some fancy wound care dressings (Mepilex Lite) for Grace—these dressings have saved us from hospital trips, including the one that seemed imminent after Grace removed her fingernail last month. Anthem denied them.

I called the medical supply company and spoke to a rep, who told me that because Anthem would not pay the full cost of the dressings, they could not fulfill the order. I asked her how much Anthem would pay, and she said they would pay nothing. I asked her what the total cost was, and she said it was $800 for the box of four 8″x20″ sheets of Mepilex. WOW. Next, I emailed Grace’s nurse case manager at Anthem and explained the situation and asked for her help. I mentioned in my email that an $800 box of supplies could save Anthem from paying for a $30,000 hospital stay, so the seemingly high cost of the Mepilex is totally worth it.

The nurse case manager blew me off for a week. I kept bugging her, sending emails and reminders, and finally one day she called with a rep from the medical supply company conferenced in. Unfortunately, I didn’t hear my phone ring. The nurse case manager and med supply rep informed me that the company from which I was ordering the medical supplies doesn’t contract with Medicaid, so because they are contractually unable to bill me directly for the cost, they could not fulfill the order. The nurse case manager drove home the point that it was Medicaid, not Anthem, holding up the order. Infuriating—I’m actually very glad I didn’t hear the call.

In the meantime, Grace’s fingers healed to the point where she didn’t need the fancy wound care supplies. THAT is a miracle—her body is getting stronger, apparently, because that wouldn’t have happened a year ago.

I emailed Grace’s doctor to find out if she knew any other way for us to order Mepilex, or if she knew any companies that contract with both Anthem and Medicaid. I also looked online and found a box of four sheets of 8″x20″ Mepilex Lite for $129 from a different medical supply company. (Keep in mind the other company was charging $800 for the exact same thing.) Amazon carries it, too, but they charge slightly more—$133 for the box of four sheets.

So, my rant is this—the company that works with Anthem and Children’s Hospital charges over six times as much for the exact same thing as a company I found using a simple Google search. Why do they mark it up so much? Because they know the insurance company is only going to pay them a fraction of what they bill. Why would the insurance company agree to this? Because it drives up the cost of health care, thereby netting more income for the insurance company. ARGH!!! This is a serious problem. The Affordable Care Act did great things to help Gracie stay insured, but did nothing to touch the fraud and imbalance at the core of the system.

There is a happy ending to this story. After I ordered the Mepilex Lite at $129, I emailed Gracie’s doctor again, and she was upset that we had paid out of pocket, so she got her office manager to work on getting it covered for us. I am expecting a call from a different medical supply company that does contract with Medicaid, and if I can get the Mepilex covered by insurance, I can return the box we paid for out of pocket (hopefully—not sure if they’ll take it back but they should because it’s unopened). At least Gracie’s doctor is on our side. She works hard for us, in between working hard for all her other patients. Now if I could only get that nurse case manager to do something, too…


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