Tuesday, August 11, 2009

I'm Coming Out (Warning: You will be here a while.)

Of the closet. The pregnancy closet. I am in my 11th week (according to "last menstrual period" calculations). Yes, we are happy. Extremely happy. In my first three weeks, I took test after test to confirm that the previous one was correct. And that the baby was still hanging in there. Yes, thrilled.

But I think it only fair that people know what's been going on. We "let the cat out of the bag" early and let a lot of people--probably you, fair reader--in on the secret earlier than we wanted to because we needed help. As I have learned over the past few weeks, Indiana has a poor history of maternal health and prenatal care. So some programs have been created to help pregnant women get the proper care needed for themselves and their unborn and newborn babies. "That sounds wonderful!" you might be thinking. But let me tell you that I now understand WHY Indiana has a poor history of women getting the proper prenatal care they need. Much of it has to do with location, location, location.

M and I have been "trying" to get pregnant since about the time we got married. We had insurance until M lost his job in February of this year. We decided to take our chances. Honestly, I figured I hadn't been able to get pregnant this far, so what were the odds. I should have known. I may be a Stringham now, but I am still a Seifert, and subject to what my dad likes to call Seifert's Law. We managed to get M enrolled in a very affordable health insurance made available for farmers and self-employed people in May, effective June 1. But I was not eligible because of my BMI. I have to lose about 60 pounds to be covered by them. But the agents were very helpful and told me about this wonderful program that Indiana has to make sure that all residents have health insurance available--regardless of preexisting conditions. Yep, I looked into it. I'm generally healthy, but I appreciate the need for health insurance. Because I am a woman of childbearing age, my premium would have been somewhere between $400 and $600 a month. (Yup, for a woman from 18 to about 60 years, it's the same cost. Not so for men.) Now, I'm making fairly decent money on my own, but I'm supporting both of us, and a large portion of the money has to be set back for taxes and Social Security--you know, all those things that employers help you pay?

And we're trying to be responsible, here, and pay off our debts. They are considerable, and they are mostly mine. I have student loans to pay for, and I have substantial credit card debt because we almost lived off my credit cards for certain periods while we were both in grad school and when M was done with grad school and was looking for a job. Now, things are tight, but we've been paying our bills, and even making some headway on the debt. But $400 to $600 a month, we didn't have. But of course, I was practicing good eating habits and exercising in an attempt to lose weight TO GET HEALTH INSURANCE, so that most likely contributed to us actually conceiving this time (early June).

So, you might be thinking that if I had been lighter, I could have been on the same insurance as M and therefore had my pregnancy covered. Not so fast, boss. Most private insurances like this (M's included) require that a woman be enrolled for a year BEFORE pregnancy is covered. So, obviously, there must be some insurance out there that would take me despite my weight? Sure, maybe, for a very high premium. But still, pregnancy not covered unless you've been enrolled for a year. Hmmm... And even if they HAD decided to cover me despite my weight? Pregnancy is a preexisting condition, and private insurance...well, they tend to frown upon preexisting conditions.

"So, what next?" you may ask. Well, ever the resourceful, talented, and brilliant woman I am, I extended my request for help and information to all the talented, resourceful, brilliant people I know. I was given lots of helpful advice. Well, much of it would have been helpful for someone. Here's what I've found, folks:

Cinergy is not health insurance. They make it sound like it is in the commercials, but it's not. It's a health discount plan. This means they have a network of providers who have agreed to automatically discount for people bearing a membership card. Many such programs guarantee that they will save you x% over what you would have been able to negotiate. On doing further research, I have found that this is often not the case, if you know how to negotiate and use the correct words: "cash patient," "self-pay," and "pre-pay." Oh, and, in the case of the hospital, "pre-register." (More on this later.)

Midwives are wonderful. I'd love to have one. In Indiana, however, a midwife must be a Certified Nurse Midwife (CNM) and must be working with/under the supervision of a doctor. All well and good, but it is relatively difficult to find a CNM in Indiana unless you're in a city, as I have found. (But not impossible, as I have also found...but more on this later.)

Medicaid. Well, yes, Medicaid does provide help to people who make very little money. For a family of three (that's counting the unborn child), that's a monthly income of about $300. Well, M brings in more than that from his unemployment insurance. But Medicaid in IN has a plan for pregnant women--premium-free healthcare coverage. And the minimum monthly income is greatly increased--largely, I believe, because of the abominally damned difficult time pregnant women in this state have getting care. But still, we make in this household just a bit more than that monthly allowance. Ah, but in the fine print, I see a note saying that for self-employed people, 40% of their income is automatically removed in calculating eligible income. This means that only 60% of our monthly income is calculated in determining my eligibility. I do the calculations and find that we're still awfully close, and depending on just how they figure, we may still make just a SMIDGE too much for us to be covered. But it's worth applying. So I print out an application from online and prepare to submit it. But what's that I see? Proof is needed. Proof of income. A little difficult because of my self-employment, but I keep detailed records, and that shouldn't be a problem. A letter from a healthcare provider stating when the pregnancy began. Of course. They don't want to provide pregnancy coverage for a woman who's not actually pregnant.

So I begin calling around to see who can administer a pregnancy test (I'm fairly certain that taking in my own pee stick to the social services office doesn't count as a letter from a healthcare provider). What am I told? "Congratulations on your pregnancy! We'll be happy to take you in as a new patient. What insurance do you have? None? I'm sorry, but I can't schedule an appointment with you if you don't have insurance." Well, this complicates things...I can't get insurance without a letter verifying the pregnancy from a HEALTHCARE PROFESSIONAL, and I can't see a professional without insurance. [At this point, I'm already frustrated and want to stop. I have work to be doing to earn money, after all. But if I am this frustrated and discouraged and I have a Master's degree in health communication (focusing largely on the issues had by people who can't get insurance or can't get decent insurance) and a neonatal intensive care nurse for a mother-in-law, how the hell do most women in my area (who probably have a high school diploma, if that) feel when they are without health insurance?] So I ask the woman on the other end of the line if she knows WHERE I might be able to get such a pregnancy test and a letter confirming my pregnancy so I might be able to get some public assistance. [After all, I've been paying taxes since I was 15, and I've never used a dime of Federal or state money. Except for the educational LOANS, which I am currently repaying to a private company.]

Well, the Women's Resource Center might be able to help me. Hooray, a lead! Yes, they can certainly give me a test and provide me a letter. Free of charge. They are volunteers and provide counseling and abortion-alternative services to women. Yes, I went in. They administered a pee test. Yup, just like the ones I took over and over, but this one was administered by a nurse who volunteers at the center, so I was able to get a letter. Along with some questions about my religious history and my church-attendance and my relationship with God. *sigh* Although I don't really profess to be a Christian, I was raised a Christian, and I am still on good terms (as far as I am aware) with the Big Enchilada, and I speak with it nearly every day if not every day. Especially since becoming pregnant. So I am vague enough in my answers to maybe just sound like 80% of people who have been raised Christian but no longer attend church...live my life well, talk to God, depend on God, yadda yadda yadda. M was a bit uncomfortable when the nurse asked to pray with us for the health of the baby, but I was perfectly content. Prayer is a good thing, and the more people asking for the health and well-being of our child, the better.

Okay, so, with my letter in hand on a Monday morning, I call the social services office to ask what I need for proof of income now that I am self-employed and my husband unemployed. I gather these things together and go down to the office to apply in person. I am handed a form, fill it out, give it back, and am asked if I would be available at 10 AM the following Thursday for a phone interview with a case worker. No, I didn't need my proof of income or proof of pregnancy at that time. Well, folks, had I known that ahead of time, I could have applied two or three weeks earlier and gathered all my information in the meantime. But that's okay, it's all gathered.

Now for all the hard work. Oh, yes, there's more. So much more.

You may not need to read this if you've been through a pregnancy before, but chances are, you had insurance. Here's what it's like. Here's all the research I had to do on my own.

I called my OB/GYN in Carmel and asked to get an appointment set up. Self-pay. I don't want to keep my care in Carmel, considering I'll have to make treks there for appointments in the middle of winter, and that's not fun when I'm not nervous and pregnant. But I can at least get some initial care while I continue looking for providers in our area. Sure, they can do that, and they'll transfer me to the business office to tell me everything I need to know about paying cash. Here's what I found out: I had to have $700 to step through the door the morning of my appointment. Let's stop there and consider that a moment, folks.

$700 before I can sit down with anyone in the business office and work out a payment plan. And that's with the 20% cash discount. But really, it's explained to me, only $200 of that goes toward the care for me and the baby. $500 is for lab fees because so many tests are done on that first visit. And at any visit when a lab will be done, I have to pay for the test before I get to see the doctor. For example, around 28 weeks, their standard 1 ultrasound will be done, and that will cost about $330. That I'll have to pay before I can even have my visit. The very nice, helpful, informative lady in the business office (I am completely serious here--she was very polite and did not seem in a hurry to rush me off the phone throughout all my questions and note-taking) informed me that I could expect to spend about $900-$1200 on labs throughout the pregnancy.

Then there's the $2400 charged by the doctor for the delivery fee. This covers all my visits and a normal vaginal delivery, but not hospital costs. The doctor offers a cash discount, so the cost would only be $1920 if I'm paying cash. What a bargain. But it's due in full at 24 weeks. Well, at that point, I was already 10 weeks along. Hmm...that's not sounding promising. And they can set up a payment plan, but if they do that, well, there's no discount. Hm. So we're back to $2400 because I can't just come up with $1920 in the next 14 weeks. It may seem simple, but I can't remember the last time we had expendable income adding up to $137 a week. Oh, and if I would happen to get the Medicaid insurance (Hoosier Healthwise), they would not accept that. And then there would be the hospital fees. I would be able to choose one of two hospitals in the Indianapolis area to deliver at. Either one accepts Hoosier Healthwise. For either, fees for a normal vaginal birth for a 2-day stay would be $6000-$8000 paid up front or $10,000-$12,000 not up front. Not including anesthesia if I would so choose to partake. Not including any extra fees if something would go wrong or a C-section were needed. All for the privilege of delivering in their hospital.

All that, on top of both the doc and the hospitals being a good hour's drive from where we live. Not feasible. So I begin researching in our area again. I call various departments in our local hospital, various doctors, the Women's Resource Center, Planned Parenthood in Lafayette, and the neighborhood clinic provided free or for simply $12 for the people of the area. We have a serious lack of OBs in the area. And few general practitioners who will do OB. The Women's Resource Center does not provide prenatal care. Planned Parenthood does not provide prenatal care. The neighborhood clinic does not provide prenatal care. (Basically, the neighborhood clinic cares for any of a person's needs except prenatal care.) Well now. I've read that some hospitals will provide prenatal care for cash to women without insurance. When I speak to someone at the hospital, they say they do not provide prenatal care, but they tell me to speak with the OBs who practice at the hospital. The number they give me is the number of the practice I called when I was informed they couldn't even schedule an appointment if I didn't have insurance.

Oh, the joy.

Finally, I send an email to the hospital seeking further information. Anything, I say, will be helpful, but I need information. How can I get care if I don't have insurance? A few hours later, I was informed that I needed to call that practice again and speak with the business manager. They do, indeed, provide care to people without insurance, but there are special requirements. Here we go again.

Yes, the business manager is very nice and very helpful, if a bit in a hurry and wanting to get me off the phone (or maybe she doesn't like being on the phone). But I am stubborn, and I have come prepared with a list of questions so I cannot be rushed and forget my questions. And this is for our baby. I need information, and I intend to get it. $2400 for vaginal delivery and all prenatal care. With a 20% discount, it comes out to $1920. Well, this all sounds familiar. I am not heartened. But only $420 is due at the first visit, and then there are 6 monthly payments of $250. Okay, I feel a little better. Relieved, even. This works out to everything being paid in full around the time of delivery. Much better than at 24 weeks. Ah, but there's more. (Isn't there always?) That doesn't include any labs, ultrasounds, or hospital fees. Ah, there's the kicker. She can't really tell me the cost of these things because they are billed directly from the lab to us. But she gives me the telephone number and billing extension for the lab so I can ask about the cost.
Oh, and yes, they do accept Medicaid, but until that coverage goes through, I would be treated and have to pay as a cash patient. Then, if the Medicaid goes through, I will be refunded all the money I have paid. Well, it's promising, and I understand completely. Oh, and they operate their practice such that I alternate between the three practitioners--an MD, an OB, and a CNM. They will all be familiar with my care, and whoever is on duty when it is time for me to deliver will deliver. Excellent. In the mix is a doctor I was told doesn't set much stock in how valuable your time is (but she's only in the office about once a week), a doctor who was praised highly to me, and a midwife. Two out of three ain't bad. I mean, really, if it weren't for my mom's history of preeclampsia and my weight, I'd prefer having only a midwife and consider having a home birth...

Next, I call the lab and ask what they charge for standard prenatal tests. Well, they can't tell me for sure without the specific names of the tests because every doctor orders different tests, and there are just too many, apparently, for them to list all to me with prices. I will have to have specific names in mind. I hastily thank the lady and hang up. Damn! I have forgotten to ask about payment plans. I call back and receive a friendlier assistant this time. Yes, they do offer payment plans (could we really get so lucky?). There are no set payment plans in order, I am told. They LIKE to have everything paid off within 4 to 5 months. But, by the lady's tone, I can tell, this is not a requirement. I am really taking heart. Further, they offer a cash discount if the fees for the labs are paid within 10 days and they don't have to bill insurance (in other words, if they don't have to deal with insurance and you pay quickly, you're saving them money). I am substantially relieved, but I still don't know how much they charge for all their labs. I'm guessing it's in the range of $900 to $1200 quoted me by the earlier doctor. But being able to work out payments rather than pay for labs before I even have the labs done? Well, that's a load off my mind.

Still, we're planning to ask the doctor (whenever we finally get one) about every single test and its necessity. We're going to have the baby even if it has some small problem, and I'm not at risk for any of the big genetic problems, etc.

Now, to call the hospital. Again, a perfectly lovely person in billing was happy to patiently answer all of my questions. The cost for a 2-day stay for a normal vaginal delivery is $9500. Am I insured? No. Oh, well, then I can pay $4750 one month before the delivery, and then the hospital will write off the cost of the baby's stay and care. I waited for further details. To hear what was due after the birth. There were no more details forthcoming. "Okay," I say, "I want to make sure I understand this correctly. If I have paid $4750 a month before the baby is due, I don't have to pay a single dollar more, if the delivery goes well and I don't need anesthesia or anything like that?" That's correct, this angel on the other end of the line tells me. And all I have to do is contact the hospital ahead of time and tell them I'm a prepay. I can even set up payments. All I have to do is call and pre-register and get an account number, and then I can send in payments whenever I like. All up to $4750, so long as I've paid it all a month before the baby is due. "Is that something you'd be interested in?" she asks. "Of course it is!" I want to shout in joy. A 50% discount. But I slowly say, "I think so, but I have to discuss things with my husband. I'll call back to pre-register later."

So, what have I (and M, to a lesser extent) learned from this journey?
1. I have not made the money I need to earn in these past two weeks because I have been too busy calling what feels like every agency set up to help the poor and/or pregnant in a 50-mile radius just to find care for my unborn child.

2. Obama's healthcare plan won't go into effect soon enough to help me. (Think what you want about his plan--and I agree that many people who have the power to make these decisions are suggesting all the wrong things, never having dealt with these situations before--but I sure would be happy to have it right now. Especially considering that I (1) have paid in for social programs since I was 15, (2) have been covered by health insurance all my life until February 2009, (3) STILL pay for social benefits such as Medicare and Medicaid, and (4) cannot get healthcare now when I need it most, because I am too fat, am pregnant, am self-employed, and make so much money that I "should" be able to pay for care on my own. [See a rather brief but beautifully concise discussion of the pros and cons of such "government-run healthcare" at my friend Peachy's blog for 13 July 2009.]

3. We are far less worried about the costs of providing a good life for our baby than the costs of bringing our baby into the world.

4. If the social services caseworker I speak with this week does not feel I qualify for Medicaid for prenatal care, I will fall into the so-called "donut hole" that is swallowing more and more middle-class people these days in healthcare. And we have to come up with about $8200 to have a baby through the traditional means, with nothing going at all wrong. It's a good thing I already planned to have as natural a childbirth as possible. And, by all that is holy, now more than ever, I hope for as easy a birth as my mother was blessed with.

5. M and I would never ask for monetary help. (And I am not asking for it now.) But we are in no position to deny such help if it comes our way. And if, for some reason, you would want to contribute to a gift for a baby shower, might I suggest, instead, money so we can make sure our child has a healthy start in this world? We already have the means to feed and cloth and shelter the child.

Oh, and I'm still holding out hope for Hoosier Healthwise. And I pray for the help and a sympathetic caseworker every day.

And if you have already given us assistance by way of information or money or emotional support, thank you, thank you, thank you many times over.

No comments:

Post a Comment