Thread to talk about relatives gaming the system

Something about me makes Whiskey irrationally angry. I sometimes wonder if he’s my bitter ex-husband (who actually did troll me on AO), but my ex didn’t care about the Seahawks so either it’s an epic troll job or, more likely, not actually him. But I don’t know why he’s so angry. :woman_shrugging:

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Yeah, I didn’t really think it based on how long he was on AO.

Pulled from a thread where this was an unnecessary sidebar leading to this.

That’s fucking terrifying to me as somebody who would probably be “lasered” because of the drugs I need for my body to function halfway normally.

It’s self-serving to want M4A but I’ll advocate for others with issues I am not affected by. M4A is important to me and we need to detangle medical care from employment. It sucks when I can’t afford to make “more money” at a different company because of healthcare.

Can you explain why you can’t make more money at another company because of healthcare? Are you worried about discrimination due to a disability? Accidentally disclosing a medical condition during the interview process???

Whiskey is just. He doesn’t like it when rich people take advantage of the poor, and he doesn’t like it when minorities get disenfranchised by the privileged.

You like to overshare, sometimes to the extent that has nothing to do with the topic at hand. You’re oversharing in a thread that talks about relatives gaming the system. And you are thinking that’s okay.

Connect the dots.

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To go to another employer, I would need to confirm:

1a) Their healthcare insurance covers my drugs
1b) At the dose prescribed by my doctor
1c) At the frequency prescribed by my doctor (all of this has been disputed and a huge headache)
1d) My doctor accepts their insurance for visits (I could pay out-of-network if needed)
1e) My specialty pharmacy doesn’t have issues with the new insurance
1f) My in-home nurse organization contracts with the new insurance
2a) I’ll need COBRA until the new insurance can kick in, which is frequently 1 full calendar month of employment
2b) I don’t know how COBRA coordinates with everything in the above, they may or may not but I’m not sure.
3) The new insurance may or may not coordinate with my prescription reimbursement plan, which in the worst case could lead to me spending $121,512 on my medicine per year.

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Are you unfamiliar with the problem of people being stuck in jobs because they can’t get suitable healthcare if they leave?


I have rejected employment offers because of inadequate healthcare. It sucks to go through (sometimes several) interviews and get excited about a company, only to learn their insurance won’t cover my medicine.

Regarding being worried about discrimination, lol no. It was probably day 3 that I emailed HR and Cc’d my boss about my disability in my current role.

We’re going through this with my wife currently. Long story short, she wanted to move from the insurance company at her employer to my employer’s plan. She gets frequent migraines and had pretty much dialed in what worked and what didn’t… but then the new insurance company denied a prescription, wanted her to fail on cheaper drugs (aka step therapy) before giving her what works.

So she got her PCP to call the insurance company and explain that she’d been through step therapy already and doing it again was pointless. The insurance company denied it anyway, so now my wife is trying to figure out whether to go through step therapy again, or try appealing this again with the insurance company, or doing both to see which pans out first. And in the meantime she now gets more migraines, lovely.

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Ah yes, step therapy. Forgot that phrase. I used to be on medicine that cost $360/year until a new insurer made me go back through step therapy, which is how I got worse and now need the ~$120,000/year medicine.

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The last time i saw a doctor, he was in hold when i entered his office. He seemed to have been on hold for a while. And remained in hold for most of my visit. At one point he said, “this is rationing by inaccessibility”. The point is to make it hard enough for all concerned to get a treatment approved that they give up.

After I’d been there half an hour, someone picked up, and he talked to the insurance company. But the person he reached wasn’t the person who could actually approve the treatment. He asked for that person to call him back. I bet they didn’t.

I’ve absolutely seen this play out. I’ve had nurses on hold for over an hour trying to get ahold of an insurance company. In one of the more frustrating cases they were on hold for an hour, then the line went dead because the company was closed for the day.

I like that phrase, and hate that it exists. I did tell my wife that was perhaps a feature and not a bug, from the insurer’s perspective.

I guess now we’ve come 180° from ‘relatives gaming the system’ to ‘insurers gaming their members,’ or thereabouts.

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If your spouse is covered via an ASO contract, then odds are that the decision on care is coming from the HR department. It may have changed since I was involved in medium sized group health 10 years ago, but whenever the employer is self insuring- and that included the contracts with individual and group stop loss covers - the guy footing the bills wanted to be in charge. See, the insurance company wasn’t really underwriting the risk. It wasn’t their money.

We are a small company, I doubt we are ASO but not 100% sure.

How does this work for ASO? Is this the payer offering different tiers at different prices, and HR picks one? And then the payer just pays or rejects things based on the benefit plan design?

I was familiar that this was an issue pre-Obamacare, sure. I thought that was one of the problems Obamacare allegedly solved.

I can see all the items under 1 being potential issues. Obamacare did almost nothing to prescription drugs.

For 2, I think most white collar jobs have insurance kick in on Day 1, although I’m sure a few don’t. But if you did need COBRA for a month, I think it’s just your old insurance that you’re now paying employer + employee premiums.

I don’t think I understand the third item. Aren’t prescriptions required by Obamacare to count towards the out of pocket maximum? Which I think is $8,700?

Well that sucks. Seems like there should be a standard and if there’s reasonable documentation that she’s already tried the cheaper options then they shouldn’t make her keep proving it again & again.

Stupid insurance industry… glad none of us have anything to do with it… oh wait.

I feel like I say this almost weekly about something healthcare-related.

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