I AM LIVID - advice appreciated

[Anonymous]

The law was enacted in 1995, and prevents any federal health insurance program from paying for abortions. All of the cruel pps above who stated that it was the ops fault - not so - ANY of her choices would have had the same policy in place.

Sec. 524. <<NOTE: Abortion.>> No funds appropriated by this Act
shall be available to pay for an abortion, or the administrative
expenses in connection with any health plan under the Federal employees
health benefit program which provides any benefits or coverage for
abortions, after the last day of the contract currently in force for any
such negotiated plan.
Sec. 525. The provision of section 524 shall not apply where the
life of the mother would be endangered if the fetus were carried to
term, or that the pregnancy is the result of an act of rape or incest.

http://www.prochoiceamerica.org/assets/files/abortion-access-to-abortion-women-government-federal-employees.pdf

Getting the procedure properly coded by your OB is probably your only option - the Hyde amendment is pretty clear - rape, incest or life of the mother.

I am so offended and sad that you have to go through this on top of what you have already suffered. The real slippery slope here is the idea that women should not be able to choose whether or not to continue a pregnancy. How awful to think that you will have no medical coverage unless you "choose" to continue this pregnancy that is ultimately not viable.

I'm sorry for your loss, and wish you luck in your appeal. Perhaps we'll see you testifying before congress some day, ultimately overturning this inhumane law.

[Anonymous]

I don't have any advice, but I am so sorry you are going through this

[Anonymous]

To the original poster: First, I am very sorry for your loss, your grief, and ultimately being seriously let down by the system.

In order to make some positive outcomes out of this very painful ordeal, I would:

1. Contact my insurance commissioner (every state has one, incl. the District) These folks are very helpful in working with your insurance company and health care provider (they can leave OPM most likely).

2. Contact your congressional member (if you have a pro-lifer, find someone else in your state that would be sympathetic to your cause)

3. Contact NOW, NARAL, and Planned Parenthood. they have excellent advocates for women.

For everyone else nitpicking about what she should have done, could have done -- stop it. We are all in the same boat with crazy insurance mandates. Let's band together and demand that women's health issues be taken seriously and stop letting this kind of issues victimize women.

Best of luck to you! I have faith that you can win this one.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:While I do sympathize with the OP, part of the fault lies with her for not checking with her insurance what was covered or needed pre-certification before she had the procedure. Before I get flamed, I recently miscarried late and even though I was upset, I called my insurance company to find out what would be covered/required pre-certification and what did not. I would have loved to have had the placenta tested but they refused to cover it. In any event, OP can't demand that the terms of her insurance contract be changed - best bet would be to try to get it recoded by your Drs and have your Drs directly appeal to the ins co as to the medical necessity of the procedure.

Agree 100 percent. And my health insurance plans have put me through the ringer for issues ranging from infertility to a vanishing twin to pregnancy. I paid $12k out of pocket to have my second child because my husband is self-employed and we live in the District (this means that NO plan will cover more than $5k for maternity costs).

Her plan has limitations. She chose the plan. It sucks, but that's what she chose. Agree too about changing the code, though it will probably look very fishy at this point, and if you get caught doing something like that, they can yank your insurance from you and make you pay back all your recent costs.

OMG! These two terrible humans who posted this should be disregarded. I'm sorry for your loss, OP. I don't have much to add. Hang in there. And this is NOT your fault. Not even slightly.

Excuse me? I am the first poster you quoted. Why am I a "terrible human" -- because I pointed out that OP did not check these things with her ins co before she had the procedure? Like OP, I am also a lawyer, and we know firsthand how these contracts work - they are better at excluding claims than including them. As I said, I do sympathize with what she is going though, and I myself have experienced loss (and other serious illness resulting in fights with ins cos), but at the same time a contact is a contract, and that is what insurance coverage is -- we are not Entitled to get every procedure covered and see whichever doctor we choose. Do I personally think OP's situation should have been covered in this instance? Absolutely. But, at the same time, I also think that we have to be proactive and be our own best advocate, meaning do your homework and take whatever steps necessary in advance to obtain the desired outcome.

I'm the one who quoted you. You're a terrible human (at least acting like one above) by posting the way you did. You knew your post was inflammatory before you hit submit, otherwise you wouldn't have tried to squirrel out from under it with your qualifier "before you flame me..."

I don't think you need a law degree to know that a contract is a contract, but why would OP think that a medically necessary procedure that her doctor stressed was important would be denied? Most people don't even have any inkling how much crap an insurance company rejects until the shocking bills begin to roll in. And although I'm not one, I would bet many lawyers would agree.

Even so, there were many other ways you could have phrased your post here if you wanted to be helpful. In fact, you said nothing helpful at all. You've got an OP who is devastated and pissed and then you have some jackass stranger on a forum oh-so-helpfully telling her it's her own fault. Oh, but you sympathize and have suffered yourself. That makes it ok.

Sorry, but yuck.

You have some nerve calling me a terrible human - you don't even know me?? I mean, seriously? My post was NOT meant to be inflammatory - I prefaced it that way because based on the responses thus far, none of which raised the point I was about to raise, I knew I would get flamed. OP's post was NOT about her loss, which is tragic, but rather a question about her insurance policy coverage, and what she should do about the denial in coverage. In addition, OP said:

"I am also open to anyone out there who believes that I should just suck it up and pay for this out of pocket. My husband and I have the ability to pay it by using some of our savings. Am I wrong to believe that I shouldn't have to?"

I was giving OP an honest answer to her question, which I thought she was looking for. But I guess the name of the game here is sympatethic ears only.

[Anonymous]

Anonymous wrote:To the original poster: First, I am very sorry for your loss, your grief, and ultimately being seriously let down by the system.

In order to make some positive outcomes out of this very painful ordeal, I would:

1. Contact my insurance commissioner (every state has one, incl. the District) These folks are very helpful in working with your insurance company and health care provider (they can leave OPM most likely).

2. Contact your congressional member (if you have a pro-lifer, find someone else in your state that would be sympathetic to your cause)

3. Contact NOW, NARAL, and Planned Parenthood. they have excellent advocates for women.

For everyone else nitpicking about what she should have done, could have done -- stop it. We are all in the same boat with crazy insurance mandates. Let's band together and demand that women's health issues be taken seriously and stop letting this kind of issues victimize women.

Best of luck to you! I have faith that you can win this one.

PP here, apologies for sooo many typos in my original post!

I had another thought. Why not pass a memo along to an aide of Michelle Obama's at one of her listening tour events about your situation? Also, if you have any political friends, I would highly suggest activating them to get resolution to this if your problem cannot be resolved through current channels. These laws must change!

[Anonymous]

OP here. I had no idea that the federal employee coverage contained that clause. 1995, hmm, I guess there must have been too much other stuff in the bill for Clinton to veto it. At that point in history, Newt was running things, he might have gotten it overridden. Apparently, I had no choice in the matter, it wasn't BCBS, it was all federal insurance.

I am still angry, but at least I now have a better understanding. I am going to try some of you suggestions. I am hoping that my appeal will find more sympathy in an Obama OPM; however, they might not have the leeway to overrule them either if it is codified.

Thanks for all the information and ideas.

[Anonymous]

OP,

Ok so now that it has turned into a legislative issue, maybe I can advise.

First, it seems like it's possible that your doctor may still be able to say that your life was at risk in carrying the baby to term in medical language that is undeniable. There could be a code for this or perhaps a doctor's note is needed. That's one avenue to pursue.

In addition, you're also on the right track in contacting your members of Congress and those nearby. Please consider, as others have counseled, contacting the govt affairs reps at Naral. They may be able to tell you which members of Congress opposed this provision in the 1995 law. Particularly, Committee chairpersons or ranking members on the various health and human services committees are a good place to start.

From the language posted, it appears that this restrictive language was placed in an appropriations bill. That would make it very hard to vote against. However, I bet there was an amendment to insert it or strip it out. If so, you should be able, with some research, to get a good roll call vote on that bill. That's where I think contacting Naral might save you some time. Once you do that, it might serve your case to become a lobbyist for yourself. Sit down with the Committee chairs with jurisdiction over this issue. A letter is easier to ignore than an earnest face. You will most likely have to deal with staff, so make sure you're meeting with Committee staff and not just the personal staffers for the Committee chairmen or ranking members.

I certainly hope you will be able to find someone to advocate on your behalf.

In the meantime, have you considered asking your OB to reduce the costs for the procedure for you? It's extremely possible, especially if you're with a smaller practice, that they'll cut you a break if they know you are paying out of pocket. My doctors have always known which procedures my insurance would cover and which they would not. There may be something there -- your OB might have warned you that this could be an objectionable expense in the eyes of your insurance company.

I continue to be revolted by this whole issue and truly hope you get resolution. I'm a lobbyist, so I'll see if I can dig something up quickly for you on those names.

Also, a previous poster called this change the hyde amendment, but I think it was in fact the Nickels amendment (the Hyde amendment prohibited using medicaid funds for abortion). Here is something I found about the Nickels amendment.

4. Federal Employees Health Benefits
From 1984 to 1993, the Smith/Ashbrook Amendment to the Treasury/Postal Appropriations Bill
prohibited the coverage of abortions in the Federal Employees Health Benefits program, except to save
the life of the mother. However, in 1993 and 1994, Congress passed the bill without any abortion
restrictions. The Fiscal Year 96 appropriations bill contained the Nickles Amendment prohibiting
abortion funding except when the mother's life is endangered or in cases of rape or incest. This measure
became law. Attempts to remove the policy from Fiscal Year 97 appropriations were unsuccessful and
the policy was again included in law.

Note the bolded sentence (emphasis mine). OP can find out who led the charge for stripping this amendment and see if that office or Committee can help her. They would certainly know how to point her to other resources or help her direct her approach. Chances are slim that personal staff will remember this particular amendment, but it's possible some long-tenured Committee staffer would have worked the bill.

And one final thought, I'm also the poster who criticized the "it's OP's own fault" poster. I've said what I needed to say there. The reason I thought those were bad posts is that they were absolutely not helpful. Why criticize if you have nothing positive or helpful to say?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:While I do sympathize with the OP, part of the fault lies with her for not checking with her insurance what was covered or needed pre-certification before she had the procedure. Before I get flamed, I recently miscarried late and even though I was upset, I called my insurance company to find out what would be covered/required pre-certification and what did not. I would have loved to have had the placenta tested but they refused to cover it. In any event, OP can't demand that the terms of her insurance contract be changed - best bet would be to try to get it recoded by your Drs and have your Drs directly appeal to the ins co as to the medical necessity of the procedure.

Agree 100 percent. And my health insurance plans have put me through the ringer for issues ranging from infertility to a vanishing twin to pregnancy. I paid $12k out of pocket to have my second child because my husband is self-employed and we live in the District (this means that NO plan will cover more than $5k for maternity costs).

Her plan has limitations. She chose the plan. It sucks, but that's what she chose. Agree too about changing the code, though it will probably look very fishy at this point, and if you get caught doing something like that, they can yank your insurance from you and make you pay back all your recent costs.

OMG! These two terrible humans who posted this should be disregarded. I'm sorry for your loss, OP. I don't have much to add. Hang in there. And this is NOT your fault. Not even slightly.

Excuse me? I am the first poster you quoted. Why am I a "terrible human" -- because I pointed out that OP did not check these things with her ins co before she had the procedure? Like OP, I am also a lawyer, and we know firsthand how these contracts work - they are better at excluding claims than including them. As I said, I do sympathize with what she is going though, and I myself have experienced loss (and other serious illness resulting in fights with ins cos), but at the same time a contact is a contract, and that is what insurance coverage is -- we are not Entitled to get every procedure covered and see whichever doctor we choose. Do I personally think OP's situation should have been covered in this instance? Absolutely. But, at the same time, I also think that we have to be proactive and be our own best advocate, meaning do your homework and take whatever steps necessary in advance to obtain the desired outcome.

I'm the one who quoted you. You're a terrible human (at least acting like one above) by posting the way you did. You knew your post was inflammatory before you hit submit, otherwise you wouldn't have tried to squirrel out from under it with your qualifier "before you flame me..."

I don't think you need a law degree to know that a contract is a contract, but why would OP think that a medically necessary procedure that her doctor stressed was important would be denied? Most people don't even have any inkling how much crap an insurance company rejects until the shocking bills begin to roll in. And although I'm not one, I would bet many lawyers would agree.

Even so, there were many other ways you could have phrased your post here if you wanted to be helpful. In fact, you said nothing helpful at all. You've got an OP who is devastated and pissed and then you have some jackass stranger on a forum oh-so-helpfully telling her it's her own fault. Oh, but you sympathize and have suffered yourself. That makes it ok.

Sorry, but yuck.

You have some nerve calling me a terrible human - you don't even know me?? I mean, seriously? My post was NOT meant to be inflammatory - I prefaced it that way because based on the responses thus far, none of which raised the point I was about to raise, I knew I would get flamed. OP's post was NOT about her loss, which is tragic, but rather a question about her insurance policy coverage, and what she should do about the denial in coverage. In addition, OP said:

"I am also open to anyone out there who believes that I should just suck it up and pay for this out of pocket. My husband and I have the ability to pay it by using some of our savings. Am I wrong to believe that I shouldn't have to?"

I was giving OP an honest answer to her question, which I thought she was looking for. But I guess the name of the game here is sympatethic ears only.

No, you're right. And don't think for a moment that these other posters care a whit about OP. They are just using her to further their strident political agendas.

The procedure wasn't covered by the policy. Most doctors work around this issues by coding procedures in different ways. Her doctor did not. Therefore, end of story. Except for the crazies on DCUMs, especially the nut who wants to slip Michelle Obama about this woman's story.

[Anonymous]

To the PP, no this is not the end of the story. Women are being used as pawns of political debate and bottom line issues, when their health is the only thing of question.

It only takes one person to cause change. This can only happen in this case through political channels.

Think smart and strategically -- that is how this law was made in the first place -- by someone not concerned about women's health. Other health insurance decisions have been made that impact children, men, etc. However, the issue at hand impacts a woman, her family, and ultimately all female federal employees and therefore taxpayers, too.

[Anonymous]

Listen, posters, if you can't say something positive, go crawl back under your rock.

My "political" agenda has nothing to do with why I offered help in this case. I reached out because this is (supposed to be) a support forum and I wanted to help. Just because you're a nasty piece of work does not mean everyone else responding here is on your level, thank god. Everyone except (what seems like) two cold-hearted posters offered a sympathetic ear and genuinely helpful advice. Yes, some people feel strongly about their pro-choice positions but it seems most posters, certainly true for me, simply feel outraged on behalf of the OP and very, very sympathetic. I'm pregnant with my first child and relate to her because I fear nothing more than getting bad news about my pregnancy, including finding out about a condition that's not compatible with life.

However one feels about abortion can honestly be set aside in this case. This isn't even a mom aborting over Down's Syndrome or a more severe (but life compatible) problem, this is terminating a pregnancy NOW that has no chance before a. the fetus dies inside the mom at a much larger size or b. mom is forced to deliver, perhaps in a high risk delivery and most likely via c-section aka major surgery -- a baby that cannot live. This is NOT an elective abortion by any stretch. OP is suffering double-time -- a tremendous loss, most importantly, and on top of that the government accusing her of just willfully aborting a child she very much wanted.

If you think she was remiss at not stopping her tears and grilling her doctor's office staff over coding procedures, why not keep that to yourself? There was no advice in either of your messages, simply blame. Didn't your mommies tell you not to speak if you had nothing nice to say? Where's your heart?

[Anonymous]

I too am livid for you! I agree with the various pieces of advice you have received about appealing through all available avenues. I'm glad to hear you have a supportive OB as well.

Please let us know how this all turns out. My fingers are crossed for you.

[Anonymous]

Anonymous wrote:OP here. I've been a Fed for 16 years now and until this issue BCBS has been pretty good. It has always paid for everything as expected. I had some bleeding issues during that pregnancy and had something like 5 sonograms during that time and they paid for everything, no questions asked.

Honestly, it never occurred to me to check on what was covered and not covered when I got pregnant. Honestly, I am a lawyer, but I would have thought that "health of the mother" would have included my situation. Really, it never would have occurred to me that the insurance claim would be denied in that situation. I figured it would be treated the same as if they found no heartbeat. The pregnancy is not viable, medical intervention needed, end of story.

As far as how the stuff was actually coded, I can't say for sure. Someone at BCBS told me it was coded as a voluntary termination, but this was when I was checking on the appeal. I don't necessarily trust what I was told. In any event, I sent all my records from the pregnancy to BCBS so they could see the diagnosis. They said there was no danger to my health so they were not going to pay. For all I know it was coded correctly and they still considered it voluntary. For the record, I was told by BCBS that they couldn't release that information(how it was coded) to me because it was a HIPAA violation. I still don't understand that one, but that was repeated several times by several different people, so it's either true or their standard operating procedure.


From a purely economic point of view, BCBS makes no sense. The procedure, while expensive, is a fraction of what prenatal care and L&D costs. It makes no sense to me that they would prefer to have had me continue the pregnancy to term and deliver a stillborn or had me continue the pregnancy and had the fetus die in utero and then it would have been an emergency that threatened my health. From what I understand, that would have been a real possibility. It makes no sense from an economic or public policy sense to me.

Thank you to those that offered your condolences on our loss. It was very painful at the time and is painful again dealing with this BS.

Sorry, but it can't be a HIPAA violation to release any aspect of your medical records to YOU. HIPAA prevents release of your records to other people without your permission and you might have to write a letter requesting the info you want so that the BCBS people have documentation that they complied with HIPAA. Perhaps you miss understood that they couldn't give you the info over the phone (because they can't guarantee that you're who you say you are and thus the HIPAA violation potential)?

In phone or in person it is not only NOT a HIPAA violation it is your RIGHT to see your medical and billing records. Either BC/BS should be able to provide this or your provider's office.

[Anonymous]

PPs suggesting contact with NARAL are making a good suggestion. Better, I think, is getting in touch with attorneys at the Center for Reproductive Rights, which has a long history of litigation on behalf of abortion rights and whose attorneys have argued some of the most important SC cases on this issue.

In fact, see CRR's recent press release asking Obama to move against the Hyde Amendment, which is the law that prohibits use of federal funds for abortion. http://reproductiverights.org/en/press-room/center-calls-on-obama-to-strike-down-hyde-on-roe-anniversary

It is true that for a long time pro-life advocates have sought to eliminate abortion or, failing that, to restrict it in all cases except those which would affect the life (not health) of the mother. Your BC/BS policy declining your procedure is a natural extension of that philosophy. I hope you will speak out more publicly about your experience than on the DCUM forum when you are ready.

BTW, your arguments about the cost of the abortion v. the cost of L&D, while rational, are probably not the arguments most likely to resonate neither in the near term with your insurer nor in terms of long term policy debate.

[Anonymous]

OP here. Now I understand that this refusal is codified, I understand why it was refused. I spoke to my doctor and she is going to write a letter discussing all the potential life threatening things that could have happened had we not terminated this pregnancy. I am hoping that an Obama OPM has a broader view of health of the mother.

I am still angry. I resent that my healthcare is political. I should have known better. I have been involved in pro-choice causes for at least 20 years. I should have known that this provision had been slipped into an appropriations bill. I spoke to a friend of mine, apparently no one knew until it was too late. Now I get to direct my anger at Newt et al, as opposed to GWB. I can still be angry at him (GWB) just because.

Looking ahead, in the event that this claim does not get paid, does anyone know how I get a hold of what the negotiated rates for the procedures listed on my EOB form? I might try to negotiate with them to pay what they would have gotten if the claim was covered. I have to be realistic. An Obama OPM's hands may still be tied because this is federal law.

Thanks for all your support and ideas.

[Anonymous]

I understand exactly how you feel. Ever since I moved to the U.S (a non-American), I have felt that way with the state of health insurance in this country. It's one big joke of a system. You pay through your nose for basic coverage and prescription medicine, and even then, it's NEVER enough! You're always forking out more...
Sorry, this is probably not the place to bring it up, but I just can't believe how ridiculous it is to leave the hands of something as vital as the health of your people in the hands of greedy insurance companies.