ObamaCare to fix holes in mental health benefits: a case study

By Michael Grodsky, founder, HealthInsuranceForArtists.com

In January 2014 the Affordable Care Act will require insurers to cover more mental health services in all health plans, benefits that are currently mandated only in health plans offered by large employers. LA Times reporter Noam Levy writes ”that among the biggest barriers to treatment have been cost and limits placed on care by insurance companies.” (Noam Levy, 1/19/2013, Obama intends to fix holes in mental health coverage; www.latimes.com)

Acronym & Vocabulary Lesson!
• CPT code = Current Procedural Terminology Code (also known as a billing code).
• UCR rate = usual, reasonable, customary rate for a treatment in a given geographic area.
• EOB = Explanation of Benefits (sent by insurance company to show who paid what).

• Grievance form. Grievances include both complaints and appeals. Complaints can include concerns about people, quality of service, quality of care, benefit exclusions or eligibility. Appeals are requests to reverse a prior denial or modified decision about your care.

Client Case Study

Josh’s teenage son Oliver (not their real names) was diagnosed with OCD (obsessive-compulsive disorder), and Josh found a highly regarded outpatient facility that featured a month-long intensive treatment program. It cost $24,000, a big chunk for anyone, but Josh was determined to help his son get well, whether that meant using retirement savings or trading in their home's value.

The treatment facility and doctor were not in-network with any insurance plan, but the family’s PPO policy covered 50% of the UCR cost up to 20 days per year. From a conversation with the insurer’s representative we learned the UCR rate for CPT code 90808* (not a zip code!) was $375, meaning the insurance company’s 50% share would be about $187 per day after Oliver’s $2,000 non-network deductible was met.  *CPT code 90808 = Outpatient Individual medical psychotherapy, 75 – 80 minutes

Yet when the EOB was mailed to Josh, he discovered the insurer’s covered amount per treatment was $137, not $375, of which the insurer paid only half ($69 per day). Did the medical provider incorrectly label the billing code as an office visit instead of “individual medical psychotherapy?” 

It turned out the correct code was applied, and there were four treatments each day, instead of the one treatment per day listed on the EOB. This was likely an oversight of a busy medical billing department, but thankfully the doctor provided Josh with a "To Whom It May Concern" letter that asks the insurer to give credit for four treatments per day. Josh attached this letter to a Grievance form downloaded from the insurer's website, and faxed everything to the number on the form.

As of this writing, the insurer has paid only $788 of the $24,173 bill. The issue of what is the correct reimbursement amount ($375 or $137) has not been resolved. It remains to be seen if credit for four treatments per day will be allowed. To be fair, the insurer was not initially provided with the correct number of treatments. And the underlying problem, how to effectively access mental health benefits, is not something you can blame the insurer for because is competing in the individual and family marketplace with all other insurers. 

Instead, this is a public policy matter, and fortunately people with mental illnesses will significantly benefit from health insurance reform with the changes coming January 2014. The details are still being worked out, but know, for example, that autism and acupuncture benefits are provided in what is called Essential Health Benefits.

This struggle for mental health benefits is one hole that cannot be fixed soon enough!

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Author Bio
Michael Grodsky, AIF, is founder of Aquarius Financial & Insurance Services, providing unbiased education and access to health insurance for Californians. He is a board member of Side Street Projects, a non-profit artist-run organization, and is an insurance and financial planning specialist for GYST, an artist-run company providing information and technology solutions for artists. Michael’s Health Insurance 101 workshops have been hosted by non-profit organizations throughout Los Angeles County.  He leads the ‘Health Insurance 101’ monthly informational workshop at the Cancer Support Community-Benjamin Center.

How I Learned How To Dress Well Despite Cancer

Here's a piece I wrote for my writing class through "Elizabeth's Canvas" called "Create Your Story" with instructor Julie Cobb.  It's called "The Storyboard" and it's a partially fictional account featuring an interview with a fashion designer I created named Vickie Elizabeth. She was previously diagnosed with breast cancer and had been cancer-free since 2007. To celebrate she used her disease as an inspiration for her Spring 2012 collection and was going to present it at the Cancer Support Community-Benjamin Center. When I wrote this I'd just finished reading young adult author Olivia Bennett's series "The Allegra Biscotti Collection" and "Who, What, Wear" about a very young designer who's talented enough to be the next Coco Chanel.  The clothes in my story are described as if a real designer conceived them. I hope this story helps those who're going through the same problems I faced while making my transformation after my mastectomy.

                                         "The Storyboard" by Victoria Moore (March 11, 2012)

I'll never forget the day the surgeon came into the examining room and told me I had Stage II A breast cancer. I would need to have a mastectomy, lymph nodes removed under my left arm and chemotherapy. My appearance was going to take a beating.  My cancer was in my left breast so it would have to be removed, and despite my oncologist's optimism, I knew I was going to lose all of my hair during chemo. Despite all of these seemingly important obstacles the only thing I could manage to worry about was, "How am I going to write about fashion if I'm going through breast cancer?"

If you'd have meet me at an L.A. Fashion Week event at the California Mart a few years ago, before my diagnosis, I'd be the tall, thin, quirky writer holding a reporter's pad and wearing my favorite black 1960s vintage dress, black Hue tights and my black 1950s vintage shoes. Almost to the second I heard I had the Big C the color black became my least favorite color. Oh, I still planned to wear it occasionally--just not head-to-toe, like I did before.

Around the time I got breast cancer I started going through my wardrobe and picking out things I could and couldn't wear to accommodate my current disability. Button-down shirts were definitely something I'd need along with cardigan sweaters and hoodies for doctor's appointments, the chemo suite and other hospital procedures. Heels were definitely out right now since I needed more secure soles.  I chose athletic shoes, loafers, ankle boots and men's oxfords. The sun also wasn't my friend so I chose clothes that were both comfortable and protective for my skin, such as leggings, jeans, longer skirts and dresses, hats, scarves and a green fringed parasol. Finally after I examined everything and organized what I had left, I realized I needed to buy some new things by a designer whose clothes would fit in with my own stuff and reflect who I was now.

"Wouldn't it be great to find a designer who'd already gone through breast cancer and understood the challenges of dressing every day from that vantage point?" I thought.

One Wednesday afternoon, while waiting for my Writing Group to begin at the Cancer Support Community, I was looking at the new flyers for upcoming events when I saw one for Vickie Elizabeth, an L.A.-based fashion designer who had just designed a new collection for Spring inspired by her journey with breast cancer. To celebrate her fifth cancer-free year she was presenting a special fashion show at CSC-BC along with an accompanying workshop and luncheon afterwards.

"She's exactly who I've been looking for," I thought. "I have to interview her and buy some of her clothes too, " I mumbled to myself as I wrote down her contact information into my pink "Hello Kitty" notebook.

A week later, after I called her, I went to her studio in Venice, California and sat down for an interview. Below is an excerpt.:

V.M.:  When were you diagnosed with breast cancer?
V.E.:    In 2006.
V.M.:   Why did you decide to use your journey, with breast cancer, as your inspiration for your Spring 2012 Collection?
V.E.:    Because it was such a significant time for me, and although I faced a lot of sartorial challenges, I knew I could help other women who were going through the same thing.
V.M.:   What colors did you use and why?
V.E.:    I chose ones that meant something to me. Ultimately I ended up with orange, which means "strong and passionate," pink, which is "feminine and healthy," browns, which are "earthy," and white which is "pure and refined."
V.M.:   Which fabrics did you use?
V.E.:    Cotton, silk, light-weight wool, chiffon and tulle.
V.M.:   Which silhouettes did you use?
V.E.:    Fitted and flowy. Masculine and feminine.
V.M.:   What inspired you?
V.E.:    The 1930s and the 1980s.
V.M.:   Which piece from your collection stands out and why?
V.E.:    The long floral maxi dress because it can be worn either during the day or at night depending on what you coordinate it with. If you pair it with a denim jacket and Converse it can be worn out to a casual date, and if worn with a jeweled cardigan sweater and strappy sandals, it can be worn to a fancy dinner.
V.M.:   What fashion advice would you give women struggling with breast cancer and body issues?
V.E.:    Don't forget to continue enjoying fashion and remember for every door that closes another one opens.
  

Getting Rid of Stuff and Finding Myself

 

I took this photo of my closet after I'd organized some of my clothes

Source: Victoria Moore's closet

Have you ever tried to move from one place to another and not known where some of your stuff came from and why you were hanging onto it? That's the predicament I found myself in about a month ago when I decided to "declutter" my space and simplify my life. Please don't recoil in horror that I live like a hoarder or shopaholic who's so out of control she needs an intervention, because that's not the case. I'm what you might call a "collector". Some things I legitimately collect, such as vintage clothes and accessories, t-shirts, Hello Kitty collectibles and Japanese fashion magazines while others just accumulate over time. The problem with getting rid of my accumulations are the memories attached to them and re-living the issues that came up when I tried to throw them away. Believe me it was a heavy duty job, but it had to be done, so that I could make room for the future.

First I had to assess my current state of mind to determine whether or not I was ready to let go of the past and move forward. The four issues I'm dealing with right now are my health (i.e., post breast cancer treatments, lupus, rheumatoid arthritis and depression), unemployment, living in a city that's becoming more complicated and exhausting every day and adjusting to a life that's changed significantly since I was diagnosed with Stage II A breast cancer in 2010.

To help motivate myself I signed up for a workshop on October 19 at Cancer Support Community-Benjamin Center, "Declutter 101", taught by Regina Lark owner of "A Clear Path" ("an L.A.-based professional organizing business"). To set us on the road to organization she required that we bring in a "junk drawer" to organize at the workshop.  I don't really have one so I brought a bunch of "junk" in a large ziploc bag—a heart-shaped lace potpourri sachet, pencils, pens, chopsticks from various Japanese restaurants I'd eaten at, a framed black-and-white photo of my first tap teacher Mark Mendonca, various Hello Kitty note pads, etc., etc.  

She then had everyone put their items on the table and walked by to examine a few. I'm happy to report that I passed the test by separating everything into categories. Unfortunately my euphoria was short-lived when she saw my "collection" of chop sticks. Without a second's remorse she gathered them up and threw them in the trash!  Bye-bye "Miyako"!  Adios "Sushi Cat"!  Later "Mitsuwa Marketplace"...

"Oh, so that's how it's done... You just toss everything you absolutely don't need and can't use.  I think I can do that," I thought to myself.

Overall the most important bit of advice I left the workshop with was "to get rid of things that have caused me pain and only surround myself with those that have a higher good".  When I actually started doing this, on my own, I found that it was easier said than done.  

It didn't help that I began with my closet and I'm a clothes horse with wearables everywhere. To try and make it easier for myself, I tried a little experiment by separating all of my black garments out from the rest of my wardrobe to coordinate together as if I were going to work at "Sear's", "Macy's" or "Bloomingdale's".  Whenever I've gone into those stores I've noticed all of the staff wears black head-to-toe.  Once I got so curious about this phenomenon I asked a salesperson at "Bloomingdale's" about it and she told me, "It's our dress code and a requirement." "Doesn't it bother you to be surrounded by so many different colors and styles and not be allowed to wear them?" I asked her. "Sometimes," she said, "that's why on my days off I wear the brightest colors and prints I can to balance everything out."

I guess I should tell you why I have such an aversion to all black.  After I was diagnosed, and I started chemotherapy, my skin changed color and I had dark bags under my eyes that the color black accentuated horribly.  Today, even though my hair's grown back, my face has returned to its rosy glow and I don't feel as sick.  Black represents that time so I stay away from it when it's not broken up with another color.  Getting back to my experiment . . .

After collecting all of my black dresses, jackets, skirts, blouses, pants and shoes I went through all of my "Vogue's", "Harper's Bazaar", "Elle's" and "Marie Claire's" and tore out fashion layouts and ads of swanky dark ensembles. Through hours of coordinating and translating them with my own clothes the only one that really spoke to me was a short, flirty black lace party dress in the "Mulberry" ad paired with black-and-white polka dotted flats and a big black leather bag. Fun, cute, and eternally young, it represents my philosophy about fashion.

In the end, I didn't get a job working at any of the stores I previously mentioned, which is just as well because my experiment with all-black failed and I reverted back to the eclectic blend I'm comfortable wearing.  I guess uniforms just aren't my thing, whether it's on a job, in a tap dance class or in everyday life.  For me fashion is meant to be enjoyed and shared and you can't do that if you're a conformist.

While I was working on my wardrobe I read a few fashion/style books—The Gospel According To Chanel,  Lloyd Boston's, The Style Checklist: The Ultimate Wardrobe Essentials For You, LAUREN CONRAD Style, and IN STYLE Instant Style—to help me bring order and cohesion. From the Chanel book I think I learned the most because I learned that the reason her look is still so iconic is that it's autobiographical. When I was asked to list my "all-time favorite pieces of clothing" in the "IN STYLE" book I was surprised that they were similar to Chanel's and included a black dress, a striped French sailor shirt, a white t-shirt, jeans and a white button-down shirt. It's funny, but from this small list, I visualized at least five different outfits.  Now that's organization that I can live with.

At this point in my journey I can only say that my "decluttering" project is still a work in progress, but now that I've taken the plunge, I will continue with a renewed sense of purpose.

Blog Author: Victoria Moore