Getting healthcare in the United States has a history of being convoluted and I think it has left a lot of us feeling jaded and unsupported. There are accesses to healthcare providers through state and federal programs, but sometimes it is difficult to find out what we qualify for or that a resource even exists. I am not an expert in health insurance but I wanted to describe my personal experience with health insurance coverage for a Kaiser plan through Covered California (coveredca.com) and how it helped save me from financial ruin.
Before the Affordable Care Act (ACA), there were few alternatives to being insured outside of an employer’s provided plan, which dictated the coverage details and co-paid premium amount. Employer-provided health insurance was sometimes pretty expensive (high monthly premiums, high deductibles, long reimbursement processes), but without other choices, we took what we could get. Some people remained employed at jobs only for the health insurance. Some employers didn’t provide health insurance plans to employees at all. If you didn’t qualify for Medi-Cal and you were in between jobs, working freelance, or at a job that didn’t offer health insurance, the options were COBRA or private insurance—both extremely expensive. This left many people without health insurance and discouraged about getting healthcare. Periods of being uninsured and restrictions on acceptable “preexisting conditions” made it even harder to get health insurance coverage.
There are still many improvements to be made statewide and countrywide regarding the Affordable Care Act. Covered CA is California’s response to it and I think it has resulted in some positive changes. Unfortunately, availability only applies if you live in California but many Californians qualify. If you live in California, regardless of income level, citizenship status, or anything, check it out. There is also guidance on Medi-Cal and county-based coverages on the coveredca.com website.
My Personal Experience with Covered CA
My husband and I have been enrolled in Covered CA for three years and we felt pretty good about it, but I would be lying if I said I felt totally secure. I was afraid that some cost would come up because something we originally thought was covered was actually at full cost or that the premium we were paying would be considered underpaid at tax filing time and we would owe, even if we had no income changes.
We are both doing okay right now and have thankfully avoided getting COVID for the time being, but we have had our fair share of time in medical facilities during this ongoing pandemic.
I already wrote at length about getting my left retina reattached in 2020 here. When the e-bill arrived, I saw a line item for the co-pay amount charged and paid (by me), then I saw a line item for the surgery amount charged and paid (by insurance). I was relieved. I later developed mild cataracts and Adie’s pupil in my left eye and also ended up getting a preventative laser procedure on my right retina, so I had to go back for multiple appointments throughout 2021. For each of the appointments, all I had to pay was the co-pay.
The eye stuff was a bummer, but the outcome was good and it wasn’t one of those drop-everything kind of emergencies. My husband, on the other hand, has had quite a year. He is doing okay right now and said it’s okay that I share this information.
Right at the beginning of 2021, he had a severe tachycardia episode that made his heart rate very high and it wasn’t going down. We went to urgent care because it was 15 miles closer than the emergency room. The EKG recorded his heart rate at 220 beats per minute. They weren’t sure what was wrong with him and they needed to treat him quickly. Instead of medication, they decided to “restart” his heart rhythm with a shock from a defibrillator. My husband was awake the whole time, which was a good thing, but he had to feel that shock. He said it was like running full speed into a brick wall. But it worked, it got his heart to a more reasonable rate, albeit still high.
(Side note: Initially, we were told we shouldn’t have gone to urgent care even if it was a closer facility and instead we should’ve gone to the emergency room. Later, a doctor said it was actually the right place to be to get the EKG reading as accurate as possible. Ultimately, if you’re experiencing a medical emergency, call for an ambulance or go to the ER.)
Next, they called an ambulance to transfer him to the emergency room. They wanted to bring him to a closer one, but it was at capacity. So they went to the next closest ER, which worked out because it was Kaiser. He stayed overnight and was admitted to the hospital where he had lots of tests including an angiogram, which thankfully ruled out heart disease. Doctors used data from the EKG readings and a 30-day Holter monitor to tentatively diagnose him with Supraventricular Tachycardia (SVT) that could be treated via daily medication or ablation surgery. The surgery was considered elective and they initially tried the medication, which didn’t work well with him. After a few months, he was accepted for ablation surgery. The surgery went well and the EKG that was taken at urgent care helped locate where to do the ablation and he was officially diagnosed with SVT.
The ablation procedure is much less invasive than full open surgery, but there is still recovery time, which was challenging. My husband was feeling okay mentally, but for all of 2021 he continued to experience symptoms from either the surgery, medications, or from the SVT itself. He was diagnosed with somatic PTSD with symptoms including ectopic heart beats (PACs/PVCs), extremely cold hands and feet, dizziness, and chest/abdominal discomfort. Over several months of trial and error, he was prescribed three different anti-anxiety medications. Unfortunately none of them really worked and caused more symptoms. The last one he tried (Remeron) may have successfully treated the cold hands and feet symptom, but it also triggered more frequent PACs/PVCs. So he is not on any medication right now.
My husband’s tachycardia episode and ablation surgery all happened before vaccines were available. Thankfully, we are both vaccinated and boosted now. After my husband got the second vaccine dose, he had another (more mild) tachycardia which resulted in another trip to urgent care, this time via an appointment. He self-stabilized but was monitored for a couple of hours and then cleared to go home. Nobody knows what the culprit was. It could have been the vaccine, going on and off different medications, or his heart healing from the ablation. His doctors gave him the okay to get the booster when it was available and he just had to wait an extra 15 minutes after getting the injection. He had no reaction to the booster nor the first dose.
With medical professionals and facilities being pushed and stretched over their limits, we are really grateful for all of the attentive care and the accessibility to it in the midst of this pandemic. I know there are many other people who have not been as lucky.
As of mid-February, over a year since his ER stay, my husband is feeling notably better. Each step of the way throughout the past year, we watched the e-bills come in. Again, I braced myself for unexpected charges, but there weren’t any. We had to pay the full deductible for 2021 because much of the expense for my husband’s care fell under the co-insurance costs that required the deductible to be maxed out before insurance started paying 100% (ambulance, ER, OR surgery). The deductible wasn’t nothing, but it paled in comparison to all of the costs that the insurance covered after the max deductible was met. Right before my husband’s surgery, there was a billing miscommunication that showed a partial balance of the deductible due even though it had already been paid. He had to pay before being admitted for surgery, which was frustrating. It took months, but they finally credited it back to the credit card. So, not perfect, but still a more positive financial outcome than anticipated.
The Kaiser plan coverage from Covered CA made it possible for the two of us to affordably have emergency surgeries/procedures, urgent care visits, an ambulance ride, an ER stay with hospital room admittance, three rounds of heart monitors, multiple imaging scans (ultrasounds, X-rays, CTs, MRIs, EKGs, angiogram), procedure and pathology on a (thankfully benign) biopsy, labs, medications, primary doctor and referral visits, email correspondence with our doctors, and access to mental health care. We had all these things done within 18 months. I cannot stress this enough, I have no idea what we would have done without this coverage.
Some Details About Covered CA Enrollment:
Open enrollment period is usually November through January. There is special enrollment provided outside of the regular enrollment periods for qualifying life events, e.g. pregnancy, job loss, etc. As of when I write this, due to COVID-19, the enrollment period has remained open for people to apply today if they need it.
The premium price is based on which plan you choose and then they calculate the amount of money you get credited back based on your household income. You can choose to either get the money credited back automatically on a monthly basis or in one lump sum as a tax return. Personally, I don’t see any benefit to waiting for the credit in your tax return. We chose monthly auto-applied credits and have an affordable monthly payment.
If you work freelance, you would input your estimated yearly earnings based off of the past year. If you end up making more/less enough to put you in a different income bracket, you would owe/receive when you file your income taxes. If you are unemployed and do not plan to earn money throughout the year, there is a form you can fill out and sign that says you earn zero dollars.
If you end up getting a job midyear and would like to keep your Covered CA health insurance, you would report a change. This can get confusing for freelance work, so if you have any questions about anything, I would suggest calling their provided customer service line. They actually do help you. Honestly, the website can be wonky sometimes, so all the better that their customer service is responsive.
Any changes (a move, income/job change, gain/lose a dependent, any status change, etc.) must be reported in 30 days (Medi-Cal requires reports within 10 days). Changes reported can result in a change of the plan options available to you and a reset in your deductible, so be aware of this. It is one of the things that I feel can be approved upon, but I am still happy with the Kaiser plan we chose.
Other health provider plans are available through Covered CA, but Kaiser was the most affordable with the best care coverage in my opinion. You choose between different plans available for your income bracket (bronze, silver, gold, platinum). There are some minor differences in what is covered between the Kaiser plans, but the main difference is the deductible maximum (the amount the insured person pays for co-insurance costs before insurance kicks in 100%).
Side note: Ophthalmology is covered in the Kaiser plan we have, but Vision and Dental are separate. Choices for Vision and Dental insurance are notoriously limited. Covered CA offers some options, but we chose to pay out-of-pocket for a vision prescription and glasses from Costco and for private dental coverage through Cigna because the dentist we go to is out-of-network for the options Covered CA provides. Also, the yearly costs of our choices pretty much even out.
Hopefully some of this information is helpful. In the times of an emergency, or seeking any medical care, thinking about the costs or how much of something is covered should not have to be on anybody’s minds. That should be the point of health insurance, but it often times isn’t. I appreciate the efforts I have seen in healthcare guidance communication from both inside and outside of the industry. Even with their help, it is still difficult to ascertain what is right for you.
I hope to see Covered CA continue to improve on what it offers and hopefully other states can offer the same or better. Until we can get to a better system all around, I am thankful for the coverage we have. If you live in California and are without health insurance or are looking for an alternative to your current coverage, I encourage you to look into Covered CA (coveredca.com).