New Insurance

My family has employer-provided health insurance.  A few months ago I heard that the company was considering switching to a new carrier.  I was horrified.  We have a pretty good policy, and I don’t want anything screwing up my coverage.

Open enrollment came and went, but coverage options remained the same and nothing more was said about a new carrier.  Whew!  What a relief!

Tonight I was informed that the company can save a significant amount of money by switching.  Great for the company, but I don’t expect it will be good for my pocketbook.  They’re not going to save $75K by giving me better coverage.  Before things are final, however, I have the opportunity to make a list of questions – details that the owners might not think to ask.

I need your help so I don’t forget to ask anything important.

My current list is:

  1. Are the same doctors and hospitals covered on this new plan as on the old one?
  2. What is the coverage if we choose a physician not on the preferred provider list?
  3. How long does it take to process claims?  How quickly/slowly will my doctors be paid?
  4. What will the new co-payment be for coverage?
  5. Currently, if I see more than one doctor on the same day, I owe only one co-pay.  How will the new policy handle this situation? 
  6. What will be the annual out-of-pocket individual/family limit?
  7. What is the coverage on preventive care?  What is the annual limit on this benefit? (existing policy is $300 per year)
  8. Are both adult and childhood vaccines covered?
  9. Are travel vaccines included under preventive health coverage?  Or covered at all?
  10. How is coverage handled for accidents/illnesses that occur away from home?
  11. Does this policy cover foreign travel?
  12. Is the medical necessity of testing left to the discretion of my physician who holds a medical degree, or must he obtain pre-approval from someone who did not attend medical school?  ( MRI, ultrasound, CT, lab work, x-rays, etc.)
  13. Are physician-prescribed orthotics covered for conditions other than diabetes?  If so, what are the details on this coverage?
  14. Are referrals required from our PCP for us to see specialists?  If so, will existing referrals be honored, or must new referrals be written?

Prescriptions

  1. Will insurance continue to cover my current prescriptions?
  2. Are medication decisions left to the discretion of my physician who holds a medical degree, or must he obtain pre-approval from an insurance company employee who did not attend medical school?  If some medications require pre-approval, which ones?  How long does the approval process take?
  3. Our current prescription coverage has flat copays of $10/$25/$40.  What is the prescription co-pay on this new policy?
  4. Is it possible to get a copy of the formulary to know which medications are listed in which tier?
  5. Does money spent on prescriptions count toward our annual out-of-pocket maximum?

I have until tomorrow morning to add to this list.
Can you think of other things I should be asking?

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Edit to add:

I’ve also added questions about PT/OT limits/exclusions.  Last year we were allowed 20 PT visits annually.  This year it dropped to 15 visits/$2000.

I also added a question about surgery coverage. Our current policy will only pay for surgery within two years of diagnosis, which means I might be SOL for having our current insurance pay to fix my shoulder if it ever becomes necessary.  A longer time limit under the new plan would be a welcome change.

Nephrology

The work of kidneys goes on without much fanfare, and it’s easy to ignore them — unless something goes wrong.  Or you’re told that something might go wrong.  When my doctor wrote prescriptions and said that I’d have to have blood drawn frequently to make sure that those drugs don’t harm my kidneys, well, suddenly I had have a new respect for those little organs.

Aside from a general, “somewhere in the abdomen,” I wasn’t even sure exactly where the kidneys are located.  Now I know.

Learning where they’re located didn’t mean I knew what the kidneys do, though.

Some days I wonder if I ever learned anything useful in school!  A zillion years of formal education (with pretty good grades), and I never had to learn basic anatomy.  That seems so wrong – and is why my children are learning some basics about how their bodies work.  But I digress.

Whenever something goes into people’s mouths (steak, tofu, twinkies, salad, asparagus, ice cream…), their bodies use the nutrients they need, and sends waste into the bloodstream.  The bloodstream then flows through the kidneys, which are incredibly complex filters. 

They do more than act as filters, though.

Our kidneys analyze the stuff they’re sent and sort everything.  Electrolytes that the body needs (sodium, potassium, etc) are measured out in just the right amounts and allowed into the bloodstream.  Waste and extra water is shuffled off to the bladder for removal as urine.

It doesn’t stop there, though.  In addition to filtering out wastes, these fist-sized organs release one hormone to tell our bone marrow to make red blood cells, another that helps regulate blood pressure, and a third substance involved in calcium maintenance in the bloodstream.  When the kidneys aren’t doing their job, these things don’t get done.  The kidneys are important!

But I still had some questions.

  • Why are lab tests that check kidney function called a renal panel?
  • Why are kidney doctors called nephrologists?
  • What about those lab tests?

Slowly, I’m learning.

Renal – The Latin word for kidney is ren, plural renes.

Nephrology –  Just as the lungs are full of little air sacks called alveoli, the kidneys are full of little tubes called nephrons.  (So why do we have pulmonologists, instead of alveolologists?)

This didn’t just turn into an etymology blog, but if you’re into word origins, it’s interesting to note that νεφρός (transliterated nephros) is the Greek word for kidney.

Labs – A renal panel includes electrolytes (sodium, potassium, chloride, and bicarbonate), blood urea nitrogen, creatinine, glucose, albumin, calcium, and phosphate.  My doctor has never ordered a renal panel.  Either she orders a CMP (which includes all these tests and more), or a few select tests.

BUN - blood urea nitrogen – the normal range for this test is around 6-20 mg/dL (or 2.1-7.1 mmol/L) in adults, although there can be slight variations between different labs (my lab uses 7-23 as its normal range).  Labs usually print their reference range right on the report, which is nice because we don’t have to guess.  High numbers can indicate a problem, but can also be due to dehydration or a high protein diet.

Creatinine - according to LabTestsOnline, the normal range for this test depends on age and gender:  0.6-1.1 for women age 18-60, and 0.9-1.3 for men in the same age range are reasonable numbers.  Again, labs can vary.  My lab’s normal range for this blood test is 0.4-1.0.  As with BUN, high numbers can indicate a kidney problem, but can also be due to dehydration.  Note that creatinine can also be checked with a urine test.

BUN/CRE Ratio – some labs will also report the ratio of blood urea nitrogen to serum creatinine.  Ratios are interesting.  The individual components can fall within the normal range, yet the ratio of one to the other be out of whack (to use a technical term).

eGFR – Estimated Glomerular Filtration Rate - this is a calculation (not a separate test) based on serum creat and a bunch of other details.  The National Kidney Foundation has a handy-dandy eGFR calculator available online.  And if you wonder, as I did, where they came up with a name like glomerular, the glomerulus is one little part of every nephron.

Since these lab tests are easily affected by what people eat and how much they’ve had to drink, it’s easy to see why doctors don’t worry about fluctuations of one or two numbers.  That explains why, if something is outside the normal range, my doctor orders a re-test.  It’s the long-term trend she’s looking for, not the occasional blip caused by my steak & eggs breakfast.

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For more reading about the kidneys: