KYNECT: My Experience with Kentucky's Health Exchange Network

It's not my habit or even inclination to write about local or state issues. I usually try to leave that to those who have the interest and, frankly, the connections. As the editor of Another Opinion, I try to keep the focus on the "big picture"; national and international events which affect everyone. I least of all like to write about myself. To be honest, I don't think I'm that interesting. But I must make an exception this time. This is a personal story which has to be told, not for my sake but the sake of others affected by Kentucky's health exchange, KYNECT, which has often (and erroneously) been billed as "America's Model Health Exchange" by former Governor Steve Beshear in response to the Affordable Care Act or as it's more commonly called, "Obamacare"; the healthcare law that isn't. This isn't my first go around with KYNECT, only the most recent. I will try to avoid using identifiable or real names of those I've dealt since many, if not all, are still employed and I have no bone to pick with any of them or desire to cause them harm in any way. Most were simply trying to do their job to the best of their ability and simply either lacked the proper training or authority. However, it was the system itself and the bureaucracy built around it which plays the primary role as villain in this little drama. So, with further ado, let's begin.

Like most Americans, one of the first projects I begin working on following New Year's, is gathering and sorting through piles of receipts, notes, and other documents in order to file my taxes; an annual ritual that most Americans both curse and gleefully anticipate like kids at Christmas in the hopes that dear ole "Uncle Sam" will be sending them money for new washers or dryers, or down payments on cars, boats, vacations, or whatever with stopping to realize that it's their money in the first place that they were denied use of for a year, but I digress. After dutifully gather all my paperwork together for 2015, I headed off to a professional tax preparer on February 13th. After dropping everything off and quick review, I headed home knowing that's one more problem off my plate and secure in the knowledge that they'll be done right while I focus on more mundane tasks like cleaning the garage. Alas, that wasn't to be this year. By the time I had arrived home, the tax preparer had called and left a message for me to call back. "That can't good" I thought, and I was right.

It turned out that KYNECT had sent a 1095A form, which meant nothing to me. As the tax expert matter-of-factly explained, it meant that we had been enrolled in a insurance program for which we didn't qualify for based on my wife's part time job and income reported on her W2. She recommended that I call KYNECT and get a corrected 1095B form, which is what KYNECT should have provided based on the insurance program we were enrolled in. Sounded simple enough. So, I called and after a brief hold spoke with a rather chipper customer service representative named Shayne. I explained the problem to Shayne, who politely said they would correct the problem and get a 1095B out to me as soon as possible. A few days later, almost miraculously I received a 1095B and immediately I dropped it off at the tax preparers' office. Once more, I had a phone message waiting for me by the time I got back home. So, feeling like a kindergartener who got caught skipping down the hall, I called her back. As it turned out, the 1095B they sent went with the 1095B and so it's wrong too. She explained that the 1095A should be zeroed out since we never received supplemented coverage KYNECT was showing and the 1095B should reflect the policy we actually did have. So, on February 23rd, I called and spoke with Jasmine at KYNECT and gave her my story. Jasmine promised to review with her supervisor and send a corrected 1095A and 1095B, but again, I received the same incorrect forms a few days later.

On March 2nd, I called an explained the situation again to the poor unsuspecting customer care representative who had the misfortune to answer the call. She reviewed the notes in the system and refreshingly admitted that this was above her head and then politely asked if she could place me on hold while she spoke to her supervisor. Jackie. No problem. I explained to Jackie the situation and my justifiable frustration. Jackie said she had reviewed the notes and thought she understood the problem and had a possible solution. According to Jackie, either the system or someone, had entered our annual income into the wrong column. The yearly income, based on my wife's part time job, was mistakenly shown as our January 2015 income. This automatically kicked us out of our insurance plan and into a supplemented insurance plan, at least for a few weeks when the mistake was probably caught by someone reviewing the data. The system showed that we were placed in plan which showed no income for January 30th to February 1st, and then back into our original plan starting February 2 through the rest of the year. Confusing, but at least we had an explanation. All that was needed, according to Jackie, was to transfer me to the folks who handled 1095A forms and have them zero out the January 1st through the 30th. That would automatically generate a corrected 1095A form and would generate a correct 1095B form. Jackie also said she would make sure this would be amply detailed so everyone would know what happened. Hallelujah!

So, Jackie transferred me to the folks who handled those dreaded 1095A forms. As it turned out, I spoke with a very sympathetic Amanda. Amanda asked for my claim number and as I started to explain, she said she had just read Jackie's beautifully detailed notes and knew just what to do. Amanda said she had already entered a ticket to have the 1095A form, the bane of my existence at this point, zeroed out. I should receive a new, and hopefully correct, 1095B form. To be sure, Amanda transferred me to Shasha in the 1095B department. Again, they were on the ball. Shasha had the information from Jackie and Amanda, and assured me a new and accurate 1095B should be generated and on its way to me shortly. For the first time in weeks, I had a good feeling about this. I immediately called and let my tax preparer know the good news. Actually, I think she was almost as pleased as I was (probably because she knew she was going to get this off her desk and paid).

On March 7th, I received a call from Jackie at KYNECT to make sure everything was taken care of. I brought her up to date and thanked her for help. I deeply appreciated everything she had done. On March 10th, I called to confirm that everything was proceeding as discussed and there were no hiccups. John, another one of the customer care reps, was a bit less friendly (personally, I think he saw all the notes and was afraid I was going to ask him a question). John confirmed that the revisions were being processed and there was a ticket to expedite the handling of my claim. "Excellent" I thought, and that's when the other shoe dropped...with a dull pain-in-the-pit-of-my-stomach thud.

On the morning of March 17th, I received a phone call from Jeanette at KYNECT. Apparently she must work in the 1095A department since she said he supervisor had asked her to call me and see "if I really wanted to have the 1095A form corrected". What? I asked Jeanette if she or her supervisor had read the notes, and she said her supervisor had but was wanting to know if I really wanted to do this? She went on to say that their system showed that we didn't qualify for the program we were in due to our "substantial income for the month of January 2015" and that's why we were placed in the other supplemented insurance plan which generated the 1095A. I think that for a moment I was actually numb. How could this be happening...again? Didn't anyone actually read the notes? Why were they just now working on this---10 days later? I explained as rationally and briefly as I could what the error was and what had been done, but somehow I don't think I was getting through. In her eyes, I was making the claim that their system was wrong; it was flawed, but I suspect she was thinking that it was I who was wrong.

Immediately, I gathered up all my documentation and notes and called KYNECT. Enough was enough. The unfortunate soul who answered for KYNECT was Jaz. She dutifully asked for my claim number and then...silence. I think she was just as stymied by all the notes as I was in knowing where to begin. As I started to explain, she very politely asked to place me on hold while she spoke with her supervisor. After a brief hold, Jaz came back on and in a refreshingly honest tone said that this was over her head and recommended I speak with her supervisor, and so I spoke with Dannie. Dannie introduced herself and asked if she could place me on hold for a few minutes while she read all the notes. "No problem" I said. I let her know that I wanted someone who knew the facts before we went any further. After about five minutes, she came back and said she had read through the notes. She asked if I had ever been referred over to Community Based Services (CBS), which oversaw our insurance plan. I said no and she said that she hadn't seen anything either. She explained that she understood everything that had happened but was flabbergasted that I hadn't been referred to CBS since they had oversight over our plan. She went on to say that only CBS could make the correction which would then flow over to KYNECT's 1095A and B departments where new forms could be generated. Until CBS made the change, the system would keep editing out the corrections and perpetuate the original error. This was now March 24th and I had started the process on February 15th. I had wasted weeks of effort.

So, Dannie transferred me to Community Based Services where, after an hour and a half wait, I spoke with a cordial Jane. Jane read through the mass of notes and was surprised that no one---not customer service reps or supervisors or their supervisors---no one had thought to refer me to them. We discussed the problem in detail and she issued a ticket for an immediate correction. She said the 1095A would have to be backdated, if possible since we never had (or knew of) the tax credit, as a result of being bumped out of our original insurance plan, and in fact, had never enrolled new plan. The insurance company which underwrote the new plan didn't have a new member ID number for us, and obviously we never received a new insurance card. We never even received notice of a change in plans. Nothing. As I advised Jane, we, in fact, had continued to use our original insurance card as always with no problems. The problem, however, for us was whether the system would allow a backdating of the entry to correct their error. She also pointed out that this wasn't a system error. It was human error in making a data entry. Some minimum wage summer help goofed and now I'm paying the price I thought to myself. Jane promised to follow up, however reminded me that nearly the public safety net for the State of Kentucky was in turmoil due to errors generated by the recent mergers of social programs which had caused thousands of individuals to bumped out of programs on which they depended, such as food stamps, housing assistance, natal care, and so forth. My problem, as important as it was, would not be considered priority. Jane suggested that I give KYNECT a call in a few hours. By then they should had the change from her side and could reprint a corrected 1095A and B. She added that KYNECT could read their notes since they were on the same system (besides, CBS can read KYNECT's notes).

About three hours later, I called KYNECT and spoke with Aretha. She said there were no changes showing; nothing. I asked her to check with her supervisor who may have a higher access. She came back and said that KYNECT was unable to read anything from CBS. Jane had recommended that I request a letter from KYNECT explaining their error for my tax records. Aretha said that under HIPAA guidelines that was not possible, even with a oral or written request. In short, KYNECT wasn't going to step up and own their mistake. At that point, I was fed up. I was tired. I had done everything in my power to get this resolved but nothing I did worked. I was dealing with a bunch of apparatchiks that would have made the Soviet Union proud. Since I know a few people on the executive side of State government, I felt the time had come to reach out for assistance. I contacted someone I knew and as briefly as I could explained what had happened and asked if there was anything he could do to help. I made sure this was done formally to both protect each other as well as to give it the weight of a formal request for assistance.

On March 30th, I was pleasantly surprised with a call from the Kentucky Cabinet of Health and Human Services. After a bit of clutter about what their system was still showing, etc, I was able to explain what had happened and needed to happen. I was told I would need a special letter of exemption, which she would discuss with her boss about providing. However, she never had heard of a problem quite like this before and acknowledged that she didn't know what, ultimately, they could do. I was promised a call back as soon as she knew something. I was hopeful that this bureaucratic nightmare was about over but I knew better than to get my hopes up again, and as it turned out, I was right.

Approximately a week or so later, I received another letter from KYNECT. It was the same incorrect forms as before showing the same incorrect coverage and the same incorrect income. After all this time, nothing whatsoever had been accomplished. I phoned my contact at CHHS to ask what had happened. She said that coverage apparently became available as a result of the income entry error. There was no coverage actually provided, though the company which had picked us up did, apparently, received payment from the State. I reminded her that no new member number was ever assigned. No notice of the change in coverage was ever provided. There had been no contact from either the new insurance provider or by me with KYNECT. In fact, I had received a notice from KYNECT in December 2014 advising that my coverage would continue as before for 2015. After the error was ultimately caught and corrected late January, the money was returned by the new insurance company to the State and we were resigned our original coverage as if nothing had happened, except for the incorrect 1095A and 1095B.

I asked how we was assigned the new provider and was advised that either I or someone else had selected them since the system doesn't automatically assign individuals (at this point, I don't think they know what the system actually does and doesn't do). I reminded her that I hadn't contacted anyone at all with KYNECT in 2015 and I keep very detailed notes of my dealings with KYNECT. They had caused me enough problems once before, in 2013, so the less I had to deal with them the better as far as I was concerned. So, apparently someone at KYNECT---perhaps that same minimum wage summer help---made the selection for us. As for backdating the system to correct them original program, they can't. There is no mechanism in the system to allow this type of correction. After nearly two months of dealing with this so-called "health exchange model", I was stuck with their mistake. No ability to correct data errors. No letter of exemption. No letter acknowledging their mistake. Nothing.

Most of those I dealt with were helpful, and like many State and local government employees overworked, stressed, and often underpaid while the department administrators are very well compensated and usually have linebackers to keep them separated from the common riff-raff. Of course some entry level employees are rude, unproductive, and unprofessional. I didn't find that here, though some were obviously totally lost. I didn't get what I needed, a correction of KYNECT's original, a correct 1095A and 1095B form, or written acknowledgement of their error, I wouldn't describe this as a "loss". I was successful in exposing the often ignored individual employees who went above and beyond to help me address a problem not of my making as well as highlighting failures in KYNECT's employee training, in its bureaucratic roadblocks designed to protect KYNECT's administration, and perhaps most importantly, in revealing a flawed system which lacks the proper programming to allow its users the ability to correct errors. I am sure there will be those who won't care one bit for this being exposed to the public. That's too bad since it's our tax dollars which are paying for this. If KYNECT is a "model" of a healthcare exchange, it's the model of what could be a successful exchange rather than of one that is.

Having the Stones to Take on Goliath

As readers of Another Opinion know, I've been engaged in a battle Kynect (Kentucky's "model" insurance exchange) and with Humana, to which I've been assigned. Just to briefly recap, my wife and I applied for insurance through the Kentucky insurance exchange known as "Kynect" (we have the distinction of being the second applicants to register when it went operational in August 2013). Somehow we managed to find every computer glitch and SNAFU in the system despite repeated assurances to the world by Governor Beshear that program was working without any hitches. By early October, our status had been elevated to the highest tier and I found myself dealing with programmers, systems analysts, and systems designers as they attempted to create "work arounds" in their programming and a host of other corrections.

Finally, by February 2014, things had settled down. Since we were enrolled in the system at the end of 2013, we were permitted to pick our start date for coverage to begin. We could chose from January, February or March. Since January had past and we had no medical bills worth any note, and as February was about over, we opted from March. However, "someone" at Kynect decided, when entering the information, that we really meant to say April instead of March, and changed our start date so we ended up absorbing medical bills for March (in all fairness, the senior manager at Kynect with whom we had been working gave us the option of correcting it back to March, however, the time required would have put us well into April anyway, so we opted just to "eat" the costs). Nevertheless, we ended up with some pretty good insurance, but no good deed goes unpunished, especially when dealing with the government.

At the end of 2014, we started getting notices from Kynect saying our coverage was changing (and apparently without our consent). I called our insurance provider several times over the next 45 or so days and was "assured" that our coverage was not changing and we should ignore the notices received from Kynect; we would keep our existing coverage we were repeatedly told. Finally, in early February 2015, I phoned Kynect to see what was going on. Well, it seems that their income calculation formula had changed and we were being removed from our insurance provider and transferred to Humana. Despite my protestations, we were moved in mid-February. At the same time, we received notices from our (now) former provider that our premiums were about to expire (Kynect paid a portion and we paid the balance). Although I repeatedly explained what had happened and offered to fax or email our notices from Kynect, I was advised that my offer (and my explanation) were appreciated but not acceptable. They needed "official" notice direct for Kynect. "Okey dokey" I said, and promptly contacted Kynect to (again) express my frustration and relay their request. I was told that an official notice will be sent, however, an "advisement" had already been issued.

Meanwhile, I discovered that despite Kynect's repeated promises (parroting Obama's) that I could keep my doctors, that in the event I

couldn't, my new carrier would pay for any prescriptions and tests. I, however, would be responsible for paying the office visit. Needless to say, I was dismayed when my primary doctor of 32 years (and who is the area's only known sub-specialist) wouldn't see me when I showed up for my scheduled appointment. I was told that I couldn't even pay cash money for the visit, and to jab the knife a little deeper, my doctor could not write me any more prescriptions while I searched for his replacement. Once my refills ran out, I was, to use the proper medical terminology, screwed. As soon as I got home, I immediately phoned Kynect. Again, they offered their heartfelt and most sincere apologies, but there was nothing that could do about changing the insurer. It was suggested to connect my new provider, Humana, to see if they could locate a doctor for me. "Fat chance" I thought as I said "thank you" as politely as I could muster and hung up the phone.

So I contacted Humana's Customer Service Department. After going through a battery of options to select from (which included what language I wanted---I will never ever press a button for English as long as I live in this country), and a ten minute wait, I finally spoke with a living breathing person. After explaining my situation (while listening to timely interjections of "we're sorry for your inconvenience), I was given a list of six doctors for me to call. I quickly learned that none of these were specialist of the type I needed, but it didn't matter. None were accepting Humana. So, for the next two months, I made my daily calls with the latest of doctors Human had given me, but I jump ahead of myself.

Somewhere along the third week, I managed to get lucky. One of the customer representatives I spoke with (and whose first language was apparently English), blurted out near the end of one of my frustrated phone calls that I could submit a "Continuing Patient Care Request" and then almost as an afterthought, asked if I would like to do so. "Hell yeah" I said. So together---her writing out the synopsis while I provided my medical history, prescriptions, and reason for my request. When we ended, she said it would take approximately 7 to 10 days to get a decision (really? That was like a sleepover by this time). So while I waited, I continued to make my calls and get my daily rejections only to call Humana and get my next list of six doctors with the names sounding less and less familiar by the day from the ever changing representatives (after, of course, having to repeat my story). Some of the rejections were due to the physician winding down their practice; moved out of state; or were simply located in the wrong part of the state; wrong specialty; or simply was not accepting Humana any longer.

Finally, the tenth day came and I was on the phone for what I hoped would be my approval. However, as if to throw salt on the previously mentioned proverbial knife wound, I was told that no decision had been reached yet, so in addition to calling for my list of six, I now had to ask for status updates (as an aside, I was also providing them with updates on the doctors whose names they had given me. Evidently their list hadn't been updated in quiet awhile). Then it came.

I had been reading when the phone rang. I started to ignore the call, figuring it was another solicitor calling, despite my being on the "No Call" list, when I noticed it was my (now) former primary doctor's office calling. So I answered, expecting to hear some other piece of bad news. I don't know if I can correctly express my emotion or thoughts as I was informed that they had just concluded a series of conference calls with my current provider and given my medical needs and length of time I've been with their office, my request was approved. She was calling as quickly as possible to let me know and schedule an appointment as soon as I wanted. I remember being instantly relieved; excited; angry at having been put through the hoops; the corporate and government bureaucracy, that I must of had her repeat herself two or three times (I don't she minded. She knew me from all these years and how much I had fought this).

So, we scheduled an appointment and she explain that my efforts also resulted in a change in policy, both for their offices as well

as for Humana's that would allow longstanding patients to remain with their primary care physician provided the physician was willing to keep the patient on. I didn't feel the need to gloat but I was quietly pleased to know that my efforts may also be helpful to others in a similar position as mine. Most people would have given up I realize, but I not one of those people. I don't believe in giving up the fight if the cause is just, be it for me or for someone else. I've been a community and political activist for well over 35 years. I've also helped countless numbers of individuals take on their own "Goliath" over the decades (while "Goliath" is a good, if not common, analogy, I'm reminded more of Odysseus and the Cyclops, Polyhemus, and in particular Odysseus's response as he sailed away; having outwitted this son of Poseidon). I did it from elementary school on; while in the military; in college; and in every job I ever had. It's simply my nature I guess.

As an comical aside, remember those notices I had been receiving from my the original insurance provider mentioned above? Well, I continue to receive them, advising me that my premium remain due while I continue to advise them that I was removed by Kynect at the end of January. Meanwhile, I've checked with Kynect and have been assured that they have been repeatedly notified of my removal from their policy (I was even provided a reference number which I had sent on). Despite their disinterest in my notices from Kynect, I faxed of copies to them all the same. Just a few days ago, I received a new set of membership cards. You just have to love corporate bureaucracy.


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Is there a Doctor in the House? No Seriously....Is there?

It's amazing how something so simple as finding a physician can suddenly become so difficult. As I'm sure all the regular readers of A/O know, I've been having an ongoing series of problems with the insurance assigned to us by Kynect, the Kentucky healthcare exchange which was modeled after Obamacare. Supposedly, Kynect was going to make our lives so much more easier when it came to getting insurance. It was supposed to evaluate our healthcare needs, income levels, and provide a list of potential plans to select from. In some instances, it also picks up partial coverage. After a pretty rough start (I had initially applied in August 2013 but didn't get coverage until April 2014), I was pretty pleased with the coverage. Kynect picked up a portion of the premium while we paid for the rest. The quality was good and there were no problems with our doctors or prescriptions. By the end of 2014, I started receiving notices that my coverage would soon be changing. Puzzled, I contacted the insurance company. They assured me that my coverage remained the same, although the name of the plan was changing, that was all and I should ignore the notices, which I did. However, I received a second and then a third notice. I contacted the insurance carrier again and got the same response. I decided to contact Kynect this time.

Well, it turned out that Kynect was changing my coverage and my insurance provider...effective March 2015. "Why?" I asked. Because there had been a change in their income formulation. I advised the "navigator", as Kynect likes to call its customer service folks, that nothing had changed on my part. However, the change in calculation was on their end and as a result, I couldn't keep my current provider. Needless to say, I wasn't happy. At that point, I was transferred to a new department; one in which I would have to deal with from here on out.

While I found the individuals at Kynect to be polite and somewhat helpful, they maintained that their hands were tied and there was nothing they could do. I had the choice of accepting the new provider they assigned or pay full price for coverage on the open market, which, they said, would be in the neighborhood of about $2500.00 per month (an awfully expensive neighborhood I thought to myself). However, on the upside (as if this was actually an "upside), I could still pay for any office visits if my doctor didn't accept the insurance; they would still pay for any lab work or x-rays.

Well, as it turned out, I had a upcoming visit to my primary doctor of 32 years for my annual physical in a few weeks so I decided to wait and see what happens. After all, I had been told there wouldn't be any problems and I would lose my primary doctor. When I showed up, I was told they no longer accepted my insurance provider effective the first of January. Not a problem I thought. I told the receptionist that I would go ahead and pay cash for the visit. "Sorry, but you can't do that" she said. She went on to tell me that under this policy, it was either accepted or I walk. I was not allowed to pay cash, check, or even credit card for the office visit. To do so, I was further informed, would be considered "fraud". WTH? So, I left feeling slightly embarrassed and more than a little flustered. Because of a change in policy calculation that I neither had anything to do with or knew about, I lost the insurance policy I liked and in the process my primary doctor of 32 years, and, oh by the way, what about my prescriptions?

After I got home, I called Kynect to vent. I was told there was nothing they could do and it was suggested I call the new insurance provider, which I did. I explained the situation to that first poor soul who had the misfortune to get my call. Despite the continuous "I'm sorry" which I concluded was written into a script somewhere to sound sympathetic, there was nothing she could do. So, once again, I was transferred to another department which was a near carbon copy of the first. Finally, I managed to work my way up the food chain, where I was told I could submit a "Continuation of Patient Care" form if I wanted to. Seriously? Hell yeah I wanted too! After completing the process with my newly found best friend, I was warned that this review process could take up to 7 to 10 days and I should be patient (little did she know!).

The 10 days came and went without a word, so once more I was on the phone. I called everyday for almost two weeks beyond their 10 day cutoff date. Finally, I heard back. I was told that they wouldn't allow me to keep my primary doctor. I had previously stressed that not only was this my doctor of 32 years, he's also a subspecialist and as far as I knew, the only one around! While my now former bestie went on to repeatedly apologize, she managed to work in that there were no appeals, but they would be happy to help me find a new doctor. Really? Someone who is a subspecialist? Well, no I was told, but they may be just as good! It was at that point I started to wonder just how bad prison food really was.

Well, to make a much longer story more manageable, I've called some 24 doctors now and there's been no takers. The first six were GPs (which I didn't need or want). Most of the doctors weren't accepting new patients; some acknowledged up front they couldn't treat me; and the rest were a hodgepodge of winding down their practice, not being able to understand them or their staff, and one who had been repeatedly cited by the Kentucky Medical Board. Where are the doctors? What good does it do me to have insurance but no doctors? Is the game now to find competent care? Am I going to have this same problem with hospitals or outpatient care? Sigh. So, I called the insurance company again and as usual, had to bring ever-changing customer service rep up-to-date (she also put me on hold for about 10 minutes while she read the notes on my case. I chuckled to myself as I envisioned her cursing her bad luck).

When she returned and after the obligatory "I'm sorry for the problems you've encountered", we got down to business. I told her that I needed more doctors. She suggested that I give her the names of those I called; it might make things go a little faster. I was again given six more names (and with each their names got more difficult to pronounce). She then asked me how I was doing on my prescriptions. I acknowledged that I was getting low. She asked what I was taking, which I happily provided. She then put me on hold while she spoke with their in-house pharmacy. While I was on hold, I blissfully thought to myself that maybe, just maybe, they could help me with this problem resolved (such are the straws of desperation made of).

When she came back (and apologized again), our conversation began anew. First, she read back to me each of prescriptions, milligrams, and frequency I was taking them (oh boy I thought, maybe the gray clouds were finally clearing). I dutifully confirmed each one and what they were for and for how long I've taken each. After we completed the inventory process, she started reading back each one from the top then informed me that I would need to get a new prescription from your doctor. Huh? "I have to get new prescriptions?" I asked. "Yes" she said. "I don't have a primary doctor" I said. "How did you get the medication?" she asked. "From my primary doctor". "You just said you didn't have a primary doctor" she said. "I don't know. You all won't let me see him any longer". "Why?" she asked. "Because he doesn't accept your insurance " I explained. "Then you can't see him". "I know" I said, "and I can't pay cash for the office visit right?". "Under our policy, you can't pay cash for the office visit. It would be considered fraud". "I know" I said. "So, how do I get my prescriptions refilled?" I asked. "From your doctor". "But he doesn't accept your insurance" I said. "Then you

can't see him" came her deadpan response.

As for one prescription in particular, she said the doctor would need to call and get permission to write the prescription first. "Why?" I asked. "Because of the nature of the medication". "But I've been taking it for close to 10 years and it's the only thing we found that works" I said. "Would you like to speak with our in-house nurses?" she asked. "Why?" "So they can explain your medications to you" she answered. "You mean the medication I've been taking for 10 years or the other medications I've been taking for the last 15 or so years?". "Yes sir, those". I politely explained that I most likely know more about my medications than their in-house nurses. "If I did, can they refill them?" I asked. "No sir, you have to see your doctor for that" in perfect monotone. Then it dawned on me. Those weren't gray clouds over my head. They were pigeons.

The Great Obamacare Circle Jerk: The Final Round

I'm one who really hates leaving loose ends. Call it a quirk of mine. I just like finishing whatever I start, particularly if there is the potential to learn something new. So on that note, let me take you back to a previous article of mine,"The Great Obamacare Circle Jerk", which I posted on April 12. As you recall, I had been stripped of my primary healthcare provider of nearly 33 years by my state's healthcare exchange and forced in to a new healthcare program which I didn't want. My wife and I were completely happy with what we had.

I filed a "Continuity of Care" request, which was submitted to the insurance company's medical review board. I pointed out that my primary doctor and I had a strong and unique relation which stretched back close to 33 years. I stressed that he became the kind of subspecialist I needed as a result of my rather unique set of medical circumstances, and that he was perhaps the only doctor in the area with this subspecialty. He treated me as an equal partner in my care; none of this "godlike" attitude which some doctors are notorious for having. He always listen to my suggestions and read any material I came across, which we'd discuss during my next office visit (I've always taken a proactive stance to my medical care). I also pointed out that if they didn't want to cover this doctor, that I would be willing to pay for the office visit out of pocket.

Although the insurance company assured me it would be only five to ten days before received a response, it was a full two weeks after their ten day limit came and went. Meanwhile, I called every day after the tenth day passed, always getting someone new, to ask if they had made a decision; explaining each time the same events over and over to whomever was unlucky enough to get my phone call. I repeatedly stressed the importance of keeping this doctor, and pointed out that I was in need of an immediate decision since I was getting low on my prescriptions.

It was always on my own initiative in calling them. Never did they ever call me. Anyway, some two weeks after their promised response deadline lapsed, I was finally advised of their decision. According to the hapless customer service representative, my request had been denied. I was told that their decision had actually been made almost a week prior but had just recently been entered into the system. How interesting I thought since each time I'd call I was told that either an email or phone message was being left with their medical review team in change of making the decision. You would think somebody would have the professionalism or common courtesy from this committee (if indeed there really is one) to either contact their own representative for a call back to me or better yet, to call me personally since I asked that my request be treated as urgent, but no.

When I asked why, I'm given a story, which in hindsight, seems a bit farfetched. Accordingly, I was told that the medical review committee designated someone to contact the doctor's office to see if they would agree to accept their insurance. As you may recall from my previous article, my doctor had carried this particular insurance for years, but effective the first of January 2015, would no longer be accepted. I was also advised that I could not pay by credit card or even by cash! Can you imagine being turned down for cash? Well, I was, and now the insurance company is telling me that I'm not allowed to pay cash or credit card for anything medical as it would constitute a "fraud". Admittedly, my first thought was disbelief. I've never been turned down for good ole American greenbacks ever. Then I was hit with the thought, could this be what people mean by the so-called Obamacare "death panels"? You are forced to accept treatment from who they approve or do without. By the same token, they can turn you down for a particular treatment and there is nothing you could do about it or any place you can go since you are "in the system" and there's no recourse beyond the appeal. As for a new doctor, I was given a choice of three---none of which have the expertise that I require. I asked if it wouldn't be cheaper to allow me to see my existing doctor than for me to see a new doctor who was not only unfamiliar with me but unfamiliar with the type of treatment I required? The end result I pointed out could be misdiagnosis, wasted office visits and fees, not to mention useless prescriptions and possible ongoing trips to an immediate care center or even emergency room...all of which they would have to pay for.

Naturally they "sympathized" with my situation, but stated that their decision was final and there was not further appeals. Since I had previously brought the matter of prescriptions, I was told that certain medicines (including one in particular that I'm taking) could be rejected no matter what it was for or how well I responded to it. To be more specific, I was told that my doctor (whomever that turns out to be) would have to call to get permission to prescribe it each time as long as there was no generic version. Otherwise, they reserved the right to decline coverage of the prescription and/or authorizing a substitute of their own choice (thus overriding the physician). Then they had the audacity to end the call by thanking me for calling and asking if I was satisfied with their responses! I admit dear reader, I've never done well with authority figures, and I tolerate even less bureaucratic simpletons setting in a cube somewhere, who has no clue who the hell I am or cares what my unique medical needs are, making decisions about me---especially my healthcare---based on their bottom line or some profit making arrangement they've made with a drug manufacturer. That just doesn't cut it with me, but there it is.

Right now, we have several local Republicans running for governor; each of whom has promised to either reform, cut back or vanquish our Obamacare based insurance system (for that matter, so are various potential and announced GOP Presidential candidates). Listen, I am absolutely the poster boy for what's wrong with my state's insurance system. It's not the hassle free system that they try to make it out to be, but at the same time, without it, we and others like us would have no coverage at all. The problem here is that it was rolled out without being fully thought through. Two years in, and there are still plenty of bugs, glitches, and administrative "Catch 22" issues, which is where I find myself.

What is needed is something more sensible like a single payer platform wherein everyone receives a basic level of coverage and then have the option of buying an additional "add on" coverage cafeteria style that fits their unique healthcare needs. This could be done either on the open market or through their employer. That way everyone gets to see at least some measure of medical care and small companies, which couldn't afford to offer insurance to their employees, could still remain competitive and those currently offering (or struggling to offer) insurance could cut back on their benefit packages without unduly affecting their employees. Another obstacle which should be removed immediately is a simple one: allow individuals to keep their existing doctors regardless of what package they have. After all, wasn't that President Obama's primary argument in selling Obamacare to the American People---that no one would lose their doctor? Or that we wouldn't lose our prescription coverage? Well, under Obamacare and at least Kentucky's version, that is proving to be a blatant boldfaced lie. Not everyone gets to keep their doctor, even if they're a specialist and no one else is available. And no, not everyone gets to keep their medication unless there's a generic substitute, otherwise, they simply don't get the medication or they're forced into taking something which may or may not work or work as well; even to the point of potentially having a negative reaction to it.

So friends, there you have it. A firsthand account of someone who has dealt with Obamacare and Kentucky's insurance exchange. For

some, perhaps even the majority of individuals, it may work. However, it remains flawed and it has been my experience thus far, that if you happen to fall into the category where you are in some way an exception to their rule, such a requiring a specific doctor, continuing with a specific doctor, or requiring a certain medication, and I would add to that requiring certain medical procedures, you're in deep trouble. The system doesn't allow for exceptions nor do the faceless bureaucrats running system seem to particularly care about your medical needs. Their sole concern seems to be about improving their bottom line, and in that quest, just maybe, is the truth about the so-called "death panels" we've all heard about. Naturally, I'm sure it's nothing personal.

The Great Obamacare Circle Jerk

I tend to keep my private life, well, private. Mainly because I think there are more important things happening in the world which warrants more attention than me. However, did you ever have one of those days or weeks where something so absurd happen that you just simply had to say something, if, for no other reason, than for simple validation that you're not going crazy? Well, as you might have already gathered, an event like that just happened to me. I guess the best place to start is at the beginning since that's the only way to grasp the full absurdity of the situation
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Let's go back to 2013. After 24 years, the company I worked for decided to lay off its senior legal department personnel, along with some of the senior clerical staff. Well, I was "the" senior legal manager for the company. I oversaw a multi-million dollar receivables portfolio; was involved in training; the company's overall top fee earner; and held an assistant vice president level position as a special projects coordinator for the company's president. Basically, I was in charge of improving efficiency, moral, and productivity. I worked with all the department heads, as well as with the head of the North America division and with senior individuals in the home office in Paris, France (we had been bought out about six years earlier by a French commercial insurance company).

As strange as it might sound, I was ok with it. Seriously. I knew it was time to leave. I was simply waiting for the most opportune moment. Well, obviously the moment chose me instead me choosing the moment. Shortly after leaving and settling into my new life, I applied through Kentucky's new insurance exchange, Kynect, which was created as part of Obamacare. This was in August. However, it wasn't until February 2014 that we were actually able to be coverage. Despite all the positive media hype, we encountered one problem after another. Even the people who took over our application encountered repeated problems which seemed to result from issues involving programming (lots of "work throughs" and "wrap arounds"), not to mention a lack of adequate personnel---especially programmers---being available. As an aside, despite claims to the contrary from the Governor's office, Kynect was fraught with problems involving a lot people than just us.

Nevertheless, come February 2014, some six months after originally applying, my wife and I finally received coverage. Because we were already in the system, we were given our choice of start dates---January, February, or March. We though the easiest avenue (to avoid further confusion) would be March. So when the documentation was submitted by Kynect to the insurance company, someone at Kynect though we really meant to say was April, not March, and so they changed the start date without alerting us. Well, that delayed things yet again, but at this point we were used to it. After that, everything seemed to settle down. We were happy with our coverage since we could keep all of our doctors and had no problems getting any prescriptions filled. Well, you know what they say about getting to comfortable right? That's usually when the rug gets pulled out from under you.

Near the end of December, I started getting notices from Kynect about our insurance being switched. I made several calls to Kynect and to the insurance provider and was told to just ignore the letters; they were likely sent out by mistake. Yeah, right. As it turned out, Kynect opted to switch our coverage without consulting us. So, after we somewhat embarrassingly found out that we no longer had the coverage we thought did (or with who we thought), I phone Kynect to ask what happened and why it happen. I was rather nonchalantly told that our coverage had been changed and, no, apparently we couldn't really do anything about it. It was suggested, however, that I might want to speak with a customer service representative in Community Based Services. Boy, did I ever!

Well, the individual I spoke with at Community Based Services was polite enough, but, alas, said I couldn't do anything. I had to take what they offered or get coverage on the open market. Some choice. However, on the upside (from their perspective), I was eligible to pick between three different but essentially same type of policies. It was suggested that I make a list of all our doctors and prescriptions and call back to go over which of the policies includes our doctors. Sounded fair enough, so I make a list of all our doctors along with any prescriptions and called back. Although I had to speak with a different individual, the notes were clear enough for them.

We determined that most of our doctors were supposedly available under one particular policy, although my primary doctor was still a

question. Not to worry I was told. Even if he wasn't covered, I could still pay cash for the office visits and they would cover any procedures or tests. Again, I was reminded that I had the option of declining coverage and purchasing a policy on the open market (which would run about $2000.00 a month). Being newly retired, I thought the better part of valor would be to accept the policy being assigned. Besides, I though, I could always pay for my visit if I had to right?

Fast forward to mid-March this year and my first visit since our policy change (for my annual physical and update on prescriptions). As it turned out, my primary doctor doesn't participate with this insurer. So, I offered to pay cash for the visit. It turns out that I'm not allowed to pay by cash or credit card or anything else under this policy type (it would be considered "fraud"). So, I left without seeing my primary doctor of 33 years. Frustrated, I called Kynect as soon as I got home. Once again, there was nothing they could do, and so I was transferred to another department where I was told unsympathetically to simply "switch doctors". I explained that my primary doctor was a specialist; the only type of his kind in the area, and besides, I had a 33 year relationship with the guy! They offered to find me a substitute, but they'll likely want to do their own testing despite any medical summary they receive. This will only further delay my medical care. That's not going to work I said.

So, I was again transferred to yet another department where I explained the whole situation once more. This time I was told that I

could file a "continuing physician care request", but it would take seven to ten days to get a response. Well, here we are 15 days into this and they can't seem to track anyone down who can make a decision. Meanwhile, I tried to have some prescriptions refilled. Turns out that this policy also doesn't include all medications! They will only approve certain medicines. What isn't approved has to be both "justified" by the issuing physician and there has to be an generic (what happens if there's no generic? Some types of medicines aren't approved for generic yet). And so here I wait. I can't see the doctor of my choice---my primary doctor of 33 years---and I may possibly have to see a non-specialist and start from scratch unless my request can be tracked down and approved. I can't get my long standing prescriptions refilled since I no longer have a primary doctor, who, if I did, would still have to contact the insurance company and "justified" his recommendations, and still there's no guarantee they'll approve the non-generic medication.

I'm remind of an old saying which says that if you can't be a good example, at least be a good object lesson. So, if you anyone tells you that Obama's Affordable Care Act---Obamacare---allows you to keep your own doctors, or go to whatever clinic or hospital you want, or that you can get your prescriptions filled without any problems, just remember my story.