C is for Costs
Even those with the best insurance available will likely find that there are many things that are either not covered, not approved for coverage, or the portion of which you are responsible for is anywhere from challenging to exorbitant and thus simply not feasible.
There are lots of examples of things that are routinely not covered as what’s called durable medical equipment that to some are a mere nuisance but to others are an absolute necessity for a safe and functional life.
Let’s assume you were paralyzed and unable to use your legs. You can’t do some of the most routine tasks on your own without assistance. You have to fight to get the appropriate wheelchair, but thankfully the physical rehab hospital you were in after your injury was able to find a program that could help with that. When the ambulance crew transported you home from that same hospital they carried you up the stairs leading in to your apartment, but now you are literally stuck in your own home.
Providing you have the means you could have groceries delivered or potentially have a friend or family member bring them until you can locate a suitable first floor apartment once your current lease is up. Problem solved, right? Well not exactly. Even if you conquer all the aforementioned barriers what happens when that food you’ve consumed needs to exit your system?
I know that sounds like a disgusting topic, but bear with me for a moment. There’s a logic to my choice of topic. See here is where the durable medical equipment topic comes in. The thought of going to the bathroom may not enter your mind as an able-bodied person other than a task you simply must do in life. But as a paralyzed individual you are unable to transfer to the toilet without proper equipment. As such this is a major barrier to your safe and functional life.
However, the insurance company doesn’t cover the needed riser to go on top of your toilet to raise it to a safe transfer height, nor does it cover the equally as necessary toilet rails to provide you the handhold, leverage, and stability to prevent falls. These are both considered uncovered expenses and as such they are not covered. Nor is the wall mounted grip for you to use as a hand hold when transferring.
Without the equipment, your life now becomes a daily risk of further injury by falls purely because someone in an office somewhere decided that these items were “not medically necessary” for your proper and effective care. This is just one of many examples, one that I thought that maybe the most people could fathom.
One short example of another common scenario is obstructive sleep apnea. The proper treatment for the vast majority of cases is continuous positive airway pressure therapy also known as CPAP. The machines and equipment for these are not cheap by any means, and Medicare as just one example, covers only 80 percent of the “allowable” fees for the equipment. The first 12 months of using the machine they essentially rent it from the DME supplier, after which they consider it as paid for and it is yours until you qualify for a replacement, usually no sooner than five years.
During those 12 months you are responsible for the 20 percent that is not covered, usually up front in today’s world. This can amount to roughly 50 to 100 dollars a month you weren’t budgeting for. Then there’s the cost of the tubing, masks, filters which all wear out regularly and frequently need replaced. Each insurance provider may cover different amounts, but let’s say we stick with the simple 80/20 model used above. Some of these masks can cost upwards of 100 dollars a piece needing replaced roughly every three months on average.
CPAP therapy is quite literally a life saving treatment that is not only needed to keep you alive but can, as studies have shown, prevent other serious and even fatal complications from sleep apnea. Yet if you don’t happen to have the money available to pay for these items up front, you could easily find yourself making a life or death decision. One that if your machine breaks after the twelfth rental month and before the five-year authorized replacement cycle you will also be making.
Repairs typically aren’t covered unless the machine is either still under the manufacturer’s warranty, or still within the initial rental period. If it is broken beyond repair you, not your insurance, will have to figure out how to come up with roughly 500 to one thousand dollars to replace it.
What costs have you found to be a barrier to your health, safety, or quality of life? How were you able to mitigate or overcome these costs?
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