Are You Covered? Student Health Care: The Rob Ashe Case

Rob Ashe, a 24 year old guitarist and MSUM student, has had the unique experience of dealing with three different insurance companies, and dealt with the problems caused by his disease as well as the problems with the private insurance companies.

Ashe was diagnosed with juvenile rheumatoid arthritis at the age of 16. His immune system would attack the proteins in his joints, causing them to swell and making it difficult to move. At that time, he was started on a type of steroids to help with the problems, before moving on to a drug called Enbrel. Enbrel works by shutting down the immune system, which provides relief for the chronic pain and joint damage from arthiritis, but makes one more vulnerable to infections and other diseases. When it was first released, it cost about $4,400 a month, but it has recently dropped down to just below $2,000.

Ashe’s father was in the Air Force, and his military insurance extended to him. “It was great. They didn’t ask any questions,” Ashe said. “You just got your prescription from your doctor and it was filled, but there was no arguing or red tape. You got your medicine on time and received great care.”

It wasn’t until Ashe graduated that he began to run into trouble with the insurance agencies. When applying for insurance, you need to provide a Certificate of Creditable Coverage for any pre-existing conditions. This shows you’ve been covered before, and basically tells one insurance company what they had covered. When Ashe finished college, he got a job three days after graduation.

According to the CoCC form, “You can add up any creditable coverage you have, including the coverage shown on this certificate. However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a plan may not have to count the coverage you had before the break.” On average, it takes about 60 days for a business to file you under their company health insurance plan. If there was a problem with any filing, it could require a new medical exam, and his problems could be classified as pre-existing conditions.

Ashe was covered by Meritain Health at his new job. The company would agree to cover the bills, but then recode it to add costs to an earlier date. According to Ashe, Meritain Health would make estimates of how much they would cover, only to apparently realize it would cost them too much, and decide to cover less. This meant Ashe was getting bills that said what he owed at the current date was $0, but he owed thousands of dollars in the column for several months ago. Ashe ended up threatening legal action against them, and they blamed the problems on “clerical errors.” The problem is, nobody gets to see how or why they do this. “You see what happens, you just don’t get to see how it happens,” Ashe said, describing the bills.

When Ashe decided to go back to school at MSUM to pursue finishing a music degree, he saw that there was a new health insurance policy offered by the school: United Health Care. MSUM is operating as a test school for this health insurance, and United Health Care is working toward covering other state schools in Minnesota. When you sign up for school, you are automatically signed up for the health insurance, unless you opt out by telling the school you are covered by another company.

Knowing the problems he had before, he called ahead to make sure Enbrel would be covered. According to Ashe, after 45 minutes on the phone, he was given confirmation that it was covered and would be billed as a major medical expense. Once signed up for school, he found out that was incorrect. Because Enbrel is a prescribed drug and self-administered, they categorized it as a prescription expense, which has a $2,000 dollar prescription drug cap under United Health Care: enough for one month of his drugs. United Health Care was looking to cover as many students as possible, and so they kept costs low. However, this meant that the level of coverage was also low, and didn’t even have a category for major medical.

Looking to find help, he turned to something the drug company had set up called the EnCourage foundation, which helps people who can’t afford insurance get Enbrel. If you cannot afford insurance and do not have it, the drug can be provided for free. The problem is, MSUM policy requires you have health insurance. He would have to lie to the school, or drop out of school if he dropped coverage. Also, if he dropped his coverage, due to his condition, he would never be allowed back onto a health care plan because his juvenile rheumatoid arthritis would not be covered without a CoCC.

While trying to work out the problems with United Health Care and MSUM, he worked for weeks trying to get answers. He was denied his medicine and his health quickly began to deteriorate. It wasn’t until he threatened to contact his lawyer and the media that he managed to get their attention. Unfortunately, he has yet to receive word from United Health Care on his case. If he were to continue to be denied his medicine, his joints would lock up and suffer permanent damage, and he would be unable to attend school to study guitar performance and audio production.

According to Ashe, United Health Care was looking to cover the most students possible, and to do that they sacrificed on quality. Ashe contested that he, like many others, didn’t do anything wrong with the forms or didn’t do anything wrong to cause his health problems. Unfortunately, the system currently in place means that any problems that occur are on the shoulders of the citizens, leaving the insurance companies to move numbers behind the veil and deny help to those who need it the most in order to increase profits.

To be fair, United Health Care provides affordable health care to many students that might not be able to afford any health care at all. For those who can afford a choice, however, it is important to know the details of a potential investment.

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