By skyforbes I'm still fairly new to dealing with insurance shenanigans by myself, so I wasn't expecting the application last year to take so long, or if that time frame is even considered a lengthy one to begin with? I renewed my plan in June of this year, and everything went smoothly; I also received paperwork in the mail confirming the entire renewal and approval process. I was also in Boston during the summer for an internship, so I was only using my insurance for pre-existing medications, which needed a change of pharmacy location during those 3 months. I am also a trans woman, so the plan was to schedule different consultations for FFS (facial feminization surgery) after coming back from Boston, since my case manager through Fidelis Care (HMO provided through NJ Medicaid) was helping me with the bureaucratic dealings of gender-affirming healthcare through insurance. Apart from that, I am also on antidepressants and anti-anxiety/OCD medications, if that is of any help for additional context.
On the morning of August 11th, as I was getting ready to go to work, I received a call from my case manager stating that my insurance was being terminated for ineligibility, with coverage ending on July 31st. I immediately called Fidelis Care, who then added NJ Medicaid to the line in order to have this issue sorted out. They told me (and this has been restated every week since then, more on that later) that this was a system error and that I was approved for another year of Medicaid coverage in June, so this was never supposed to happen in the first place. The Medicaid agent helping me then submitted a request for escalation to a supervisor and told me to rest assured, since the issue was being handled at the highest priority level. All of this was completely wild to me, considering that I've already renewed my Medicaid for this upcoming year, so what was all of that for? At the time, I was hoping that the matter would be resolved within a month, but that was far from reality.
Since that call, I checked back in with Medicaid every week for an update (the agent who submitted the escalation told me to do so every week or two), only to find the agents didn't know what was happening. I don't want to seem negative or pessimistic, but as unrealistic as it may be, I didn't get how none of the agents seemed to know what was going on. I kept getting vague responses, something along the lines of "just call back in a week to see if we have any updates, since it's just processing right now and we don't know how long it will take," with many of them also saying that they didn't see the claim being categorized as "priority," which confused me even further because I didn't know if that was an actual category or something the first agent said to make me feel better about this system error. I kept getting these responses every week, but I didn't think much of it because I also worked in retail, so I assumed these customer service workers were operating under the same framework and genuinely didn't have access to higher-level information.
Also important to note is that during this time, I was undergoing antidepressant and anti-anxiety medication withdrawal as my psychiatrist was unable to prescribe more medications without an appointment, which, without insurance, would be $400, not including the cost of the meds. My HRT (hormone replacement therapy) is through Rutgers, so I was able to pay out-of-pocket for my estrogen and progesterone each month, and even now.
Fast forward to the first week of October (I've been back in Jersey for months now and attending university full-time) & I finally received a letter from Medicaid stating that my insurance had been reinstated, with an effective date of August 1st. I called Fidelis Care later that day, only to get the same response: they didn't see my name as active coverage on the file, and the only information found showed that my coverage ended on July 31st due to ineligibility. I called Medicaid afterwards, and they told me to give it a week or so for the systems to update and reflect the active coverage, so I did so and called back next week, only to be met with the same response. Since then, I've been calling Medicaid 2 times a week, and each time the agent puts in another escalation to a supervisor, which doesn't get a response, so it's rinse and repeat. In the last week of October, one of the agents finally gave me some new information, beyond just telling me to be patient, since my claim (multiple at this point) was "processing in the order of being received." She said that apparently there are two systems–one which Medicaid uses, and the other which everyone else uses (HMOs, county offices, doctors' offices, etc.) For some reason, the active coverage is only showing up on the Medicaid system. It hasn't yet been updated to the central system used by everyone else, which is why Fidelis Care doesn't see my active insurance coverage either. They have to enter it manually in the other system, which takes time on the supervisor/higher-up's end, so that's what's taking so long. Her advice was to wait a bit longer and keep checking in once a week, which I've been doing up until this day.
It's now November 19th, and I can't keep living like this with no access to necessary psychiatric medications and within this "insurance limbo" that prevents me from living life without suffering from severe and persistent gender dysphoria. There have been no updates in each call, and I'm genuinely confused as to how and why it would take a system this long to update. I technically am insured, but there is nothing to show for it, so what's the point? I have no idea where to go from here, or whether there's anything to wait for. I don't know if it's an irrational thought, but is this happening to me because I need medical and surgical insurance coverage? Is this a "punishment" for not being a normal 21-year-old university student and having to undergo all of these medical procedures for a chance at living a less painful life? None of the insurance agents said there was anything else I could do, anywhere else I could go, or anyone to contact for further information, if not for trying to expedite this claim. I've read some insurance posts on different subreddits that mentioned contacting a local/state representative? Would that help with my case as well? I am just so over this whole thing, and I don't know if insurance workings in the United States is always this frustrating/complicated, and if this is simply the reality that I need to get used to.
I would greatly appreciate any help or advice in this matter. If additional information is needed from my end for more specific support, then just feel free to ask!