January 4, 2014 by Tony Novak
This is the transcript of an email exchange I had today with a user of the free OnlineNavigator service. I changed the wording only where necessary to protect the privacy of the user. The bottom line is that next month this father will lose coverage for his son’s medical treatment that currently costs about $100,000 per year.
FATHER OF PATIENT: “My family will be losing COBRA coverage next month. I am self-employed and not eligible for a group plan. For three years my son has been in a residential treatment center (RTC) as that has been determined to be “medically necessary” and covered under my former employer’s plan. My son will need to remain in an RTC for approximately another year. We have maintained the COBRA coverage even though it is very expensive because it has covered the majority of the RTC expense. Is there any option where I can find coverage that includes the payment of the RTC monthly amount (or some portion of it)? Current monthly expense is about $8,600.”
ONLINENAVIGATOR: “It seems that you are destined for an insurance exchange, either the state exchange at (link removed) or a commercial exchange. Standard coverage will be available and the price of insurance is (theoretically) capped at 9.5% of household income. But the out-of-pocket costs for deductible and co-payments are generally higher than COBRA because the inherent differences between individual insurance and employer-provided plans.
The coverage for the treatment center is likely to be the same, however we really don’t have enough information to know for sure. It seems likely that the coverage for this specific treatment/facility should be the same as a matter of law regardless of the insurance plan you select. However, we are beginning to hear an increasing number of problems with restricted provider networks in the post-reform health plans. You will obviously want to check with the facility before selecting an insurance plan.
My suggestion is to first determine if you are likely to qualify for a premium tax credit (see this link), then:
– If yes, go directly to your state exchange (link removed); that is the only way to get the credit right now. It can be done directly online, but professional help may be lacking.
– If not, get a qualified insurance agent who can help with all of the exchange options to select the best plan for your situation. I have confidence in (and am paid to endorse) the agents at Members Insurance Exchange at (800) 609-0683.”
FATHER OF PATIENT: “Thanks for your help. My son’s treatment is defined as “habilitative” and as such an “essential health benefit” under the ACA. I have contacted 2 carriers in the ID exchange that will provide individual plans. When I ask if his RTC is covered they say “yes if it’s an in-network facility.” Then I ask for the list of in-network facilities and they say “there are none so it’s not covered.”
ONLINENAVIGATOR: “Wow! I am sorry to hear that you are among the newly emerging stories of life-altering problems with the Affordable Care Act.
We see that the government publication defining minimum coverage says:
If the EHB-benchmark plan does not cover any habilitative services and the state does not define those benefits, then pursuant to 45 CFR 156.115(a)(5), the issuer determines which habilitative services to offer as a part of a two year transitional policy.”
This seems to be the determining law in your state. In other words, your situation was intentionally and deliberately not covered by the Affordable Care Act in order to control claim costs and exchange premiums during the first two years of the new law! There is no requirement or motivation for the health plan to cover these services and, on the flip side, substantial risks and detriments built into the law for doing so.
I can only urge you to make your story public, bring it to your elected officials and take appropriate financial planning measures to protect yourself.
Although it is no consolation to you, I am beginning to read details more of these cases in professional forums over the past few days and I suspect they will dominate news coverage of health care reform before long.
Finally, it appears that the facility proving treatment is likely to have other patients with the same problem and may have some response. Roughly 5% of the state population is likely to be similarly affected, and therefore the treatment facility has significant motivation to develop an appropriate response.”
FATHER OF PATIENT: “This is so frustrating. It’s not that I expect my son’s expenses to be picked up by a plan as I realize our country can’t afford that health insurance that takes all pre-existing conditions. What is frustrating is that the ACA was “sold” to the voters based on just those type of false claims”.
Unfortunately, I suspect that we will read many more of these horror stories in the next few months.