Aca question

[COZICAN]

Hey guys. I came on here a few years ago so high on life about FIRE only to have it snuffed Sept 2019 with a lung cancer dx on my 57 (then) yo wife. Not to bum anybody out but the cancer has moved to her brain and we have been treating that. Small details....she is doing pretty good; I'd say most days are 85%+ with some dropping into the 60% quality of life arena. She is now under Hospice care. I am as of today on 12 weeks of FMLA and not sure what after that should she continue to survive this monster.

My question is for those who have experienced something similar (pre-existing condition) and switching to an ACA plan. I can stay on COBRA for 18 months after FMLA but the premiums are 8X what I can get on ACA. I've read the "legal stuff" about pre-existing conditions but fear being denied any type of treatment in the future. Really, what insurance company would want to jump in the middle of this.

We're 59/58 and at this point I'd guess her chance of 12 months survival is slim. Doctors had to say 6 months to get her on Hospice. I'm really not looking for sympathy but felt you need the whole story to know where we stand. Any opinions are welcome.

Coz

 

[zinger1457]

Haven't gone through anything close to what you're dealing with but being covered for pre-existing conditions has always been one of the keys to ACA, the cost to cover it is built into the high premiums. What you would need to be aware of when selecting an ACA plan is that you will be limited to that plans in-network doctors/facilities. While your wife should continue to be covered for the care she needs there's no guarantee she could continue to use her existing doctors under ACA.

 

[SecondCor521]

Sorry about your DW and the dx. Good doctors, especially experienced ones, can sadly be pretty accurate about how long someone has left.

My Mom was on hospice for the last five months of her life after about ten years with IPF (a progressive, fatal, incurable disease). Hospice was a really good choice for her and for our family because she was able to enjoy (such as it was) those months rather than waste time chasing treatments and doctors and interventions that would not have helped.

My understanding is that hospice care is also relatively inexpensive compared to typical interventional treatment, so insurers are likely to cover it. (In my Mom's case, it was morphine and oxygen.) As far as an insurance company not wanting to step in the middle of it, a well-run company charging the proper premiums and having a large enough customer base should have the funds to pay for covered care.

The ACA, again my understanding, has eliminated pre-existing conditions, so that should not be an issue. If you choose to enroll in an ACA plan, you will need a qualifying event to enroll outside of the open enrollment window (which is normally in November / December each year). If you left your job and lost your employer coverage, that would certainly be a qualifying event. In my state you need to have all your paperwork done by about the 15th of the month in order to get coverage to start on the first of the following, so keep that in mind if you transition from an employer plan to an ACA plan.

I think the main thing I would check is with any insurance plan you are looking at, make sure her existing doctors are on it. You should also read the plan documents carefully. Personally I have been on a few different ACA plans and have had exactly zero issues with them paying claims according to the policy.

You may want to check with your employer to see if they have any leave of absence benefits. My former employer had an LOA benefit that was in addition to FMLA, I just had to ask for it. I think I got a 12 week LOA and still got to keep my health insurance, earned vacation, kept stock options, and didn't burn any of my FMLA time.

Sorry again and good luck to both of you.

 

[pb4uski]

My uderstanding is that under ACA during the annual open enrollment period that the insurer can't deny dverage because of any pre-existing conditions... nor can they deny claims on pre-existing conditions once the policy is in force as long as the premiums are paid.

Just be careful that you are comparing apples-to-apples in terms of deductibles and co-pays. While I wouldn't normally recommend other than bronze level policies, in your situation a higher level policy might be better for your wife. You don't need to have the same level policies... you could have bronze if you are in good health and perhaps silver, gold or platinum for her.

Also, is your current coverage PPO? My understanding is that in most areas of the US that ACA policies have trended away from PPO and to HMO recently.

 

[davebarnes]

If your COBRA premiums are as high as you say, then get an Obamacare Gold plan for the best coverage.

 

[cathy63]

I am so sorry to hear about what you and your wife are going through.

This is not related to ACA, but one thing you might want to look into is what happens if you don't go back to your job at the end of your FMLA. The law allows your employer to recoup the cost of your benefits from you if you don't return to work after FMLA. There are some exceptions, and a spouse's continuing illness might be one of them, but it's something you should check into so that you aren't surprised later on.

 

[MBSC]

The ACA plan may have a smaller provider network and smaller drug formulary. Be sure the hospice provider and any other medical services will be in-network.

My understanding is your family is on a group plan while on FMLA and has the option of COBRA or ACA when it ends in 12 weeks (November). Any amount applied to the group plan's deductible and OOP will carry over to the COBRA plan if a change is made before 1/1. They will not carry over to the ACA plan and the Dec. premium is based on 2020 income. A move from COBRA to ACA could then be made on 1/1.

In this scenario, I would use an experienced, local insurance broker with a year round office if you choose ACA enrollment. Some popup during AEP and disappear the rest of the year. A good broker will handle enrollment and any issues for you so you can spend time with your wife. I wish your family the best.

Really, what insurance company would want to jump in the middle of this.

That is why only a few carriers offer ACA Marketplace plans in OK. The others (Aetna, Cigna, Humana, UHC, etc.) are not willing to accept the risk.

The employer may recover its share of health plan premiums if the employee fails to return to work after his or her unpaid FMLA leave entitlement has been exhausted or expires, unless the reason the employee does not return is due to:

* The continuation, recurrence or onset of a serious health condition of the employee or the employee's family member...the employer may require supporting medical certification of the condition.

Source: https://webapps.dol.gov/elaws/whd/fmla/8d4.aspx

 

[Rainbowdash]

As a physician myself, once a patient goes to hospice, it is not that important to keep the same doctors anymore, the goal of treatment has changed to just keep patient comfortable, make sure the patient does not suffer in her final days, this can be easily done by any hospice doctor, I would just choose an ACA plan that you are comfortable with (copays, deductibles, OOP max, etc ). If you choose inpatient hospice (hospice inside a facility) you will max out your OOP max, if not, you can probably just get a ACA bronze. Insurance companies have expanded hospice coverage to avoid unnecessary hospitalization and use of expensive experimental drugs. Good luck to you

 

[Scrapr]

I am so very sorry Cozican.

It was my understanding (late wife was on hospice) that the government (Medicare?) pays for the hospice care. I don't know about deductibles as we maxed out early in any year. As rainbowdash says it really should not be expensive as all active treatment has to stop. We found hospice care wonderful. Lots of help is available.

I am sending virtual hugs to you & your wife

 

[walkinwood]

I would hire a good insurance agent to make sure you have all your paperwork etc in order. It will not impact your premiums, but with all that you already have on your plate, it may be good to have someone else double check everything.

 

[COZICAN]

Thank you all. I’ve gathered some good advice and opinions. I’ll be around.

Coz