Can this Grandma find better ACA coverage for daughter's family?

[FredaNJ]

Hello,
I am not at all familiar with ACA coverage choices, since my husband and I are on Medicare with a Plan G supplement.

My daughter and her husband have an ACA Silver plan, which does not reimburse for any out-of-network health care provider. Their son has recently been diagnosed as on the autism spectrum and has started Occupational therapy and Speech therapy, which has been really helping him. Unfortunately the place they use is out-of-network and they really don't see an option to switch to anywhere else.

Since my daughter and husband cannot afford the cost of this therapy, my husband and I are paying for it. We're committed to doing this, but would like to explore whether better insurance coverage would offer at least some reimbursement, and whether the extra premium cost would be less than the anticipated reimbursement.

We have no idea how to get an answer to this. While I know my daughter could provide information directly through an ACA marketplace to see what a gold or platinum plan costs, I don't want to press her to do that. I'm hoping the knowledgable people here can give me some direction to find answers without initially involving my daughter.

Many thanks.

 

[ImaCheesehead]

Perhaps go to www.healthsherpa.com and put in their zip and ages to search for plans. You may then also be able to check to see if a certain provider is in any given plan

 

[FredaNJ]

Thanks for the healthsherpa.com. When i went to the site and plugged in the zip, they (Cigna) have not plans in the relevant zip code. I appreciate the direction to try and welcome any other ideas.

 

[cathy63]

Thanks for the healthsherpa.com. When i went to the site and plugged in the zip, they (Cigna) have not plans in the relevant zip code. I appreciate the direction to try and welcome any other ideas.

Unless she has experienced one of the qualified life events (marriage, divorce, birth or death in her family, relocation, ...) that allow for a special enrollment period, she can't make changes to her coverage right now. She has to wait until open enrollment in November to choose a new plan that will be effective on January 1, so I think you are stuck with the status quo for the remainder of this year.

For next year, why does it have to be Cigna insurance? Is that the only plan the therapist accepts? If it is, then check with Cigna and see if they sell a plan in that area that's not on the exchange that would include the therapist. Your daughter would not be eligible for a subsidy or cost sharing if she purchases a plan directly from Cigna, so if she's getting those benefits on the exchange, the math to switch may not make sense, but you'd have to run the numbers to find out.

If they are willing to switch away from a Cigna plan, you can look at the exchange for their state and see all the plans that are available to them. If it's New Jersey, the exchange is here: https://www.nj.gov/getcoverednj/ Take a look at the plans for their ZIP code and see if one covers the therapist that your grandson is using, then you can see if it would be cheaper to switch to it.

You'll have to do these calculations again in November because plans and rates for next year aren't available yet, and even if you do find a good plan now, it's possible that it won't be offered next year.

 

[ivinsfan]

Why do you have to use Cigna? And FYI any changes can't be made until open enrollment and won't kick in until Jan 1 2022...


I suggest you have your DD ask the therapy place what kind of insurance they accept as a first step.


Cross posted with Kathy63

 

[FredaNJ]

Cigna not necessary

I only mentioned Cigna because that's the company that sponsors healthsherpa.com, which was recommended as a place to start investigating. She can go with any company available that suit their needs.

I understand about waiting until open enrollment in November. We're prepared to pay out of pocket, just hoping that 2022 can be little less expensive.

I'll definitely check the NJ site that cathy63 posted. Thanks for all of the help so far.

 

[ivinsfan]

I only mentioned Cigna because that's the company that sponsors healthsherpa.com, which was recommended as a place to start investigating. She can go with any company available that suit their needs.

I understand about waiting until open enrollment in November. We're prepared to pay out of pocket, just hoping that 2022 can be little less expensive.

I'll definitely check the NJ site that cathy63 posted. Thanks for all of the help so far.

Just wondering if it's possible to get a non insurance price from the provider has your DD asked for a cash non insurance discount? You should always ask.

 

[rpguy4]

You could try using this ACA website to find a plan their doctor would be considered in-network : https://www.healthcare.gov/see-plans/#/plan/results
You have to put in some basic information, but it will let you see what plans are available, and if their doctor is considered in-network for that plan.


But as mentioned you wont be able to change anything for this year. You'll have to wait for open enrollment.

 

[candrew]

Since your DD and SIL are currently enrolled in a ACA marketplace plan, they can change plans due to the COVID-19 emergency through August 15. I went through the process myself last week. It was a straightforward and painless process. Saved myself some dough, as well!

https://www.healthcare.gov

 

[ivinsfan]

Good info candrew, but not a lot of time..


What happens to any OOP or deductibles that you might have already paid?

 

[candrew]

What happens to any OOP or deductibles that you might have already paid?

Good question. There is the chance that OOP/deductibles *might* reset if they change policies and/or insurers. That's something each person would have to weigh against any potential upside of making such a change. I elected to keep my same policy. At the very least, it is likely that the OP's DD & SIL can lower the cost of their current coverage. My premium was lowered 63%.

And yes, time is running short. Only 3 days left.

 

[PaunchyPirate]

If the OP cannot find an ACA exchange insurance plan that includes the provider as "in-network", they could also consider purchasing a plan "off" the exchange. In my county in Pennsylvania, the plans from the ACA healthcare exchange are relatively inferior offerings. They have limited networks and coverages. However, those same insurance companies sell insurance plans off the exchange that have better, wider networks and coverage models. However, they cost more because they cost more and you cannot utilize government ACA subsidies with them.

However, depending on how much per month you are talking about for the out-of-network care you are currently paying for, you might be able to find an off-exchange plan that covers it that is affordable.

The insurance companies that offer off-exchange plans may or may not be the same companies that offer the on-exchange plans. You may need to hunt around to find which companies sell off-exchange plans in your location.

 

[cathy63]

Since your DD and SIL are currently enrolled in a ACA marketplace plan, they can change plans due to the COVID-19 emergency through August 15. I went through the process myself last week. It was a straightforward and painless process. Saved myself some dough, as well!

https://www.healthcare.gov

Oh, good point! I completely forgot about the special Covid provisions.

 

[EastWest Gal]

There are provisions if there is no one in local in-network that can provide the services. They need to talk to the child's PCP and insurer, and request that the provider accept in-network rates. See below how this might be done.

And it's true, you can switch until August 15th. But don't trust the website 100%, or the OT and PT provider's website. Talk to their billing departments and find out which plans they do accept. This is probably the best avenue for this year.

In future years, be sure to find a plan in which the providers are in-network. If there is no in-network providers, then you need to work with your grandchild's pediatrician to appeal to the insurance company to pay for services as in-network. It's complicated. There are advocacy groups for autism.

Next, ASD is a considered a lifetime disability, which may make your grandchild eligible for Medicare as secondary insurance eventually.

Information for your grandchild's state may be found here:

https://www.ncsl.org/research/health/autism-and-insurance-coverage-state-laws.aspx

This document is from an ASD advocacy group. On page 17 on, it describes how to obtain coverage, including sample appeals letters.

https://autisticadvocacy.org/wp-con...es-A-Guide-for-Individuals-and-Families-1.pdf

I know this is all very daunting, and it's been years since I've been in the thick of the appeals process for an autistic patient, and I'm sure the process has changed. I've probably given you too much reading material, but I hope something helps.

 

[Aerides]

I would do the following:

Ask the facility for the complete list of providers they accept - shop the marketplace for them
If that doesn't work, and there's still no coverage...
Ask the facility for others that would be equivalent. Ask the actual doctor you are working with if needed. Most of them are going to want you to get care even if it means moving to another provider
Barring that, if there's no other place and no chance of coverage, ask for financial assistance/sliding scale support.

 

[FredaNJ]

Thanks so much to everyone who responded so far. I'm going to dig into the NJ resources referenced by EasWest Gal for sure. I'll also call the provider's office to find out whether they are in-network with any insurance companies.

I was unaware about the Medicare possibility for my grandson, and appreciate the info. I'll try Medicare.gov to see what I can find out.

Right now we're spending $800.00 per week for his therapies, none of which is covered by their insurance. We can afford it, but want to find a better way going forward.

Thanks again.

 

[ivinsfan]

Thanks so much to everyone who responded so far. I'm going to dig into the NJ resources referenced by EasWest Gal for sure. I'll also call the provider's office to find out whether they are in-network with any insurance companies.

I was unaware about the Medicare possibility for my grandson, and appreciate the info. I'll try Medicare.gov to see what I can find out.

Right now we're spending $800.00 per week for his therapies, none of which is covered by their insurance. We can afford it, but want to find a better way going forward.

Thanks again.

Have you actually asked the provider for a reduced rate. If 800 dollars is the rack rate you might be able to get some reduction from that. I'd be surprised if you didn't something knocked off. You don't actually say if you have asked.


The insurance won't pay 800 a week that's a given ....

 

[FredaNJ]

No, I haven't asked for a reduced rate and frankly never thought of that.
I did just talk to the billing person at the provider's office and found out that they aren't in-network with any insurance for the therapy he's getting. They had two suggestions:

1. Ask our insurance for an exception, as EastWestGal also suggested. We'll definitely start that process. I think the provider will help us with this.

2. Find another insurance that covers out-of-network OT and speech therapy and evaluate the premium increase vs. the level of coverage/co-insurance/deductible.
I'll try to do that, but we'll probably not be able to make the ACA enrollement deadline of August 15th.

3. Fortunately, another treatment he's scheduled to start as soon as he comes to the top of the waiting list (Applied Behavioral Analysis) is covered. Apparently NJ law requires insurance to cover this particular therapy for autism, whether in or out-of-network.

My daughter is quite overwhelmed with everything she has to do regarding his treatment and isn't as speedy as I would hope. For that reason, I'm trying to shoulder some of the burden.

 

[ivinsfan]

No, I haven't asked for a reduced rate and frankly never thought of that.
I did just talk to the billing person at the provider's office and found out that they aren't in-network with any insurance for the therapy he's getting. They had two suggestions:

1. Ask our insurance for an exception, as EastWestGal also suggested. We'll definitely start that process. I think the provider will help us with this.

2. Find another insurance that covers out-of-network OT and speech therapy and evaluate the premium increase vs. the level of coverage/co-insurance/deductible.
I'll try to do that, but we'll probably not be able to make the ACA enrollement deadline of August 15th.



3. Fortunately, another treatment he's scheduled to start as soon as he comes to the top of the waiting list (Applied Behavioral Analysis) is covered. Apparently NJ law requires insurance to cover this particular therapy for autism, whether in or out-of-network.

My daughter is quite overwhelmed with everything she has to do regarding his treatment and isn't as speedy as I would hope. For that reason, I'm trying to shoulder some of the burden.

You are a good grandma....that billing person wasn't too helpful. You'd think they would be a little more proactive since they admit they aren't in network anywhere.


Number 1 suggestion will take a lot of back and forth.


Number 2 could be workable considering the large amount of money involved. My impression is that out of network payments are smaller then in network payments so you still might owe the difference.



Do you have any contacts within a local support group for kids like your grandchild? They would most likely have some answers that could help you, more then we do anyway.

 

[FredaNJ]

Thank you, Ivinsfan. The billing person was lovely and willing to do whatever she could to facilitate the application for an exception from the insurance company. I didn't think to ask her for a reduced rate, but will certainly do so if we don't get anywhere soon.

I realize that none of our options will include full coverage for the current therapy - just hoping for some help, since this seems to be a long term commitment.

I don't have contacts with a local support group yet, but will certainly look into that. There's mountains of online information about autism treatment, but very little about insurance issues.

 

[pb4uski]

Hello,
I am not at all familiar with ACA coverage choices, since my husband and I are on Medicare with a Plan G supplement.

My daughter and her husband have an ACA Silver plan, which does not reimburse for any out-of-network health care provider. Their son has recently been diagnosed as on the autism spectrum and has started Occupational therapy and Speech therapy, which has been really helping him. Unfortunately the place they use is out-of-network and they really don't see an option to switch to anywhere else.

Since my daughter and husband cannot afford the cost of this therapy, my husband and I are paying for it. We're committed to doing this, but would like to explore whether better insurance coverage would offer at least some reimbursement, and whether the extra premium cost would be less than the anticipated reimbursement.

We have no idea how to get an answer to this. While I know my daughter could provide information directly through an ACA marketplace to see what a gold or platinum plan costs, I don't want to press her to do that. I'm hoping the knowledgable people here can give me some direction to find answers without initially involving my daughter.

Many thanks.

Perhaps you can work backwards... ask the OT and ST providers if they are in any insurer networks and see if any of those insurers offer ACA policies.

 

[ivinsfan]

Perhaps you can work backwards... ask the OT and ST providers if they are in any insurer networks and see if any of those insurers offer ACA policies.

Sadly they have already told that they aren't "in network" with any provider.



I think she shouldgo to a local support groupand see which insurers are more lenient about including out of network providers in special circumstances. Not much point in switching until they figure that out.