Well, the ACA missed a big group of people in its qualifying event list. Girls who are on their parents insurance until age 26 are usually not covered for prenatal care. Surprise! I guess it’s understandable, but it also doesn’t count as a qualifying event, so you can’t sign up via Healthcare.gov after open enrollment, nor can you jump on your employers policy. I think it should be a qualifying event, mainly because so few people realize this is the case until it’s too late. My friends daughter is now faced with bills that her insurance company, over the phone, told her would be covered. I told her to appeal based on that. Also, the dr did a second, probably not medically necessary ultrasound at 10’weeks. Her first visit was at 6 weeks, shouldn’t they have known the insurance wasn’t paying by then?
She makes too much for a subsidy. I told her I would try to figure out the best place to get private insurance in NJ. She missed the ACA deadline, but if don’t think it matters since she isn’t getting a subsidy. I directed her to finder.healthcare. Gov (not sure of site name now)
Any advice for her as far as getting a policy? She will be able to get on her company policy when the baby is born this fall. They told her she can get Cobra, but that it is usually quite expensive.
The dr just told them the claims were denied for the visits she had. They didn’t realize it wasn’t cover until now, 5 weeks after first appt. prenatal must be covered for the insured and/or spouse, NOT the dependents. I read that 70% of large company policies exclude it. Individual and small companies must include it (or so read). And, as I said, it’s not a qualifying event to change your employer coverage.
Medicaid, here she comes. Or there may be other ‘birth in NJ’ plans available to her. WIC can supply some services for her too, like food while she is pregnant and for her and the baby after birth.
People need to READ the policies and what is covered. Many plans are ACA compliant and diagnostics are covered but treatment is under the deductible - the often times $5000 deductible. Read the coverage.
She has a good job. No Medicaid, no WIC no handouts. At 23 she is realizing how much the non working receive,that the working have to pay for. A good job is great but it still,stinks to be slammed with 1,000’s of medical,expenses and a new abay at the same time, when you thought you had insurance because everybody said the ACA covers maternity…oops. And when you have a job where you could buy insurance but, oops again, it’s not a qualifying event and you just missed sign ups. I suggested a birthing center and midwife…she didn’t go for it!
I am googling and googling. It seems that you can’t buy ANY insurance after the deadline? Every site says the deadline passed and if you don’t have a qualifying event you can’t sign up. Dropping off the parents plan is not qualified event. Is it true that a person can’t just call up Horizon or Cigna and say they want to sign up? I see short term insurance mentioned, but the sites I tried don’t offer it in our area. (NJ).
My D works for a NJ company at their headquarters in NJ. She found out that her company sneakily registered and bought insurance in NY so they are not covered somethings that NJ mandates. In addition, some companies use Aetna but only to administer their self-insured policies. This will also skirt NJ mandates.
We had no idea this could happen.
Had she known earlier she would have signed up under her husband’s policy which has excellent coverages but she missed the enrollment period.
Oftentimes, you don’t know your coverages until you have to use it.
The seriously bad part is that she is willing to buy coverage (even though she has coverage!) and she seemingly can’t. But, my lazy a s s. Cousin can sit home and get Medicaid…
Now I am starting to see the side of why the ACA isn’t all bad, it just fell a little short here.
I would check how the doctor’s staff submitted the claims. I have excellent insurance and my wife has one doctor that was contiually getting claims denied for an expensive treatment. I knew it was covered and worked with the insurer. We found out the office was using the wrong code to submit the claim. Sad to say the office never could get the claim thing worked out so my wife gets the treatment somewhere else.
Sometimes the office staff is not as good as other doctor’s office staff.
She should check with hospitals in the area. Here, I knew of a couple of girls who didnt have insurance, made too much for medicaid. The local hospitals have maternity clinics, so for a flat rate of maybe 1000k , they will do all the prenatal visits, delivery, etc. Now granted this was many years ago, but it is worth a shot.
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My D works for a NJ company at their headquarters in NJ. She found out that her company sneakily registered and bought insurance in NY so they are not covered somethings that NJ mandates. In addition, some companies use Aetna but only to administer their self-insured policies. This will also skirt NJ mandates.[\quote]
Are you sure about this? I thought if an employee lives and works in a state, the laws of that state trump. To provide insurance to workers who live and work in a state, the insurance company has to be licenced in that state which means they have to abide by that state’s laws. That’s why there’s that whole discussion about selling across state lines, which now is illegal. We must be missing some of the story.
That NPR link doesn’t tell me a thing, except that you can’t sign up outside the open enrollment period if you find out you are pregnant because that in itself isn’t a ‘life event’. The concept of ‘life event’ applied to company based insurance before the ACA was ever passed. If I was working for a company and wanted to make a change to my insurance, I could only do so after the baby was born, not once I found out I was pregnant. So that isn’t an ACA change of any kind.
I am honestly still confused by the issue. If this girl WAS on her parents’ insurance policy, and didn’t drop off yet, she should have coverage. Unless she went outside their insurance network or they have a high deductible that has not been met yet. But her parents need to have signed her up for their coverage each year (including at the end of 2014 for 2015) through their employer (assuming they have employer based insurance). And she needs to use doctors and facilities that are in their network (a challenge of its own sometimes when there are specialists involved, but that would be the topic for another thread!). And someone needs to pay up to the deductible amount for the plan (there can be individual and family deductibles) and pay the copays. But prenatal care should in general be covered under ANY insurance plan if she meets those criteria. Under the ACA, I actually don’t see how the employer could get out of it.
The ACA problem, as I see it, is that it allowed women to stay on family policies until age 26 which is normally great. It just wasn’t widely publicized that the maternity coverage, so widely acclaimed by Obama about how all women will be covered, doesnt cover many of those women on parents’ policies. If this girl wasn’t able to be on her parents she’d be on her own, and be covered!
The second part is that I still don’t know if a person can buy private insurance without it being open enrollment. Yes, enrollment periods always existed for employer coverage, but did they for private coverage? I am concerned that she won’t be able to buy her own policy for coverage until open enrollment. You should be able to call,up,a company and buy from them if you want to and they are willing. Also, short term coverage is available, but maybe ot in Nj due to ridiculous over regulation.
Anyway, my point here is not to debate it. The employer and the Dr told her she is not covered. Mom is a teacher and I think someone in her building (a union rep? Benefits person?) told her she is not covered. Now what can she do? That is the question…where can she BUY coverage?
As far as I know, one cannot buy health insurance outside of open enrollment.
Yes, being dropped from a family plan feels like a life change event, but it is not according to the rules. This situation is like so many others when the government writes out rules and some people slip through the cracks- when it’s good for the person we think of it as a loophole, when it’s bad, we are all upset. The rules are written and no common sense interpretations can be applied, it is by the rules only.
I would not blame the doctors office, they only go by what the insurance company says. I had people who did sign up and were actively paying for exchange plans, but due to delays, the insurance companies saw them as not covered and took a month or two to update their insurance and then more time to redo the prior claims.
This is definitely a crack in the system. I would call several local agents and see if any of them have discovered any loopholes that could apply to this situation, they would only find this out in the way your friend found this problem. I am sure many people have not thought through and realized that this missing coverage issue exists. One thing might be possible, could they pay for add on maternity coverage via the work plan?
She can look to minimize the expenses realated to maternity care. She can look into midwifery services as they will most likely be much less expensive. I know that you already brought this idea up but she is being foolish to ignore this option. If she is near the facility, I would very highly recommend it. http://midwivesofnj.com/