Parents Discover That Even Obamacare Has Gaps

Not all health plans are the same, as Washington consumers have learned the hard way.

Many who bought health plans in the last open enrollment period assumed their coverage included big regional hospitals. Then they found out these hospitals were excluded to make the plans affordable.

Among them, 2-year-old Micah Clark, who was rushed last month to the emergency room at Seattle Children’s Hospital for severe groin pain. His mother Jenni later learned the cause was a type of hernia common in children, a condition in which the intestines bulge through the muscle wall near the groin.

“It can be life-threatening,” Clark said. “It’s really painful.”

Fortunately for Micah, his intestines retracted. But there is a chance the problem could recur. Micah would need surgery to repair the hernia.

Turns out, the procedure would be the simple part. The situation became complicated when Clark learned that Seattle Children’s was not part of their network.

“We went to Seattle Children’s assuming we were covered, and later we found out we weren’t,” Clark said. That meant the family needed pre-approval from their health carrier, LifeWise, for surgery at Children’s. So Clark put in the request.

But before she got a response, Micah was already back in the ER for the same problem. Clark then learned that her request for surgery at Seattle Children’s was denied. LifeWise said it would cover the surgery if Micah used an in-network surgeon in Auburn.

“We found out that he doesn’t typically do surgeries on young children; he primarily operates on adults,” Clark said. “And, even if he did, he wouldn’t do it because we’re covered by LifeWise, and where he does surgery is not contracted with LifeWise.”

Clark looked into two hospitals that were in her plan, but neither had pediatric surgeons. She appealed the denial, a process that can take up to 30 days. Had she known Children’s was excluded, she and her husband wouldn’t have purchased the plan.

“We didn’t know until we needed it,” Clark said. “I wonder if there are other families out there who have this coverage and won’t find out until they’re in a situation where they need it, and that’s not the ideal time to know.”

The Clarks have company.

Dr. Mark Del Beccaro, vice president of medical affairs at Seattle Children’s, said that since January, the hospital has processed requests for appointments or surgeries from more than 470 families whose health coverage didn’t include Children’s. He said that in these situations, Children’s appealed directly to the carriers. The hospital also hired four full time people to expedite cases deemed urgent.

That’s how Micah Clark was able to get his surgery.

“We’ll see them without knowing whether or not we’ll get paid or anything,” says Del Beccaro. “We just tell families we’ll do that because it’s important and it’s an urgent case.”

Seattle Children’s has sued the Office of the Insurance Commissioner. The hospital argues the commissioner shouldn’t have approved plans that exclude providers like children’s because the benefits fall short under the Affordable Care Act.

“We feel under the regulations that were brought forth from the federal government on how these plans are supposed to exist that they didn’t meet those requirements,” Del Beccaro said.

So far, a hearings officer has sided with the hospital and another hearing is scheduled in June.

Insurance Commissioner Mike Kreidler won’t comment on the lawsuit but said the new rules that take effect later this month should help consumers know who is in their health plan’s network – before they hit the purchase button.

“That’s something that wasn’t readily available to consumers starting through this enrollment cycle for 2014,” Kreidler said. “It’ll be much better, it’ll be much smoother. It’s a requirement for insurance companies to make that accessible to consumers.”

Nationwide, a growing number of hospitals are left out of provider networks. It’s become a new reality under the Affordable Care Act — how to provide consumers benefits mandated by the federal law without hurting their pocketbooks.

Eric Earling, spokesperson for Premera Blue Cross, an affiliate of LifeWise, said, “We continue to hear from consumers that affordability is a big issue.”

Affordability is why providers like Seattle Children’s were excluded.

“The reality is, there are some providers that are more expensive than others,” Earling said. “And in the case of Children’s, simply too expensive to provide full in-network coverage for all their services and still be able to offer as an affordable price as possible to all consumers.”

Earling said that doesn’t mean consumers don’t have access to specialty care. The company grants requests for so-called unique services. Since January it has approved more than 80 percent of these requests.

Clark said she’s grateful her son was able get surgery. She said she understands insurance carriers need to exclude some providers to maintain costs.

But, she said, “surgery for children, in my view, has to be something that at least someone can do.”

And when the next open enrollment period comes this fall, Clark said they know to look at which hospitals are covered in their network.