Looking back, Sam Bloechl knows that when the health insurance broker helping him find a plan asked if he had ever been diagnosed with a serious illness, it should have been a red flag. Pre-existing medical conditions don’t matter when you buy a comprehensive individual plan under the Affordable Care Act. Insurers cannot refuse people or charge them more based on their medical history.
But Bloechl, now 31, didn’t know much about health insurance. So when the broker told him that a UnitedHealthcare Golden Rule plan would cover him for a year for less than his market plan – “Unless you like throwing money, this is the plan you should buy,” he recalled saying — he signed up.
It was December 2016. A month later, Bloechl was diagnosed with stage 4 non-Hodgkin’s lymphoma after an MRI showed tumors on his spine.
To Bloechl’s dismay, he soon learned that none of the expensive care he needed would be covered by his health insurance plan. Instead of a comprehensive ACA-compliant plan, he had purchased a set of four short-term plans with three-month durations that provided only limited benefits and did not cover pre-existing conditions.
Because they tend to be cheaper, short-term plans continue to find buyers, and they have been championed by the Trump administration, which has eased restrictions against them, as an alternative for consumers.
With this year’s open enrollment period well underway, millions are seeking coverage in federal and state markets. Sometimes it’s hard to tell the difference between the comprehensive plans sold there and the “junk” plans with limited benefits and coverage restrictions.
“These plans continue to proliferate,” said Cheryl Fish-Parcham, director of access initiatives at Families USA, a consumer healthcare advocacy organization. “People need to be careful whether they buy over the phone or on a website.”
Bloechl assumed he was buying a comprehensive plan that would cover him for a life-threatening illness, although at the time he had no idea he was sick. But when doctors said Bloechl needed a stem cell transplant, Golden Rule denied the request.
The reason: He had seen a chiropractor for back pain before purchasing the plan. Bloechl had blamed the pain on the heavy work that came with running his landscaping business in Chicago. But Golden Rule argued he had sought medical treatment for a pre-existing condition – cancer – so the plan did not have to cover it. It doesn’t matter that he wasn’t diagnosed when he bought it.
The insurer also failed to cover his other chemo and radiation bills. Bloechl appealed the decision, but his appeals were unsuccessful. He had over $800,000 in healthcare bills – and that was before the stem cell transplant he desperately needed.
“It’s just disgusting that these companies expect Joe Schmo or some guy like me to perform [these policies] then get fucked at the end,” Bloechl said.
UnitedHealthcare declined to discuss this matter with KHN unless Bloechl signed a statement waiving his right to privacy. But he told KHN he didn’t feel comfortable signing a legal document provided by the insurer.
“Our agents work with individuals to help them understand their health insurance options and select a plan that best meets their needs,” UnitedHealthcare communications director Maria Gordon Shydlo said in an email. . “We tell each person their coverage options, including associated costs, network size and whether the selected plan covers pre-existing conditions. We adhere to a rigorous application process that helps ensure consumers understand the plan they ‘they buy before making a final decision.
Consumer advocates have long sounded the alarm over short-term and other plans that do not comply with Affordable Care Act rules that require plans to provide full benefits to all comers, regardless of their medical condition, and prohibit setting annual or lifetime dollar limits on coverage. However, ACA-compliant plans can also be purchased off-market, and this is where buyers can run into trouble, thinking they’re buying comprehensive coverage when they’re actually buying something a lot. more limited.
“It’s a bit of the Wild West out there,” said Sabrina Corlette, a research professor at Georgetown University’s Center for Health Insurance Reforms. “We often get calls about these products, and sometimes it can be hard to figure out what they are.”
Short-term plans have received a lot of attention in recent years. In 2017, the Obama administration limited their duration to less than three months to discourage people from relying on these limited plans for primary coverage rather than as a temporary bridge of coverage for people switching plans, as intended. But these plans were championed by the Trump administration as a cheaper option for consumers, and it issued a rule in 2018 that allowed short-term plans with terms up to 364 days, with an option to renew. up to 36 months. The rule requires that short-term plan documents explain that the plans are not full insurance and may not cover certain medical expenses.
Such plans may be attractive to healthy people who do not expect to need medical attention. But as Bloechl’s experience shows, life can be overwhelming.
“Our patients are often young and healthy,” said Ryan Holeywell, senior director of advocacy communications at the Leukemia & Lymphoma Society.
Some states restrict or even prohibit the sale of short-term plans in the retail market.
But these short-term plans are just the tip of the iceberg.
There are fixed compensation plans that pay a certain amount — $100 per day for a limited hospital stay or $150 for an OB-GYN visit, for example — that may not cover actual costs.
Accident and critical illness insurance plans provide lump sum cash benefits when people suffer medical emergencies like a heart attack or stroke under certain circumstances.
Cancer-only insurance plans can provide hospitalization coverage, but not other services. “You can get chemo and radiation but never go to the hospital,” said Anna Howard, policy manager at the American Cancer Society’s Cancer Action Network. “So politics may never pay.”
Then there are bundled plans that combine options, like a short-term plan with a prescription drug discount card and cancer coverage.
Unfortunately, consumers can’t always rely on insurance brokers to provide accurate information or direct them to comprehensive coverage, as Sam Bloechl discovered.
In August, the federal Government Accountability Office released a report on the experiences of “secret shoppers” who called 31 health insurance sales representatives and asked about the plans, saying they had pre-existing conditions such as diabetes and heart disease. In more than a quarter of cases, salespeople “engaged in potentially misleading marketing practices”, according to the report, including falsely claiming that drugs such as insulin were covered or offering a plan that did not cover not pre-existing conditions.
One of the reasons brokers might encourage consumers to buy non-ACA plans: higher commissions.
“In our survey of brokers, they report paying higher commissions than ACA plans,” Corlette said. Some brokers have indicated that they avoid non-compliant plans, however, because they pose risks to consumers.
The National Association of Health Underwriters, an organization of health insurance and benefits professionals, did not respond to a request for information and comment.
Consumers can be sure they’re getting a comprehensive, ACA-compliant plan if they buy it from the marketplaces put in place by that health law, Howard said.
Brokers can help people understand their options and buy a plan, including ACA-compliant plans, but choosing a broker can be difficult.
“Ideally go see someone in a brick-and-mortar building who has to bump into you at the grocery store,” Corlette said.
After his experience with Golden Rule, Sam Bloechl decided his best option was to offer a group plan for workers at his small landscaping company that he could also enroll in. He worked with another broker and he had lawyers review his policies. considering. He wanted to be sure that whatever plan he bought would cover his stem cell transplant.
The new plan has it covered. And by the time he went to settle his bill of more than $800,000, his income had dropped so much because of his illness that he was eligible for charity care. The hospital canceled his bill.
His cancer is in remission.
But the experience of short-term politics always makes one cringe. “Charitable care paid for the only bill and [UnitedHealthcare Golden Rule’s] competitor paid for the transplant,” he said. “They got away with it without paying a penny.