American Community/Golden Rule Takeover, Help Needed!

[CFP83]

I do not do health insurance, however I have a client who is in a real real bad situation.

He and his family was insured by AC, and now Golden Rule will be taking over these plans on guaranteed issue basis since AC went under. The kicker here is that his son has Down Syndrome.....AC covered his son's therapy treatments, however Golden Rule states although they are accepting all AC clients, their policies will not cover these treatments (because none of their policies cover these they claim). These treatments run about $1800 per month.

What is this client to do? I feel just terrible for the predicament he is in. The broker on the AC policy, who I referred him to, is struggling to come up with any solutions or answers on this. He is a higher income earner so he has some options that many would not have in this situation.

Thanks folks for any and all help!

 

[VolAgent]

Has he called the DOI? A little heat might make Golden Rule change its mind about this. Maybe there is a state program he can join that will pay for the treatments? After all, this was due to no fault of his own, he did the right think and had coverage, someone just pulled it out from under him.

Maybe you can move the kid to a child-only GI policy on Sept 23?

 

[jbage007]

Has he called the DOI? A little heat might make Golden Rule change its mind about this. Maybe there is a state program he can join that will pay for the treatments? After all, this was due to no fault of his own, he did the right think and had coverage, someone just pulled it out from under him.

Maybe you can move the kid to a child-only GI policy on Sept 23?

As much as I despise the most illogically named health insurer in history, why would they want to "change their minds" about something that is not covered under the contract???

 

[CFP83]

Maybe you can move the kid to a child-only GI policy on Sept 23?

His current health broker, the one I referred him to, and I had a phone conversation yesterday. He told me that Medical Mutual of Ohio will be the state's GI health plan. HOWEVER (and this is some real B.S), to qualify for this plan the broker has informed me that applicants need to NOT HAVE BEEN INSURED for the previous 6 months! So to get this plan for his 7 year old son with Downs, he would literally have to have him uninsured for 6 months before applying.

 

[VolAgent]

As much as I despise the most illogically named health insurer in history, why would they want to "change their minds" about something that is not covered under the contract???

Because they do not want the bad PR right as child GI goes into effect? Insurers change their minds all the time due to PR nightmares.
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His current health broker, the one I referred him to, and I had a phone conversation yesterday. He told me that Medical Mutual of Ohio will be the state's GI health plan. HOWEVER (and this is some real B.S), to qualify for this plan the broker has informed me that applicants need to NOT HAVE BEEN INSURED for the previous 6 months! So to get this plan for his 7 year old son with Downs, he would literally have to have him uninsured for 6 months before applying.

Yeah, I don't see that happening. What a real shame.

 

[CHUMPS FROM OXFORD]

There's always Ohio Open Enrollment to consider. High rates but a little more palatable for a child.

I don't get to use that word very often, but I like it. You know which one I am talking about. No...not "consider" or "more."

 

[somarco]

Insurers change their minds all the time due to PR nightmares.

True, and sometimes they pay claims extra-contractually, but this is different. This is a benefit that is (apparently) not part of their contract.

Your client can appeal and complain all they want but it won't do any good.

You need to find a plan that does cover the "treatments" and move the child there after 9/23.

And what kind of treatment is this? Some kind of special ed or physical therapy?

 

[CFP83]

And what kind of treatment is this? Some kind of special ed or physical therapy?

It is physical therapy

 

[AllenChicago]

I just looked at the State of Ohio insurance website and found this guaranteed issue program. It should work well for this particular client because the cost for a young person is very low compared to what the parents would spend on downs-syndrome therapy w/o insurance.

Program Link: Ohio Department of Insurance

Good luck CFP83!

-Allen

I do not do health insurance, however I have a client who is in a real real bad situation.

He and his family was insured by AC, and now Golden Rule will be taking over these plans on guaranteed issue basis since AC went under. The kicker here is that his son has Down Syndrome.....AC covered his son's therapy treatments, however Golden Rule states although they are accepting all AC clients, their policies will not cover these treatments (because none of their policies cover these they claim). These treatments run about $1800 per month.

What is this client to do? I feel just terrible for the predicament he is in. The broker on the AC policy, who I referred him to, is struggling to come up with any solutions or answers on this. He is a higher income earner so he has some options that many would not have in this situation.

Thanks folks for any and all help!

 

[CHUMPS FROM OXFORD]

Allen...Actually, that is the "Ohio Open Enrollment" that was previously mentioned. And you have to be careful and read the limitations very carefully. A MAN HAS GOT TO KNOW HIS LIMITATIONS. (Clint)

Here's an old sample policy:

http://www.goldenrule.com/pdf/GRI-STD-34200702.pdf