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Anyone have experience dealing with a large claim where the official parties involved might not be understanding the insurance coverage?
Yesterday I called a policyholder covered at the 94% cost sharing level on coverage through Marketplace, checking to see about how a close family member's MAPD was going. The conversation switched to the under 65 ACA subsidy client.
To shorten the situation, the doc says the carrier told his office: over $6k as the OOP for a new specialty pharma treatment. Under this client's 94% CSR that's impossible. Coverage not refused, just high OOP mentioned. Pharma co reportedly is absorbing all but a copay under a special program, but even that would most likely exceed the client's small max OOP and not contribute to meeting it if carrier doesn't pay. Sure, it would be good to not have carrier pay the $10k or so per treatment from a loss ratio hit POV. I am assuming this could come back to haunt all involved, if not handled by the book. I realize this is all filtered thru the client, but, still. Did not bring up my concerns with client...who is happy as is, thinking it's the only option.
I left a message with carrier, may be coming in late due to weather. Will see how this plays out.
Yesterday I called a policyholder covered at the 94% cost sharing level on coverage through Marketplace, checking to see about how a close family member's MAPD was going. The conversation switched to the under 65 ACA subsidy client.
To shorten the situation, the doc says the carrier told his office: over $6k as the OOP for a new specialty pharma treatment. Under this client's 94% CSR that's impossible. Coverage not refused, just high OOP mentioned. Pharma co reportedly is absorbing all but a copay under a special program, but even that would most likely exceed the client's small max OOP and not contribute to meeting it if carrier doesn't pay. Sure, it would be good to not have carrier pay the $10k or so per treatment from a loss ratio hit POV. I am assuming this could come back to haunt all involved, if not handled by the book. I realize this is all filtered thru the client, but, still. Did not bring up my concerns with client...who is happy as is, thinking it's the only option.
I left a message with carrier, may be coming in late due to weather. Will see how this plays out.