Sorry, You're Screwed

Good news never comes with that many names on the top of the letter... new post on Health Insurance Issues With Dave

The letter came from The State of Ohio, The Ohio Department of Insurance, and Medical Mutual. Good news never comes with that many names on the top of the letter.

We are sorry to inform you that your Ohio High Risk Pool coverage will be canceled at the end of the day on November 30, 2012.

The letter was dated November 12, 2012. 

Some of the unhealthiest residents of the State of Ohio were being tossed off their insurance policy, the Ohio High Risk Pool. In less than three weeks they would no longer be insured. And nobody is standing in line to cover them. How could this happen? 

The Ohio High Risk Pool is part of the Patient Protection and Affordable Care Act(PPACA). A stop gap measure, the states were charged with the duty of offering coverage for the chronically uninsured suffering from significant preexisting conditions. The federal government also provided five billion dollars of which Ohio received $152,000,000 for the four year program.

To qualify for the Ohio High Risk Pool you must prove:

  1. Citizenship
  2. That you have not been credible insurance coverage for at least six months
  3. That you have been declined by two insurers within the last six months
  4. You may skip #3 if your medical records show that you have a major illness that would have gotten you declined 

You can not have had credible insurance coverage in the six months leading up to your application for coverage under the Ohio High Risk Pool. This is a federal requirement. Neither the State of Ohio nor Medical Mutual of Ohio, the insurer running our plan, has anything to do with this rule. Some people who are not easily insured have purchased supplements, a better than nothing option. If something happened while they were attempting to find real insurance or qualify for an affordable program, these responsible people were trying to do what they could. 

My friend Dave is a conscientious insurance agent. He took a letter from American Medical and Life Insurance Company (AMLI) to the Ohio High Risk Pool. The letter, dated February 11, 2011 was sent to clients to advise them that their policy was no longer HIPAA credible coverage. Dave verified that since the AMLI CoreValue policy was no longer credible coverage, his clients, including family members, could retain this minimum semblance of coverage until they had six months of no real insurance and could enter the Ohio High Risk Pool. NO PROBLEM. 

It is those people, those responsible people who attempted to have some coverage, no matter what, who are being kicked to the curb. The letter from the State specifically notes:

Our records indicate you were enrolled in an AMLI policy in the six months prior to enrolling in the Ohio High Risk Pool Program. Therefore, CMS directed us to cancel your coverage because you are not eligible for this program.

The PPACA is a poorly written law. We know that. Worse, the rules and regulations are being written on the fly. What complies one day is non-compliant the next. We went through this with the grandfathering rules. The costs, both human and financial, can’t possibly be calculated. 

The Ohioans being kicked out of the High Risk Pool did nothing wrong. They followed the rules of that moment. We are talking about individuals who are gravely ill. What do they do now?

This post is contributed by a community member. The views expressed in this blog are those of the author and do not necessarily reflect those of Patch Media Corporation. Everyone is welcome to submit a post to Patch. If you'd like to post a blog, go here to get started.

Bethany Tipton Snyder November 16, 2012 at 10:33 AM
I am an insurance agent also and I understand your point. Supplemental health insurance is not the same as regular health insurance but it *is* insurance. And frankly before ACA there was NO high risk health pool at all. A half measure is certainly better than no measure.
Linda Ellis November 17, 2012 at 06:22 PM
There seems to be a lot of conflict and confusion to go around here. CoreValue Medical is truly not real health insurance. When I became uninsured in June of 2010, an independent agent tried to sell me on purchasing a CoreValue policy. After "Googling" CoreValue and learning about the complaints registered against them, I said "no way!" They are not real insurance and pay so much less on claims than what many people realize. I am not an expert on this exact situation, but all I can say is for people to please do their homework!! If in doubt, contact the Ohio High Risk Pool to learn more and write down names and dates too for your discussion. The agent involved here who promised that it should not be a problem to enroll in the Ohio High Risk Pool got it wrong; maybe innocently so. However, please don't lay all of the blame on the Affordable Care Act! CoreValue Medical has been a 'bad apple', and in states like Washington and New York their department of insurance officials have dealt with them harshly. What more people need to realize is that before the ACA all Ohio had to offer someone losing their creditable coverage was "Open-Enrollment" Plans with monthly premiums that range over $1,000 to $2,000 a month; especially for older folks. Hopefully with the exchanges in 2014 more affordable options will emerge.
Linda Ellis November 17, 2012 at 06:35 PM
Thank you for bringing this to light Dave. The problem I always had is that if you call the ODI they'll tell you to contact HHS. Finding the right people at HHS in order to register a complaint is bigger problem. Then we get back to Medical Mutual who will only tell you that they administer the plan. Maybe too many fingers in the pie. I am not surprised though to see situation occur with CoreValue Medical. It seems to me that since ODI, Medical Mutual and Ohio.gov are all on the letterhead, some answers should be able to be gotten from them.
Linda Ellis November 17, 2012 at 06:38 PM
SOURCE: http://www.corevaluemedical.com/default/index.cfm/plans-and-benefits1/#eligibility "**These limited benefits plans are underwritten by American Medical and Life Insurance Company and are subject to the company’s underwriting guidelines, exclusions, limitations, terms and conditions of coverage as set forth in the insurance policy and certificate issued which include a pre-existing condition limitation and other restrictions. This insurance is not basic health insurance or major medical coverage, and is not designated as a substitute for basic health insurance or major medical coverage. This is a limited medical benefits plan that provides benefits with limits defined by covered type of medical care or procedure. The limitations are disclosed in the certificate of coverage which is a part of the member kit made available shortly after completion of enrollment."
lyn November 17, 2012 at 06:39 PM
I think its terrible that certain things are "grandfathered". Just because you might be part of a plan, certain things, like preventative costs, are not covered as those who are newly covered. Another bad part of all this. Don't get me wrong - I like much of what Obamacare offers. But, when things like a colonoscopy are not fully covered under existing plans but are under new plans, that is ridiculous. This could mean people deciding to not go through this test which is recommended because it will cost several hundred dollars - unless you have a new policy. Dumb! The costs are minimal compared to what they would be if cancer should develop, and this could have been easily prevented.
Linda Ellis November 17, 2012 at 06:47 PM
Offering some reading. SOURCES: http://www.complaintsboard.com/complaints/core-value-medical-plan-pennsylvania-c344257.html http://www.complaintsboard.com/complaints/american-medical-life-insurance-co-florida-c342781.html
Dave Cunix November 17, 2012 at 08:59 PM
Linda Ellis - I am not personally familiar with the CoreValue policy. I have not written it. The agent in question did contact the Ohio High Risk Pool prior to getting getting this policy for several people. One of the people involved is a gravely ill family member. He, his clients, and his family members were very aware of the policy's limitations. This was strictly better than nothing for the six months or less that they needed to wait. It is the fact that he did his due diligence that makes this such a fiasco. Lyn - Grandfathered policies may be less than current contracts. The colonoscopy you cited is $3500 and it isn't getting cheaper. That is part of the difference.
lyn November 17, 2012 at 09:08 PM
If you are on a company plan, they can claim the plan was in effect prior to Obamacare, so you are in a no win situation. You are stuck in having to pay your deductible and copay if they didn't cover a preventative exam that would be fully covered under Obamacare - is that fair? Seems that is one of many things wrong in the whole Obamacare due to pushing it through so fast, without knowing what they were approving, and without getting input from more than just one party.
lyn November 17, 2012 at 09:14 PM
The only way to get around the grandfathered clause is to go out and get a completely new heath plan - not very likely or reasonable.
Linda Ellis November 17, 2012 at 11:30 PM
Hi David. It sounds like a rep. who just picks up the phone at the Ohio High Risk Pool, if that is who the agent spoke with, probably didn't realize that there would be an issue which would cause the person to be denied. A gravely ill person certainly would not be getting much coverage for their serious illness by being enrolled in CoreValue Medical. It just might have been better to go uninsured if the parties involved qualified for some assistance. Many facilities like the Cleveland Clinic for example offer significant help, as you know, even if your income is over the FPL. I went uninsured for six months and had both types of experiences, good and bad.
Linda Ellis November 18, 2012 at 05:00 PM
I have always felt that among the biggest drawbacks of the high risk pools, like the Ohio High Risk Pool, is the mandatory six month wait a person must put in just to qualify to enroll. I don't think I've ever really heard a sensible argument to explain the reason why that had to be. I mostly hear "so people don't jump ship all at once from their insurance companies." But, then people will stay on extremely expensive plans if they can handle the costs (or think they can)) until they qualify for Medicare or even Medicaid if need be. Being uninsured forces a person to look for creative ways to qualify for other types of help even if they don't qualify for Medicaid. Cleveland Clinic, as one example, offers help even for those 400% over the FPL: Source: http://my.clevelandclinic.org/patients-visitors/billing-insurance/financial-assistance.aspx Hopefully, one year from now as 2014 approaches, and Americans know shortly they will no longer be denied from enrolling in legitimate, affordable (we hope it will be!) and worthwhile (no longer $5 to $10 thousand dollar deductible plans with $50 co-pays at specialists) health insurance plans, the future will be brighter. It can be a long and arduous time when you need to patch together your life as best you can when your insurance options are quite limited. Not understanding poorly worded details can lead someone to making wrong choices for handling their health care needs.
Linda Ellis November 18, 2012 at 05:14 PM
Hopefully in a little over 13 months, with the onset of the insurance exchanges, this problem will go away for those who need health insurance but have not been able to qualify to get it. Then there will no longer be a need for scams to operate or the extremely expensive "Open-Enrollment" plans we have had in place here in Ohio where monthly premiums can be over $2,000 a month that prevent most uninsured people from enrollining in them due to the unafforadably high cost.
Dave Cunix November 18, 2012 at 10:07 PM
Not everyone qualifies for help from the Cleveland Clinic. Not everyone would ask for that help, even if he/she might qualify. I recently watched someone sweat out the six months. It was a nerve wracking experience for her. The whole six months with no coverage business has put more than a few people in a bind.
Linda Ellis November 18, 2012 at 10:24 PM
Hi David. I merely used the Cleveland Clinic as one example. Certainly not everyone would ask for that help. I worked for 42 years, 26 of which was for Progressive Insurance before my layoff in 2008 at age 60. There is a lot of pride we have in being able to pay for our own insurance. After my COBRA ended, I also was uninsured six months and during that time I broke a finger for the first time in my life! I also had a need for a blood draw during that time which was a learning experience. I was turned away from the lab when I did not have an insurance card to present. I ended up at the financial councellor's office for over an hour (it was a complicated blood test) and paid $262.00 out of pocket with a credit card before I was allowed back in the lab and my blood drawn per my doctor's script. It doesn't hurt for people to explore all of their options; to me there is no shame in it. Facilities that offer extra help are there for those who qualify. We don't always know if we qualify until we apply. Again, I feel there is no shame in applying if the program is available. I was run through the Medicaid system and denied so I knew my status, but the extra help can mean a lot to someone who is uninsured and still not eligble for the high risk pool. Being uninsured may mean only a six month period, which can be long for some and yet considered a short period for the long-term uninsured. The main thing is not to enroll in a program that is truly a scam like CoreValue.
lyn November 19, 2012 at 12:10 AM
Since you know when COBRA will end, can't you arrange for coverage ahead of time so that the new policy will begin when COBRA ends? I thought you could do this so the end dates and begin dates of the 2 policies would coincide - but then again, I'm not an expert in the insurance field like the 2 of you.
Linda Ellis November 19, 2012 at 12:34 AM
Hi Lyn, I did apply in the private insurance market weeks prior to when my COBRA coverage would end stating I desired a coverage start date to commence the day after COBRA ended. Believe me I was working ahead and keeping my nose to the grindstone with this issue so hopefully I would give myself the best chance to have a seamless coverage from COBRA to private insurance since I did not have another job with employer-sponsored health insurance. I applied mainly by accessing the website: ehealthinsurance.com. I applied to 4 different carriers: Celtic, Aetna, Anthem, Medical Mutual. One by one, I started receiving my replies. Most determination notices came right to my in-box, others by regular mail. In all cases, I was rejected for coverage due to having pre-existing health conditions. I was told that when you are first rejected, you are most likely to face denial for coverage by other private insurers, and that was true for me. So, yes, you can apply for health insurance prior to losing COBRA coverage. I believe most carriers would request you submit your HIPAA letter to them to prove your previous 18 months of creditable coverage which COBRA will provide to you after your coverage with them ends. Lyn, I certainly do not consider myself an expert, just someone who has lived through some of the experiences connected with losing employer-sponsored health insurance and found it difficult to obtain a viable affordable replacement plan.
Sandy Giancola December 05, 2012 at 11:30 PM
Yes, I am one of those who "just got screwed" I had core medical, have $13,000 in denied claims, have the paperwork that says "core value is NOT credible insurance, which is the reason I was accepted to Medical Mutual High Risk, only for them to revoke it 4 months later. Sent in my appeal along with the denied claims, which they now say is credible "enough". But still dumped. Im extremely upset that they can do this, am being told many people are getting lawyers because it is illegal what they are doing. But here I am, uninsured, and being told that I might have to go at least a year with no insurance.
Linda Ellis December 06, 2012 at 12:18 AM
Hi Sandy, thank you for sharing your story as well. I am not an expert, but I have known that CoreValue is nothing but trouble, and your experiences prove it. I know when I first read the CoreValue brochure back in the Spring of 2010 it stated that they were HIPAA compliant, etc. and I took it to mean that they were offering creditable coverage. Now, I see that is not the case. This change obviously is causing a lot of confusion and headaches. Have you contacted the Ohio Department of Insurance about your situation? Also, your state and/or federal representatives may be of some assistance in trying to help you get this sorted out so you don't lose your Ohio High Risk Pool coverage and become uninsured. Do you think if you become uninsured you would qualify for some assistance in other ways? Perhaps your primary care provider would agree to still see you and you can pay a co-pay upfront. Yes, the exchanges will not come onboard until January of 2014 unfortunately when adults can no longer be denied insurance coverage due to having pre-existing conditions. If you were only on the Ohio High Risk Pool 4 months, that is less than 18 months, so I'm not sure how much that will work to help you obtain new coverage. Obviously, since you have been on the Ohio HIgh Risk Pool I'm sure you were denied coverage in the private market. I would contact all those whom you think can help you, Sandy, at this point it seems you would have nothing to lose.
David Randolph December 31, 2012 at 02:16 PM
The OHRP policy holders cancelled effective December 1 2012 have been reinstated retro back to December 1. They were cancelled not because of anything they did wrong, but by a misunderstanding within HHS of the definition of Credible Coverage. The good news is that HHS renstated their coverage and my faith in the system. This was never a question of was the Core Value any good. It is not a Major Medical Plan. Not Credible coverage under PPCA laws and was used only to bridge the 6 month gap required by law to qualify for the OHRP. These policy holders have coverage again and that is all that matters. The system will work for and protect them as promised.
Dave Cunix December 31, 2012 at 02:44 PM
David, That is great news. I know that you and other agents spent an incredible amount of time and energy to get this error reversed. And yes, it is important to note and thank the people at HHS and the Ohio Dept of Insurance for sticking with this and finding a solution. As anyone working in the senior market knows, there are more than a few glitches in the system. The Patient Protection and Affordable Care Act minimizes an agent's function to that of a Navigator, someone who will point the consumer in the right direction. That would be like saying that the main duty of a Congressman is to appear on Sunday morning talk shows.
Linda Ellis December 31, 2012 at 02:48 PM
Thank you Dave for reporting the good news about the final outcome. I remember back in June of 2010 when Core Value was suggested to me, I was sent their brochure by email by the independent agent trying to help me get health insurance after I was rejected for coverage in the private market. I know they had their HIPAA compliant statement included on the online brochure. Now, when I last looked it was no longer there. But, no matter how you look it at, Core Value was never actual health insurance as one would consider it to be such as what we have been familiar with on employer-sponsored plans or private insurers such as Medical Mutual or Aetna. The best news is that starting 2014, when the marketplace exchanges begin, and the Ohio High Risk Pool sunsets, people seeking private insurance who are not able to obtain health insurance any other way, will no longer be shut out due to having pre-existing health conditions.
Linda Ellis January 11, 2013 at 07:19 PM
This situation looks to have been reversed? http://www.politico.com/story/2013/01/feds-ohio-in-dispute-over-high-risk-pool-eligibility-86036.html http://www.politico.com/story/2013/01/feds-ohio-in-dispute-over-high-risk-pool-eligibility-86036_Page2.html
john nafal January 11, 2013 at 07:31 PM
I heard moda of lakewood is clearing out the men's section. They are expanding thier women's end of retail.They are not closing the store at 14203 madison.You must see the prices in the men's section everythings $7.00 dollars or less.
Linda Ellis January 11, 2013 at 07:37 PM
What does your comment have to do with this topic?
john nafal January 11, 2013 at 07:49 PM
Sorry wrong article.
Linda Ellis January 11, 2013 at 09:18 PM
Linda Ellis January 11, 2013 at 09:20 PM
Hi David, I just saw this news story today. So, was this decision reversed again??? See link below. http://www.politico.com/story/2013/01/feds-ohio-in-dispute-over-high-risk-pool-eligibility-86036.html http://www.politico.com/story/2013/01/feds-ohio-in-dispute-over-high-risk-pool-eligibility-86036_Page2.html
Dave Cunix January 21, 2013 at 11:08 PM
This article from AP details Medical Mutual's lawsuit to clarify which government body has the final regulatory say. Special kudos to MMO and Mary Taylor for going the extra step for these Ohio residents. http://www.ajc.com/news/ap/financial-services/ohio-health-insurance-company-sues-state-feds/nTz4F/
Linda Ellis January 21, 2013 at 11:27 PM
Yes, this is good news. Let's hope it sets an example should this situation arise in the future. Fortunately, there is less than a year to go at this point with the high risk pools created under the ACA. They will sunset on January 1, 2014 and the exchanges will replace them where situations like this will no longer arise.
Linda Ellis January 21, 2013 at 11:30 PM
Thanks for the good news Dave. I can't imagine how relieved those folks are to have their health insurance re-instated for them. It was such a long hard fought battle to pass the ACA, and the law has withstood many challenges since that time for this type of problem to happen. Hopefully, there won't be any more like it this year.


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