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Maine Family Endures Health Insurance Nightmare

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Erica Fallon of Gardiner and her three oldest children

Erica Fallon of Gardiner and her three oldest children

A Maine family is enduring a nightmare as the result of systemic data problems with the government-run health insurance exchanges created under President Obama’s health care reform law.

Sean and Erica Fallon live in Gardiner, Maine. Like most Americans, they were aware of the drastic changes the Affordable Care Act, also known as Obamacare, brought this year to the health insurance market.

But they never imagined the government-run exchanges would come to stand between them and health coverage for their newborn daughter.

Sean is an Army Reserve veteran of Operation Iraqi Freedom who served with the 619th Transportation unit out of Dexter and Auburn. While his medical services are covered through the Veterans Affairs health care system, his family was covered through his employer-provided insurance until February when he changed jobs.

Not wanting a lapse in coverage, Sean called Anthem Blue Cross Blue Shield to purchase a health insurance plan for Erica and their three children.

A customer service representative with Anthem navigated Sean through the healthcare.gov exchange to select a plan. Starting in February, he began making monthly payments on a Gold Level plan covering his wife and three children.

The trouble began on May 27 when the Fallons gave birth to their fourth child, Teagan, a baby girl.

Sean moved quickly to get coverage for his newborn daughter, calling Anthem the day after she was born to add her to the plan he purchased on the exchange. “Every policy I’ve had it’s good to notify them when you have a baby,” Sean told me. “They said everything was fine.”

The Affordable Care Act limits the time period when individuals can purchase insurance to select “open enrollment” time frames. When a child is born, a special open enrollment period is created under the law. This allows newborns to be placed on their family’s insurance plans and lasts for 60 days.

Within a week of Teagan’s birth, Sean called to formally add her to his family’s health insurance policy. However, Anthem representatives told him they could not make changes to the plan as it was provided under the marketplace exchange.

On June 25, the Falllons received a formal letter from ABCBS informing them that it could not make changes to their insurance plan. “As your coverage is through your marketplace (also referred to as the exchange), this request must be submitted to your marketplace,” the letter stated.

Fallon Letter redacted

Anthem could not add a newborn to a health insurance plan because of the government-run exchange.

Even though the Fallons did not receive any subsidy or benefit from the exchange, they would be forced to go through the exchange to add Teagan to their plan. But when Sean contacted the exchange, services representatives could not find his application or any of his information. “It was like they didn’t even know we existed,” he said.

The apparent confusion between the Fallons’ insurer, Anthem, and the government contractors running the healthcare.gov exchange lasted for more than two weeks and included 13 separate phone calls. “We’ve probably spent 18 to 20 hours on the phone trying to get this resolved,” said Ericka.

“It boils down to, we have a child we cannot cover,” said Sean. “Our child is in danger. And open enrollment isn’t until November. We can’t get her covered.”

The fear the Fallons have is that they will be liable to pay for the health care Teagan will need in her first six months of life if they are not able to add her to their health insurance.

In addition to facing those untold out-of-pocket costs, they also worry that the Internal Revenue Service will hound them for the ACA’s individual mandate penalty (or tax) next spring if they can’t get their newest family member covered in time.

“Is the exchange going to prevent us from covering our baby and then slam us with a tax because we didn’t get her covered?” asked Sean. “We just don’t know.”

“We’re just a normal family,” said Ericka. “We’re doing what we’re supposed to do. And this is what happens? It’s unfair and it’s frustrating.”

“It sounds impossible, but it’s not, because the government is involved,” she said. “This law is totally screwing up our lives.”

CHAOS IN THE MARKET PLACE

The Fallons set out to finally resolve their health insurance problem this week. Sean took time off from work solely to wrestle with exchange workers and Anthem representatives on the phone. Their urgency stems from the fear that government regulations will prevent them from getting coverage for Teagan if they do not do so before the 60-day special enrollment window closes.

The Fallons provided a recent audio recording of a phone call in which an exchange supervisor (“Alicia”) attempts to help them resolve the issue. (The recording is not being placed online due to the sensitive nature of information discussed.)

Throughout the conversation, Alicia’s revealing comments portray a maddeningly complex and inconsistent process for resolving problems. She also states clearly that the Fallons are not the only ones suffering from government intervention into the world of health insurance.

Frustration reigned throughout the phone call for both parties: “Sometimes the application will ask such repetitive questions,” the worker said. “We know it’s frustrating. I know it’s frustrating,” she said.

Where several of her colleagues failed, Alicia, for whatever reason, was able to locate some of the Fallons’ application data: “It could be that the person couldn’t do the correct search. I don’t know. I don’t have an answer to give you,” she said. “I don’t know what made it so easy for me to find it,” she said.  “Looks like his [Social Security number] was never saved in the application, so that’s definitely a factor,” he said.

Alicia said she found the application data by searching for the Fallons using their names, a function she said was not available until May.

“When they did it they didn’t put anyone’s Social Security number in the application. So if I’m asking it’s because it’s not here,” she said, before realizing that she does actually need the number: “You don’t have to provide it due to the fact that you’re not even having the income check because you’re not asking for help. So we can actually continue on without it.”

The question that vexes the Fallons, as well as Alicia, is why they needed to go through the exchange in the first place if they weren’t looking for government subsidies?

“I don’t why, especially if you’re just getting coverage, you didn’t want any government subsidies or anything like that, so that’s confusing for me,” Alicia said.

To Alicia’s credit, she was calm and kind, and sounded nearly as frustrated with the complexities of the health care law as the Fallons. At one point she states that she will not hang up the phone until the situation is resolved.

“Don’t be sorry, we deal with it all day long, so I definitely understand,” she said at one point in the call. “This happens all day,” she said. “Trust me, like I said, we go through this all day.”

“We get a lot of people that call in and they’re yelling and screaming,” she said.

“You get to a point where you feel so helpless,” Erica told Alicia. “I understand,” she replied.

“It’s hard because we get to a point where it’s just like, I don’t really know what to say,” she said. “I feel bad. I’ve had people call in crying. I don’t know what to do. It’s like, I wanna cry with you because I don’t know what to do either,” she said.

“It’s rough. Hopefully, I mean, we’re doing what we’re supposed to do, at least I hope, where we’re reporting the errors we’re running into, the problems we’re running into. And there’s someone somewhere working on these so that when the start up of the next open enrollment comes around it’ll be a whole lot smoother than this one,” she said. “This one had people here pulling out hair, stressing out, losing weight, not coming into work.”

At another point in the call, Erica asks whether they can get rid of the exchange as a middleman between them and the insurance company since they’re not receiving any subsidies or benefits.

“Is there any point that we can, without cancelling our policy entirely, not have anything to do with the exchange, because we do not get benefits or our special tax break,” asked Erica. “How do we eliminate this third party?”

“I was under the assumption that they could do the application themselves without having to go through the marketplace, so… I don’t know. Because in all honesty, Ms. Fallon, I’ve heard some insurance reps say ‘yes we can do the application ourselves… and I’ve heard others say we can’t do anything unless it goes through the marketplace. So it’s really up to the insurance company.”

“I’m confused as to why they even did that. I don’t know,” she said.

By the end of the phone call, Alicia appears to have succeeded in navigating the procedures necessary to add the Teagan Fallon to her parents’ health insurance, but Sean and Erica won’t know for sure until paperwork comes in the mail from Anthem.

PROBLEM NOT UNIQUE

The problem the Fallons encountered is but one example of the difficulties ordinary Americans have encountered with the troubled rollout of the health care law. From the initial launch in October, the federal health care exchange has been plagued with data problems and glitches. According to government statements and news reports, as many as 2 million applications may have data inconsistencies likely to cause headaches down the road.

A representative from Anthem was unable to speak about the Fallons situation due to privacy laws concerning medical information.

Joel Allumbaugh, chairman of the National Worksite Benefit Group and health care policy analyst with the Maine Heritage Policy Center, said the Fallons’ ordeal was entirely predictable and easily avoidable. (Disclosure: The Maine Wire is a project of the Maine Heritage Policy Center.)

“The exchange has been so totally mismanaged and flawed in its design that lost data is not the least bit surprising, with very real practical implications, the Fallons’ case in point,” said Allumbaugh.

“This is why people should work with licensed agents, to have someone knowledgeable and regulated to guide them through and go back to if there are issues,” he said.

Under the ACA, the insurance agents who used to guide people through the process of purchasing health insurance have been supplanted by unlicensed, unregulated “navigators” with little or no experience, he said.

UPDATE: Tune into WGAN Saturday morning at 8:00AM to hear Erica Fallon tell her story.

Steve Robinson
Editor, The Maine Wire

About Steve Robinson

Steve Robinson is the former editor of The Maine Wire and currently producer for the Howie Carr Show. Follow him on Twitter @Stevie_Rob or send him an email at Steve@HowieCarrShow.com.

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