A Maine family is enduring a nightmare as the result of systemic data problems with the government-run health insurance exchange created under President Obama’s health care reform law.
Sean and Erica Fallon live in Gardiner. Like most Americans, they were aware of the drastic changes that the Affordable Care Act, also known as Obamacare, brought this year to the health insurance market.
Sean is a veteran of the Army Reserve who served in Operation Iraqi Freedom with the 619th Transportation Company 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.
THE TROUBLE STARTS
Not wanting a lapse in coverage, Sean called Anthem BlueCross BlueShield to purchase a health insurance plan for Erica and their three children in February.
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. But trouble began on May 27, when the Fallons’ fourth child, Teagan, a baby girl, was born.
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,” said Sean. “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, on June 25, the Fallons received a formal letter from Anthem 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.
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,” Sean told me.
The apparent confusion between the Fallons’ insurer, Anthem, and the government contractors running the healthcare.gov exchange has lasted for more than two weeks and has included 13 separate phone calls. “We’ve probably spent 18 to 20 hours on the phone trying to get this resolved,” said Erica.
“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 getting coverage for our baby and then slam us with a tax because we didn’t get her covered?” asked Sean. “We just don’t know.”
CONFUSING RESOLUTION PROCESS
“We’re just a normal family,” said Erica. “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. This law is totally screwing up our lives.”
The Fallons provided me with a recent audio recording of a call in which an exchange supervisor (“Alicia”) attempts to help them resolve the issue.
Throughout the phone 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.
By the end of the phone call, Alicia appears to have succeeded in navigating the procedures necessary to add Teagan Fallon to her parents’ health insurance, but Sean and Erica won’t know for sure until paperwork comes in the mail.
Steven E. Robinson is editor of TheMaineWire.Com and a policy analyst for the Maine Heritage Policy Center. He can be contacted at: