Interesting (and sad) case

My acquaintance called because he knew I dabbled in the health insurance field, and hoped I could give his family some advice and insight on what options might be available.

Oh, there’s an interesting twist, which may play an integral part: the daughter, who had never given up her US citizenship, had nonetheless spent the past few years living abroad, and had moved back here just before she became ill.

This is important, because one of the Special Open Enrollment triggers is “Changed your primary place of living.” Now, it actually gets more specific:

“Moves that may qualify you for a Special Open Enrollment Period [include] … To the US from a foreign county.”

Which seems a slam dunk, but then there’s this caveat:

“Important: To qualify for an SEP, you must prove you had qualifying health coverage for at least one day during the 60 days before your move except moves from a foreign country).” [emphasis in original]

This is crucial because it seems to be referring to the so-called “60-day rule;” that is, you must exercise your SEP opportunity within 60 days of becoming eligible for it. I think she’s missed that window, but I’m not entirely sure, and so I urged my acquaintance to call the nice folks at the Marketplace to confirm, and also to see if the daughter might be eligible for a subsidy.

We then looked at what plans and carriers were available in their area, to get an idea of costs and benefits. The less expensive Bronze level plans were, of course, very affordable even without the subsidy, but the out-of-pockets were pretty hefty. The other issue is that, at least in Ohio in 2019, all plans are built on an HMO chassis, which means basically zero out-of-network coverage, which might be an issue (or maybe not: after all, she doesn’t have insurance now).

Okay, that’s the insurance side, but maybe there’s another line of attack open to us?

And indeed there may well be:

I then suggested that they also consider other options. For one thing, a call to the local Medicaid office might be helpful: those folks have access to information on all kinds of medical financing options.

I also asked if he was aware of Direct Primary Care. I explained that these practices worked like a gym membership, with monthly dues granting 24/7 access to a physician. They also often have big-ticket diagnostic equipment in the office, saving even more (eg: MRI’s costing hundreds of dollars, not thousands), as well as discounted prices on meds. They are also very helpful in referring patients to fellow cash-only-type providers in the area for non-primary care services.

I promised to send him the link to the latest directory of DPC practices, but I also cautioned him to beware that they aren’t much help with catastrophic medical issues, and that’s something to consider, as well.

Looking forward to seeing how this plays out and, of course, always happy to help.