General Discussion
Related: Editorials & Other Articles, Issue Forums, Alliance Forums, Region ForumsProblem with enforcement of Obamacare? Just recieved call about annual maximum limits...
on prescription drugs, which are considered an essential health service.
Got a call from a woman about her copays for her medications tripling this month, look in the system, and the insurance is paying none of it, she's now at 100% copay, with a simple message, Benefit Maximum Exceeded. Looked at her plan documents, and it shows a 1,000 dollar annual limit on her plan. That means, for the rest of this year, she has to pay 100% of the cost for her prescription drugs, and as you can gather, given how early in the year it is, her drugs are rather expensive.
I looked it up, and some grandfathered plans are allowed annual benefit limits, however, this plan that she is on wasn't instituted until 01/01/2014, after the ACA was put into effect. I don't know how this is legal, whether I should report it, or if I'm missing something. The only thing I do know is that this is complete bullshit, seriously, she already is out of pocket for premiums, now the plan won't pay for any prescriptions for the rest of the year? Almost better off not being insured in that case.
TheKentuckian
(25,035 posts)There are plenty of parts of coverage that are limited from the number of visits and dollar amounts and plenty of exclusions of coverage types entirely.
Make whatever stink you can though the squeaky wheel gets the grease in these kind of matters more often than is discussed but the limitation is likely still legal.
enlightenment
(8,830 posts)to contact someone (state or federal) who can tell you which loophole the company has slid through in order to get away with this.
NYC_SKP
(68,644 posts)And got justice, but it wasn't easy.
Anthem Blue Cross can go fuck itself.
SalviaBlue
(2,918 posts)okaawhatever
(9,478 posts)"essential benefits"
What Are Essential Health Benefits?
Essential Health Benefits consist of ten categories of items and services required on all individual and small group plans starting in 2014.
Starting January 1st of 2014, the following Ten Essential Benefits must be included under all insurance plans with no lifetime or annual dollar limits:
Emergency services
Hospitalizations
Laboratory services
Maternity care
Mental health and substance abuse treatment
Outpatient, or ambulatory care
Pediatric care
Prescription drugs
Preventive care
Rehabilitative and rehabilitative (helping maintain daily functioning) services
Vision and dental care for children
http://obamacarefacts.com/dollar-limits/
elehhhhna
(32,076 posts)Downwinder
(12,869 posts)prescription Assistance Program?
MineralMan
(146,350 posts)They'll be able to save her lots of money with discount coupons. Seriously. I use it, since I don't have Part D for my Medicare. Great prices at your local chain pharmacy, which can simply substitute their coupons for the insurance coverage. It works!