So my wife was diagnosed with Multiple Sclerosis on June 4th after dealing with optic neuritis, several doctors visits, and an MRI. We have been working through her diagnosis but luckily she got in with a great doctor in the BJC network in St. Louis and we feel really confident and comfortable with him. He founded and runs a semi-large MS clinic, is well connected with newly researched drugs, and even has a podcast focused on living well with MS. We have begun her treatment plan and are looking forward to getting her in a routine to manage symptoms and let her live as normal a life as possible. But then the health insurance issues started to kick in.
She works for a school district in SE Missouri and is insured through their group plan. Their plan states “We will not cover claims for individuals who are expected to have claims that will exceed $35,000 or more in a year, our District plan summary states that expenses related to a chronic condition or specific course of treatment exceeding that amount may be denied” We have since been told that $35,000 cap is for the life of the policy and does not reset each year. So once the $35,000 is reached the plan will not approve any claim relating to MS from that point forward.
Their work around is to offer you the “choice” to move to an ACP policy that will not have the claims cap. This obviously is not much of a choice as we can’t afford to pay out of pocket for every claim once we reach the lifetime limit of $35,000. The problem with switching plans is her doctor that is currently covered under her group plan would no longer be covered under the ACP policy so we would have to start the process all over with getting a new doctor. We really don’t want to have to settle for lesser care simply due to insurance but I am not sure what are options are. My employer states spouses can only be offered insurance through our plan if they don’t have any insurance offered through their employers so that is out unless she quits or goes part time which would then mess with her pension and retirement options. I don’t think supplemental/secondary insurance would help but honestly don’t know enough about the logistics of it to know for sure. Really at a loss and any advice would be greatly appreciated it. We are sending some emails to the teacher’s union, school district board office, MS society, etc but am not overly optimistic about them bein able to help. Thanks
submitted by /u/mbsob
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So my wife was diagnosed with Multiple Sclerosis on June 4th after dealing with optic neuritis, several doctors visits, and an MRI. We have been working through her diagnosis but luckily she got in with a great doctor in the BJC network in St. Louis and we feel really confident and comfortable with him. He founded and runs a semi-large MS clinic, is well connected with newly researched drugs, and even has a podcast focused on living well with MS. We have begun her treatment plan and are looking forward to getting her in a routine to manage symptoms and let her live as normal a life as possible. But then the health insurance issues started to kick in. She works for a school district in SE Missouri and is insured through their group plan. Their plan states “We will not cover claims for individuals who are expected to have claims that will exceed $35,000 or more in a year, our District plan summary states that expenses related to a chronic condition or specific course of treatment exceeding that amount may be denied” We have since been told that $35,000 cap is for the life of the policy and does not reset each year. So once the $35,000 is reached the plan will not approve any claim relating to MS from that point forward. Their work around is to offer you the “choice” to move to an ACP policy that will not have the claims cap. This obviously is not much of a choice as we can’t afford to pay out of pocket for every claim once we reach the lifetime limit of $35,000. The problem with switching plans is her doctor that is currently covered under her group plan would no longer be covered under the ACP policy so we would have to start the process all over with getting a new doctor. We really don’t want to have to settle for lesser care simply due to insurance but I am not sure what are options are. My employer states spouses can only be offered insurance through our plan if they don’t have any insurance offered through their employers so that is out unless she quits or goes part time which would then mess with her pension and retirement options. I don’t think supplemental/secondary insurance would help but honestly don’t know enough about the logistics of it to know for sure. Really at a loss and any advice would be greatly appreciated it. We are sending some emails to the teacher’s union, school district board office, MS society, etc but am not overly optimistic about them bein able to help. Thanks
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