I’m on Kaiser Bronze Plan via ACA. Kaiser denied my claim, claiming I need a “supplement” policy that I cannot legally buy for a common medical device they prescribed. Is this legal??

I’m self employed, buying through the CoveredCA.com website, which says I have 60% coverage for “durable medical equipment”.

My Kaiser ENT surgeon prescribed a Kaiser sleep study, which showed life-threatening levels of sleep apnea and he prescribed a CPAP device. He even filed the claim for me, which was denied due to “lack of coverage”. I called Kaiser Member services, which CONFIRMED I do indeed have 60% coverage.

I contacted a person in the sleep department (not a policy department), who gave this response:

….

As far as the insurance goes, there are 2 levels of durable medical equipment coverage. The basic level, which is part of nearly any Kaiser healthcare plan, is paid for out of the patient’s own premium. The items covered under the basic level of coverage are minimal and cover a handful of prescribed medical equipment products. Since this coverage is also labeled as ‘durable medical equipment’ it often confuses even the people at Membership services who don’t always understand that different items are covered under different umbrellas. The majority of durable medical equipment products, including CPAP machines and oxygen equipment, are covered under something called a durable medical equipment supplement. There are only 3 types of durable medical equipment supplements that cover these items. One is a supplement paid to Kaiser by Medicare. One is a supplement paid to Kaiser by Medi-Cal. The 3rd is called formulary or commercial coverage, which is only made available to commercial purchasers. The cost of that coverage is absorbed or subsidized by the employer rather than the insured as part of a benefits package. Kaiser does not include supplemental coverage in any plan that is sold exclusively to an individual or family due to the costs associated with the coverage. Your Bronze level individual plan does not include the supplement. The same would be true even if you upgraded to platinum. It’s not the level of coverage you have but the fact that it is a plan sold to an individual rather than a group. Unfortunately, that is how the Kaiser plans are packaged and sold.
….

So, they admit that it’s NOT EVEN POSSIBLE for me (as a self-employed person) to purchase coverage for a medical device prescribed to me by their own doctor using their own diagnostic tests, even with clear statements on the CoveredCA(dotcom) website that says I purchased 60% coverage.

That seems illegal just based on the policy itself, as well as a violation of ACA rules that I must be allowed to purchase coverage for a serious medical condition. Am I wrong?

submitted by /u/BlueLobstertail
[link] [comments]I’m self employed, buying through the CoveredCA.com website, which says I have 60% coverage for “durable medical equipment”. My Kaiser ENT surgeon prescribed a Kaiser sleep study, which showed life-threatening levels of sleep apnea and he prescribed a CPAP device. He even filed the claim for me, which was denied due to “lack of coverage”. I called Kaiser Member services, which CONFIRMED I do indeed have 60% coverage. I contacted a person in the sleep department (not a policy department), who gave this response: …. As far as the insurance goes, there are 2 levels of durable medical equipment coverage. The basic level, which is part of nearly any Kaiser healthcare plan, is paid for out of the patient’s own premium. The items covered under the basic level of coverage are minimal and cover a handful of prescribed medical equipment products. Since this coverage is also labeled as ‘durable medical equipment’ it often confuses even the people at Membership services who don’t always understand that different items are covered under different umbrellas. The majority of durable medical equipment products, including CPAP machines and oxygen equipment, are covered under something called a durable medical equipment supplement. There are only 3 types of durable medical equipment supplements that cover these items. One is a supplement paid to Kaiser by Medicare. One is a supplement paid to Kaiser by Medi-Cal. The 3rd is called formulary or commercial coverage, which is only made available to commercial purchasers. The cost of that coverage is absorbed or subsidized by the employer rather than the insured as part of a benefits package. Kaiser does not include supplemental coverage in any plan that is sold exclusively to an individual or family due to the costs associated with the coverage. Your Bronze level individual plan does not include the supplement. The same would be true even if you upgraded to platinum. It’s not the level of coverage you have but the fact that it is a plan sold to an individual rather than a group. Unfortunately, that is how the Kaiser plans are packaged and sold. …. So, they admit that it’s NOT EVEN POSSIBLE for me (as a self-employed person) to purchase coverage for a medical device prescribed to me by their own doctor using their own diagnostic tests, even with clear statements on the CoveredCA(dotcom) website that says I purchased 60% coverage. That seems illegal just based on the policy itself, as well as a violation of ACA rules that I must be allowed to purchase coverage for a serious medical condition. Am I wrong? submitted by /u/BlueLobstertail [link] [comments]Read Morer/HealthInsurance

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