Personal Finance

10-year-old has a brain cyst; children's hospital is out-of-network

The family of a 10-year-old girl who needs treatment found their hospital was suddenly out-of-network. What can you do if this happens?

10-year-old has a brain cyst; children's hospital is out-of-network
Scripps News Cincinnati
SMS

The Affordable Care Act has made health care affordable for millions of people who don't have employer-based plans. But many ACA plans, also known as Obamacare plans, don’t have the same benefits, which is the case with a family with a daughter who needs hospital treatment.

Charlotte Mahaffey looks like a typical 10-year-old. But her parents say she has a pineal gland cyst in her brain that causes constant migraines.

“I have a really bad pressure headache in my eyes,” Charlotte said, “and it's like something is squeezing in there."

Mom and dad Faith and Jeffrey Mahaffey have to take her for frequent MRI scans.

But in January, they learned the hospital they had been using the past year, Cincinnati Children's Hospital, was no longer considered in-network under their plan.

“They no longer accept our insurance," said Faith Mahaffey.

As open enrollment begins, expect higher premiums in 2024
As open enrollment begins, expect higher premiums in 2024

As open enrollment begins, expect higher premiums in 2024

Whether covered by employer-based insurance or under the Affordable Care Act, Americans may find their premiums going up after open enrollment.

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The problem is that at the annual sign-up time, the hospital showed up as in-network, according to screen captures the Mahaffeys have on their phones.

"So when we saw that green checkmark, we just selected it,” she said.

Now they can't afford Charlotte's scans.

"It will cost us thousands of dollars,” Faith Mahaffey said. “It was already so expensive with insurance to get her scans done."

Downside of Affordable Care Act plans

They are not alone.

A recent survey by the medical research firm KFF, formerly Kaiser Family Foundation, found 6 out of 10 adults had issues with health insurance in the past year.

Common problems include:

- Doctors not having available appointments.

- A particular doctor or hospital not being covered in-network by insurance.

Kaye Pestaina of KFF said, “Negotiations can change your network from year to year. Hospitals, particularly children's hospitals, have been an issue.”

When enrolling in a plan, Pestaina said it’s important to call a provider’s office to make sure they’re in-network and don’t just rely on online directories.

“Unfortunately, you have to be relentless in finding the right person and finding the appointment,” she said.

And if you feel there aren't enough doctors in your network, she suggests you report that to your state department of insurance.

The Mahaffeys, meanwhile, have been looking for an in-network hospital to treat Charlotte, since Children’s Hospital and their provider, Anthem, were unable to reach an agreement to cover ACA patients.

"Everybody's pointing fingers at the other one; meanwhile, we're the ones suffering from it,” Faith Mahaffey said.

So we reached out to both the hospital and their insurance company. Cincinnati Children's says it can't comment on patients due to strict HIPAA Privacy Rule laws.

However, a spokesman told us, "Children’s website notes that we are contracted only with CareSource and Medical Mutual as of 2024 regarding ACA insurance."

But they can’t put Charlotte onto those other ACA plans until the end of the year. Anthem, however, appears to be working on a solution.

An Anthem spokesman told us they also can't comment on her case but said, "When we receive notice of interruption, we work with families individually."

That appears to be what is happening in this case.

Charlotte's parents now say Anthem has just called them and is trying to get them in-network coverage. They hope so, because Charlotte is in desperate need of scans and treatment.