No cap to the bills

By Marshall Allen (contact)

Saturday, Nov. 18, 2006 | 7:18 a.m.

Terri and Michael King's son was only 18 months old, but he was already reaching the lifetime limits of his health insurance.

And the options to continue his coverage - including divorce, giving the child up to another family or moving out of state - ranged from bad to ludicrous.

Matthew King was born with rare heart and lung defects that required multiple surgeries and ongoing care. His health insurance was provided through Metro Police, where Michael is a detective. The policy had a $2 million lifetime coverage cap.

The Kings had never known health insurance had a ceiling until they had Matthew.

Now they know.

An eight-inch stack of bills and insurance paperwork sits in their home. Several sheets represent $1.3 million in expenses from Matthew's two-month stay and open-heart surgery at the Lucile Packard Children's Hospital at Stanford, which is affiliated with Stanford University Medical Center in California.

A month ago the Kings were within $90,000 of Matthew's limit. Whenever possible, they delayed treatments to make the money last.

"I can't tell you how frightening it is to have a baby that is medically fragile and be running out of money," Terri King said.

Another couple, Miajoy and Ryan Wilson, discovered their insurance policy cap at the worst possible time. It was in April and they also were at Stanford, where their daughter Lily, now 19 months old, was recovering from heart surgery.

Ryan Wilson is a chef at Wynn Las Vegas, so the couple was confident their insurance would cover the costs - until hospital officials said Lily's $1 million policy was maxed out.

"They're telling me every day during rounds that I have no more insurance," MiaJoy Wilson said. "It's really awful."

Wilson praises Wynn Las Vegas for saving the family. The company purchased an additional $800,000 in coverage before the family left Stanford and also now offers a companywide no-limit plan that the Wilsons will switch to in January.

Lifetime insurance coverage caps usually range between $1 million and $5 million per individual, although some policies provide unlimited coverage. It's rare for patients to reach their caps because they usually die, get better or find a way to change policies.

Ironically, the Kings and Wilsons were in their predicament in part because they're not poor. Michael King's salary is about $90,000, more than four times what it takes to qualify for Medicaid, the government's insurance for the poor, which has no coverage cap for children.

The Kings had no better option to continue Matthew's health insurance. Michael King could have transferred to another department, but he would have lost seniority and taken a drastic pay cut. Health officials suggested they move to a state that offered residents catastrophic insurance plans, as many do. Or they could divorce so Terri King would be a single mother and Matthew would qualify for Medicaid.

The Kings were rescued from financial ruin - or being forced into horrible personal decisions - Nov. 1 when Metro increased the lifetime coverage cap to $5 million.

The Kings are determined to help other families who face similar problems. Although only a small percentage of people max out their health care coverage, those who do face a compounded crisis. While dealing with life-or-death medical problems, they also must confront a financial crisis.

Other states provide options for residents in such situations. For example, Dawn and William Zeigler of Henderson reached a $2 million lifetime maximum caring for their daughter, Brooke, who needed two open-heart surgeries and spent the better part of a year in intensive care.

Dissatisfied with the level of care they received in Las Vegas, the Zeiglers moved to Indiana, where they would have qualified for the state's high-risk pool insurance coverage.

Sadly, the little girl died in June, and the family is back in Henderson.

Brooke died before she was covered by the Indiana plan, leaving the family with $550,000 in medical bills. Dawn Zeigler says the system is so backward that if she had been Brooke's guardian instead of her mother, the little girl would have been covered by Medicaid.

Zeigler thinks it's terrible that Nevada doesn't provide a safety net for such circumstances.

"We were fortunate because my husband and I had the means to take her to another state," Zeigler said. "But most residents of Nevada wouldn't be able to afford that."

The Kings have testified before lawmakers about the problems posed by insurance caps, and support a plan by Dr. Joe Heck of Henderson, a Republican state senator, to provide a Medicaid buy-in plan for patients who reach insurance coverage limits.

Nevada is one of 14 states without a catastrophic insurance option for residents, King said.

"Most people don't know they have a cap," King said. "You are not safe. If you have anything horrible happen to you, they're telling you to move out of state."

Heck's proposal would allow families who earn up to 300 percent of the federal poverty level - about $58,000 for a family of four - to insure disabled children up to age 19 through Medicaid. The income requirements would not help families such as the Kings, but could be expanded to include higher income levels in the future, he said.

It's "critically important" to take care of hard-working and insured families who have the misfortune of having a child with severe medical problems, Heck said. And it's "absolutely ridiculous" that some people would have to get divorced or move out of state to continue coverage for a child, he added.

Charles Duarte, Nevada Medicaid's administrator, said it is uncertain how much Heck's plan would cost. The expense will be analyzed after Heck introduces the bill in the upcoming legislative session.

But it is certain, Duarte said, that legislators would need to increase Nevada Medicaid's $1.3 billion budget, which provides care for 171,000 people.

Heck estimates that about 40 people or families would benefit from his proposed legislation. But while that number is small, the need is great.

"Fortunately, in the grand scheme of things, it is unusual," Heck said. "But the problem is when someone does (need it), there's no available option for them."