Mystery illness spotlights insurance gaps | Health | taosnews.com – taosnews

As Taos Middle School student Adora Lopez recovers from an undiagnosed illness that saw her hospitalized for weeks in Albuquerque late last year, the 13-year-old’s parents find themselves navigating the vagaries of a health insurance system that either limits out-of-state treatment options or requires a major up front investment.

“Adora is doing a lot better than what she was, but the scary thing is, this is the second time this has happened,” said her father, Rocky Lopez, a well-known master stucco and plaster craftsman in Taos. “The same thing happened when she was nine years old, too, and they couldn’t really pinpoint anything then, either. Now, at 13, she came down with identical symptoms, and it put her back in the hospital.”

After spending a week at Holy Cross Medical Center, Adora was transferred to University of New Mexico Hospital in Albuquerque. Three weeks later, when she was well enough to be discharged, physicians had still not been able to nail down a diagnosis. Her father said Adora’s white blood cell count became dangerously low, her liver wasn’t functioning normally, and she was “covered in a rash from her neck to her toes,” with a fever as high as 104 degrees that lasted for weeks.

“She went over 30 days with a fever, and because she wasn’t allowed Tylenol — no medication, since her liver was so bad — they had a cooling blanket on her with us putting ice all over her and we battled it like that,” Rocky said. “Finally, her fever broke and the rash started going away.”

Although the mystery illness has retreated once again, Adora’s health is still compromised, and Rocky and Janel Lopez are determined to find a doctor who can diagnose and treat her.

“It’s been hard because nobody can tell us anything,” Rocky said. “I would like to know a [disease] name or something even in the ballpark, so if it happens again, we’re not left with her life hanging in the balance.”

Rocky said Adora’s former pediatrician, the now-retired Dr. Sylvia Villareal, recommended they seek the help of specialists either in Denver, Colo., or at a Mayo Clinic out of state.

Unfortunately, while New Mexico’s Medicaid program offers excellent and inexpensive — or even free — health insurance coverage within the state, it doesn’t cover most medical services outside of the state.

“Every state runs their own Medicaid program, and virtually all of them contract with a company like Western Skies or Centennial Care — all HMOs — and pay for in-state services,” explained Carol Holt, a Silver City-based broker with Tom Blanchard Insurance who has clients all over New Mexico, including in Taos. Insurance companies pay a small commission to brokers who give their expert advice — at no cost — to people and businesses looking for an insurance plan.

“If you have a need for care that can’t be met in-state, you would need authorization for that,” Holt continued. “And unless there is some compelling reason, they won’t usually approve that. They aren’t just totally heartless, but like all programs, they have processes.”

Adora’s father said the family is already certain it will have “to change her insurance when we take her to Colorado,” something that broker Joseph Quintana, with Thomas Gutierrez Farmer’s Insurance in Taos, said is doable, even outside the annual open enrollment period. 

Quintana said a small business owner like Rocky Lopez could sign himself and his family members up for an insurance plan through a PPO (preferred provider organization) instead of an HMO (health maintenance organization) at any time of year. Whereas HMOs have strictly limited networks of physicians and service providers, PPOs offer far more flexibility when it comes to finding medical services. Unlike HMO plans, PPOs allow the consumer the ability to find services outside of the state. 

“On the individual side of things, 100 percent of the plans offered through the state Health Insurance Exchange” — bewellnm.com — “are HMOs,” Quintana said. “Large group employer insurance plans like for towns, counties, schools, the state, are probably 50-50. On the small business group-insurance side, it’s probably 80 percent PPOs [because] people will use their business to get that PPO.”

Rocky Lopez could apply for a PPO insurance plan for himself and Adora at any time, but there’s a catch: The monthly premiums, especially for a plan with low deductibles, are expensive. Quintana said the monthly premium for a 40-year-old man, for example, could cost around $850 per month for a gold plan. Adding a 13-year-old girl would cost another $512 each month. 

“His investment would be to cover himself and then add whoever he wanted to, in this case his dependent child,” Quintana said. “He could theoretically do that at a monthly cost, which could then be written off at the end of the year. Your health insurance investment as a business is 100 percent tax-deductible.”

But missing work during the time Adora was sick, coupled with the expense of travel and accommodations while Adora was hospitalized in Albuquerque has already depleted the family’s savings, and an annual investment of $16,344 is beyond the family’s grasp at the moment. 

“My wife had just started working, and I had just finished establishing a licensed plastering company in September,” Rocky said. “I had just finished dumping money into schooling and we didn’t expect this to happen. So our safety net got depleted getting my license, and then this happened with Adora.”

In January, John Poynter persuaded Rocky and his wife Janel to launch a Caring Bridge page to let their community know about Adora’s illness, and a GoFundMe page (gofundme.com/f/help-adora-lopez) with a goal of $4,000 to help recoup some of the family’s expenses. 

Rocky said his pride made it difficult to ask for help from friends and neighbors, but “we’re at the point we could literally lose everything.”

“At the time I was working for John Poynter, and he saw all of this happen,” Rocky said. “He said ‘I want you to get on Caring Bridge and you look at the website and we’ll talk about it.'”

Rocky created a Caring Bridge page and posted a message that’s also visible on Adora’s GoFundMe page, saying, in part, “It took a lot of courage to ask for help, but [$4,000] is exactly what we need, as there will be more time needed to take off from work as we take Adora to ongoing appointments.”

So far, the Lopez family has raised $2,800.

“It’s been wonderful, the support we’ve gotten from the local people,” Rocky said.