Bob
This is a very detailed issue with many prongs ACA, subrogation, court cases, standards of Practice, etc..
The last 2 JLCPs have published on this issue. They should be read in full, but here is a post presentation excerpt from the most recent JLCP:
"Practical Application
The practical application of the ACA to the life care planning practice was then presented including practical information, suggested references and guidance with a few examples.
• There is nothing in the Standards of Practice or Consensus and Majority Statements indicating we can not provide a variety of information regarding costs and collateral sources if requested.
• Life Care Planning is a tool of Case Management.
• Life Care Planners are permitted to provide useful information to the parties as requested.
• Jurisdictional variations should be noted.
• We are not making a statement about what is the "right" cost to use, or who should pay.
• The jury and/or judge will do that.
• However, relating to costs, the issue of "reasonably available to the evaluee" (SOP 4B) cannot be ignored. This includes "reasonably available" now and in the future."
The bottom line is the life care planner should proceed in practice as usual and understand that coverage does not equate to care. Our job is to identify what items cost, not who is paying for them.
Lastly, the ACA is not a health insurance program, but regulates the health care industry by expanding health care to all Americans.
"Additional specific information included areas not commonly known, includes:
• Your maximum share of the costs of covered services may include the deductible, but otherwise exclude items that don't count toward the out of pocket limit.
• These exclusions may include: premiums, balance billed charges, items and services the health plan does not cover, penalties for failing to obtain pre-authorization, deductibles or vision. Some plans do not count all of your co-payments, deductible, co-insurance payments, out of pocket expenses or other expenses toward the out of pocket limit.
• These exclusions are costs above and beyond the limit imposed by the ACA and may not apply to policies outside of policies obtained through the state health exchanges.
• Further, and likely most significant, is the variability in policies and the annual rate increases and changes to policies in coverage beyond the "minimum essential coverage" outlined by the ACA."
What this means is the amount of maximum out-of-pocket is not the maximum amount spent by any individual. Thus it cannot reasonably be considered by the life care planner in any given year with changes in policies .
I am not comfortable telling an evaluee everything is covered for the rest of their life. I am not sure I want the E and O claim.
And as everyone saw in the popular press this week the House again voted to repeal the ACA and the President blocked it again. House Speaker Ryan was on national TV indicating if a Republican is elected it will be the first order of business to repeal it. Public knowledge. Speculative? ;-)
On we go!
Best