Mystery Illness Highlights Insurance Gaps | Local News


TAOS – As Taos middle school student Adora Lopez recovers from an undiagnosed illness that hospitalized her for weeks in Albuquerque late last year, the 13-year-old’s parents find themselves navigating a health insurance system that limits out-of-state treatment options. or requires a large initial investment.

“Adora is much better than she was, but the scary thing is that this is the second time it’s happened,” said her father, Rocky Lopez, a master stucco and plasterer. plaster in Taos.

“The same thing happened when she was 9 too, and they couldn’t really identify anything at the time either. Now, at 13, she’s come down with identical symptoms, and that’s the sent her back to the hospital,” he said.

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 released, doctors were still unable to make a diagnosis.

Her father said Adora’s white blood cell count had become dangerously low, her liver was not functioning normally and she was ‘covered in a rash from neck to toes’, with a fever of up to 104 degrees. which lasted for weeks.

“She did over 30 days with a fever, and because she wasn’t allowed Tylenol – no medicine, since her liver was so bad – they had a cooling blanket over her with us putting some ice all over her and we fought it like that,” Rocky Lopez said. “Eventually his fever went down and the rash started to go away.”

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

Adora’s former pediatrician, Dr. Sylvia Villareal, now retired, recommended that they seek help from specialists in Denver or at an out-of-state Mayo Clinic.

Unfortunately, the New Mexico Medicaid program does not cover most out-of-state medical services.

“Each state runs its own Medicaid program, and virtually all contract with a company like Western Skies or Centennial Care — all HMOs — and pay for services in the state,” said Carol Holt, a Silver-based broker. City with Tom Blanchard. Insurance that has customers all over New Mexico, including Taos.

“If you have a care need that cannot be met in the state, you would need permission for that,” Holt said. “And unless there’s a compelling reason, they generally won’t approve of that.”

Adora’s father said the family will need to purchase a new insurance policy when they take her to Colorado for treatment, which broker Joseph Quintana of Thomas Gutierrez Farmer’s Insurance in Taos said is doable. even outside the annual open registration period.

Quintana said a small business owner like Rocky Lopez could sign up and his family members for a plan through a preferred vendor organization instead of a maintenance organization. health at any time of the year. While HMOs have strictly limited networks of doctors and service providers, PPOs offer much more flexibility. PPOs allow the consumer to find services out of state.

“On the individual side of things, 100% of the plans offered through the state health insurance exchange” – – “are HMOs,” Quintana said.

But monthly premiums for PPO plans, especially for a plan with low deductibles, can be much more expensive.

Missed work while Adora was sick, coupled with travel and accommodation costs while she was hospitalized in Albuquerque, has already depleted the family’s savings.

“My wife had just started working and I had just finished setting up a licensed plastering business in September,” Rocky Lopez said. “I had just finished spending money on school, and we didn’t expect that to happen. So our safety net got exhausted getting my license, and then it happened with Adora.

In January, John Poynter persuaded the family to start a Caring Bridge page to tell their community about Adora’s disease, and a GoFundMe page with a goal of $4,000 to help recoup some of the family’s expenses.

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

He created a page on the nonprofit CaringBridge’s website to tell the community about his daughter’s illness and launched a GoFundMe campaign with a goal of $4,000.

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

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

This story first appeared in Taos Newsa sister publication of Santa Fe’s New Mexican.


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