Mystery illness spotlights insurance gaps | Local News | santafenewmexican.com – Santa Fe New Mexican

TAOS — 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 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 master stucco and plaster craftsman in Taos.

“The same thing happened when she was 9 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,” 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 discharged, physicians still were not 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 Lopez 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 her parents, Rocky and Janel Lopez, are determined to find a doctor who can diagnose and treat her.

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

Unfortunately, New Mexico’s Medicaid program doesn’t cover most medical services outside 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,” said Carol Holt, a Silver City-based broker with Tom Blanchard Insurance who has clients all over New Mexico, including in Taos.

“If you have a need for care that can’t be met in state, you would need authorization for that,” Holt said. “And unless there is some compelling reason, they won’t usually approve that.”

Adora’s father said the family will have to get a new insurance policy when they take her to Colorado for treatment, something 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 plan through a preferred provider organization instead of a health maintenance organization at any time of year. Whereas HMOs have strictly limited networks of physicians and service providers, PPOs offer far more flexibility. 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.

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

Missed work during the time Adora was sick, coupled with the expense of travel and accommodations while she was hospitalized in Albuquerque, has already depleted the family’s savings.

“My wife had just started working, and I had just finished establishing a licensed plastering company in September,” Rocky Lopez 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 the family to launch a Caring Bridge page to let their community know about Adora’s illness, 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 for help from friends and neighbors, but “we’re at the point we could literally lose everything.”

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

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

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

This story first appeared in The Taos News, a sister publication of The Santa Fe New Mexican.