Maura Carley

Maura Carley

We found this recently on the blog of Maura Carley, President and CEO of Healthcare Navigation, LLC, an healthcare consulting firm. Maura has written several posts for us on how to deal with the difficulties consumers encounter as they try to enroll in the Affordable Care Act. This post offers suggestions on getting past the glitches sometimes lurking in the “back end” of the process. At Women’s Voices we republish articles only rarely. But we had to publish this post, for nobody could explain it better. —Ed.

 

 

For many who purchased individual insurance for 2014, either on or off an exchange, this has been a trying time.  The Affordable Care Act reformed the individual insurance marketplace on January 1, and there have been numerous problems and glitches at the state and federal levels and with insurance companies themselves.  Some insurers have even run multiple full-page newspaper ads apologizing for the current state of affairs.

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What You Need to Know if You’ve Purchased Coverage

Enrollment

A completed application is just the first step in enrollment. You need a bill from the insurer, the bill must be paid, and once payment is processed, you should receive identification cards. If you didn’t receive a bill in a timely fashion and you didn’t work through a broker or a consulting firm like ours, then you need to spend time in person or on the phone to track down the status of your application. More specifically, you need to verify that your insurer has a record of the payment you made with the application.  If you have a doctor’s appointment before you have identification cards, bring a copy of the enrollment confirmation with you, if you have it, or tell the staff at the office that you have applied for new coverage and expect the cards to arrive any day.  Different offices will handle this situation in different ways (they are frustrated, too), but many will probably agree to delay claims submission until you have new cards.

The Product

You may have read that the Affordable Care Act requires products to be categorized by bronze, silver, gold, and platinum levels. Bronze would have the lowest premium and the highest potential out-of-pocket costs; platinum, the highest premiums and lowest potential out-of-pocket costs, with silver and gold in-between bronze and platinum.  Not all plans offer all levels of coverage, and some don’t use the bronze, silver, gold, platinum terminology, and this adds to the confusion.  Some people have applied for one product and were enrolled in another.  Review everything you receive thoroughly, and if you find a mistake, only you can decide whether it’s worth the time correcting it or deciding to live with the plan you were enrolled in. Hold times to reach a customer service representative can still be in excess of one hour, so  spare yourself some aggravation and have something else to do while on hold.

The Network

Many networks have changed; many networks are new, and with new names.  Some people who’ve enjoyed access to nationwide provider networks now find that their network is limited to their state of residence. Internet tools have not been as reliable as they typically are, and this has complicated matters even more.  If you want to stay in-network and you can’t verify through the insurer or the doctor or hospital that you are in-network, then you could be at some financial risk. If it’s a single visit and with a doctor you’ve been seeing on a regular basis, you are at less risk.  However, being admitted to a hospital on an out-of-network basis could leave you with substantial-balance bills.  If it’s an elective admission, you should try to work this out with the hospital in advance of the admission. 

Rules of the Plan

Before applying for coverage, you should have determined if your plan requires that you have an in-network primary care physician and a referral to see a specialist.  If you didn’t, familiarize yourself with your new plan’s requirements. If you need a referral to see a specialist, you must obtain a referral from a primary care physician with your plan, or the plan will have the right to reduce what they pay on the claim or apply to your deductible. 

State Environments

Remember that state environments, in spite of the imposition of federal law, can be quite different. New York is an extreme example. Out-of-network benefits have been eliminated in the individual market in most areas; this has shocked many who had to purchase new coverage.  New York State also maintained community rating, so one’s age does not affect premiums. This means that coverage will be relatively less affordable for young adults in New York, but young adults with lower incomes may very well qualify for a premium subsidy.

Enrollment Deadline

The Initial Enrollment Period will end on March 31, 2014. It’s always possible that the deadline will be extended, but if you don’t have coverage by then, you will most likely owe a penalty that will be either assessed as an additional tax or subtracted from your tax refund in 2015.

Also know that in the individual market, you will be locked into whatever coverage you have for the rest of 2014 when the deadline ends—unless you move or have some other major life’s event which will allow you to apply for coverage off-cycle.

The Affordable Care Act is a massive piece of legislation, with measures being implemented over a 10-year period.  Many changes and postponements have already occurred, and more changes will follow. Reforming such a substantial portion of the U.S. economy was a monumental challenge, and many organizations have disappointed those who have enrolled.  Our advice is to be as conscientious as possible with your own transition during this era of rather chaotic change.