A little gnome passed the following information onto me late last week:
the Healthcare Marketplace is currently having delays of over a week in forwarding applications to the insurance carriers. This includes enrollments for Jan 1 that were deferred to callbacks by overloading of the phone bank on Dec 15.
I had not realized that there was such a delay, I would have thought that people who were looking for January 1 coverage would have been processed on Healthcare.gov by 12/31, but I was wrong. People are still getting enrolled for coverage effective 1/1/2015 even though it is 1/5/15. Is this a big deal?
It sucks for the people who had an appointment late last week or need to pick up a prescription over the weekend, but fundamentally, it is not a big deal. Insurance companies make retro-additions all the time for all lines of business. Medicaid routinely has people switching into and out of plans up to sixty days after the fact, Commercial large group plans routinely will add and term people a month at a time, and occasionally HR will forget that Milton still works for the company and was left in the basement for several years. Medicare tends to see less retro-active movement, but there is some. The exchanges are seeing some very short term retro-active movement and enrollment plus there is a built in three month look back termination for non-payment of premiums . Retro-activity is common for all health insurance products.
So how does an insurance company handle retro-adds?
In this situation where the insurer knows there is a large pool of retro-adds that are coming shortly, I would be tempted to just hold all claims for all Exchange policies for a week or two until the retro-add file is processed. Providers won’t be thrilled as they won’t get paid quickly, but this works as it will keep claims from being denied incorrectly which means the insurers won’t have to manually re-adjust anything. Manual readjustment usually will start at $5.00 per claim per time it is touched by human hands. Insurers don’t want to pay that adjustment cost. So holding everything and sending all Exchange claims through on January 15 is a nice solution.
There are two downsides to this solution. The first is that I can almost guarantee you that there will be a second big batch of retro-adds for March 1, 2015 coverage as the open enrollment period will end on February 15. Providers don’t want to be jerked around too often on their cash flow. Holding all Exchange claims until March 15 is untenable as most provider contracts have payment guarantees that they’ll get a check within thirty or forty five days of submitting a clean claim. After that big penalties of financial and accreditation can start to hurt. The other downside is that this does nothing for the person who bought a policy on the Exchange on 12/15 but whose file has not arrived at the insurer until this afternoon but needed a prescription fill over the weekend.
In those cases, most insurers will be able to do a quick check with CMS and verify that the person in question is insured with them but the file is on its way, and temporary authorization/promise to pay can be made to a pharmacy by the insurer. As I mentioned last year, most insurance companies, including Mayhew Insurance, have unofficial directives that everyone is to do their best to avoid making the company a villian on all four local news channels for transition of care problems. Retro-adds with the Exchange are a fairly simple transition of care problem that can be dealt with as a routine issue.
MomSense
I received a letter that there was a delay in receiving the information from healthcare.gov but that my policy would be retroactive to 1/1/15 and I wouldn’t pay my first premium until 1/15/15. So far there hasn’t been any change in terms of services so I’m assuming it will get sorted out eventually.
Richard Mayhew
@MomSense: Yep, things will get sorted out eventually. That is the thrust of the piece.
rikyrah
Thanks for the information
GHayduke (formerly lojasmo)
I believe you took my stapler.
MomSense
@Richard Mayhew:
It seems like there is a very critical light being shown on all things ObamaCare as if there were never kinks,problems, rate increases, changes in providers, etc. before ObamaCare.
Kylroy
@MomSense: DINGDINGDINGDING.
US healthcare was a mess before Obamacare, and it’s a less cruel and more accessible mess afterward.
Tenar Darell
I went shopping again on the exchange this year. (Thanks for the recommendation by the way, I saved money). Anyway, this happened to me when I signed up on the 15th of December. I even made sure to pay right away, but that didn’t expedite things at all. I just made more problems because I combined my dental and health premiums.
Mnemosyne (iPad Mini)
Judging from when I ran into trouble with a COBRA payment supposedly not being received by my insurance company (I had to mail them a copy of the canceled check since this was during the Jurassic period), what will most likely happen is that you’ll get a few scary phone calls and letters from your provider, you’ll explain the situation to several different people in their business office, and then the bill(s) will magically start showing up with the correct dollar amount on them once the problem is fixed. It’s a pain in the ass and a little scary when they start rumbling about your credit rating, but stand firm and send them any confirmation you do have from the Exchange that you bought an insurance policy. Sending certified letters with copies of everything to both the insurance company and the provider helps, too.
Richard Bottoms
It sucks as I am currently finding out. But then people who wait for the last minute need to be realistic about how long it takes to process paper work. Making a January 2nd appointment after applying on December 31st is kind of dumb.
Tripod
@GHayduke (formerly lojasmo):
It’s just we’re putting new coversheets on all the TPS reports before they go out now.
Richard Mayhew
@Richard Bottoms: sometimes you don’t intend to make that appointment but after a fun filled night of projectile vomiting, your 2 year old son really needs to see a pediatrician (why yes, that is what I am doing this afternoon).
Tenar Darell
@Richard Mayhew: That does not sound fun. I hope it has stopped for now and he gets better soon.
Richard Mayhew
@Tenar Darell: It is not, my wife is picking me up in a little bit so that she can get to a meeting that she has to go to…. and then off to the pediatrician and watching Dora for the rest of the afternoon.
Monala
So Richard, really curious here. Both my husband and I have had to pick up prescriptions in the last few days and found that our copays for those prescriptions had dropped significantly over last year- mine from $30 to $8, and his from $30 to $0. Is that something happening due tot he ACA?
Tenar Darell
@Mnemosyne (iPad Mini): (Not sure if you were replying to me, but your comment reminded me I have one more important step to do. Thanks).
I’ve confirmed the payment cleared the Mass Health Connector, and also that, as Richard described, the health insurance company hasn’t even received the application yet. I even checked about what to do if I do have to go to the doctor etc. My biggest concern was “what if I get in an accident” questions, and that’s the one that would probably be a real fustercluck. (I already confirmed that there is not much I can do about that one; I suppose I should tell a someone that my application is in process, just in case I’m unable to talk).
Richard Mayhew
@Monala: Nope, the only way I can tie that to the ACA is through a quadruple bank shot. One of two things happened.
1) You two changed plans with different co-pays for different tiers of drugs. Drug X might have been in the mid-co-pay range in 2014, but under the new plan, Drug X is still in the mid copay range but the mid-copay is now $8.00.
2) The pharmacy benefit manager decided to move the drugs from mid co-pay tiers to low co-pay tiers either because they got a better deal on the drugs, or there is evidence that higher adhesion rates for the prescribed regime on Drug X lead to lower overall pharmacy utilization costs which means more profit for the pharmacy benefit manager.
ang
@Monala:
Having worked in a pharmacy, either one of Richard’s guesses is almost certainly correct, especially with the timing of it being the new year, and the cost changes effecting both of you. The only other reason I can think of offhand would be if your medication had became available in generic and the pharmacy had automatically switched you to the generic. They should always let folks know when that is done but sometimes it is lost in the shuffle.
Note for anyone paying high out-of-pocket cost for name brand meds, you can often search on-line to find when generics will be available – and if it is then ask your pharmacy why you are still on the more expensive name brand. They may have overlooked it. There are a very few exceptions where meds cannot be substituted but most can.