ACA Marketplace/Exchange Update

 

Happy New Year to all my friends, colleagues, and subscribers throughout the land! As you may have noticed, this blog went “dormant” over the holidays, which was as much a relief for my readers; I’m sure, as it was for me. So now here we are in 2014, and back to business, and weekly blog posts!
I thought I’d start the new year off with a brief update on what’s happening with the public health insurance marketplaces/exchanges. Last month involved a flurry of activity, guidance and extensions announced just prior to the holidays. Here’s the latest…
According to Julie Bataille, Director of CMS’ office of communications:
  • Healthcare.gov had 2 million visits on 12/23; and 880,000 on Christmas Eve.
  • The CMS call center received 250,000 calls on 12/23; and 317,000 on Christmas Eve.
  • There were 27,000 qualified health plan applicants enrolled in October, 110,000 in November, and 975,000 in December (in the federal and state/federal marketplaces).
  • Enrollments nearly doubled in the last few days of the enrollment period, compared to earlier in the month of December.
  • Hundreds of thousands of additional applicants have enrolled through State based exchanges (e.g., 400,000 in CA; 188,000 in NY, and nearly 60,000 in CT). And in states that expanded their Medicaid programs, thousands more have accessed such coverage.
So while the open enrollment deadline for coverage to be effective January 1st, 2014 has elapsed, the open enrollment period is still underway, and continues through March 31, 2014. Applicants that apply between now and 1/15/14 will have coverage effective 2/1/14, and so on. Also, if an applicant attempted to enroll by 12/24/13, yet encountered difficulty with the “marketplace system”, they may be eligible for a special enrollment period enabling them to secure coverage sooner (according to a resource document posted on marketplace.cms.gov – see http://marketplace.cms.gov/getofficialresources/publications-and-articles/marketplace-day-one.pdf).
For the vast majority of individuals seeking subsidized coverage through the public marketplace/exchange, the focus has now shifted from purchasing coverage, to accessing health care and paying for it with their newly acquired coverage. And based on a number of reports, this could prove challenging on a number of levels. Here is a short list of the issues newly covered individuals need to be aware of, each of which CMS provides assistance with on its website:
  • Transfer of eligibility information from the website to the insurance company
  • Acceptance and posting of insurance premiums by the insurance company
  • Matching an individual’s pharmacy needs with the formulary of the insurance plan
  • Accessing care from contracted (or preferred) providers (Note: some of the plans offered through the marketplaces/exchanges offer so called “narrow networks”, which have fewer contracted provides from which to seek care from).
  • Understanding internal and external claim appeals rights and processes.
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