Shifting into Post-Enrollment Issues: Fielding New Questions from Consumers

With a little more than 2 weeks before the end of open enrollment into health insurance coverage for 2014, navigators and other consumer assisters continue to field tough questions from individuals and families exploring their coverage options. Consumers scrambling to beat the March 31st deadline will hopefully soon join the more than 4 million individuals already enrolled in marketplace plans and begin using their benefits. But as readers of this blog know, not everyone’s coverage will have to comply with all the Affordable Care Act consumer protections, particularly for those buying coverage outside the marketplace or enrolled in a large employer plan.

As consumers use their benefits, they are likely to have questions about what they can expect in their coverage or how particular consumer protections may apply. With generous support from the Robert Wood Johnson Foundation, CHIR recently released an updated version of our Navigator Resource Guide that includes 270 FAQs addressing private insurance coverage. Questions range from the individual mandate and premium tax credits for marketplace coverage to retiree health and high risk pools. One section is devoted to questions individuals may have once enrolled, whether in individual coverage, a large employer plan, or a small employer plan. Below we excerpt some of the FAQs from that section on post-enrollment issues.

  • I heard experts now say some women should take tamoxifen to prevent breast cancer. Does that mean it will be covered without co-pays? For some women, yes, tamoxifen must be available without co-pays. If tamoxifen is recommended for you and your plan is not grandfathered, your doctor may prescribe tamoxifen or another drug that experts say may reduce the risk of breast cancer, and your plan must cover it without any cost-sharing. This update to the to the preventive services benefit takes effect with plans that start after September 24, 2014.
  • I pay more for my plan because I’m a smoker. If I stop smoking after I sign up, will my rates go down? Your insurer doesn’t have to lower your rates to reflect your new non-smoker status until you renew your coverage.
  • I got a letter saying my employer plan didn’t meet the medical loss ratio requirement (MLR). Will I get a rebate? Yes, you will get a rebate check or the equivalent value of a rebate.  The Affordable Care Act requires health insurers, including those providing employer group plans, to meet a minimum medical loss ratio (MLR) standard. The MLR, also called the 80/20 rule, is a limit on how much premium revenue an insurer can devote to profits and administrative costs (20 percent in the individual and small employer markets and 15 percent in the large employer market) compared to what they spend on patient care. In the employer group market, if an insurance company does not meet this standard, they are required to return the difference to the policyholder (usually the employer) or directly to subscribers (employees) in the form of a rebate or reduction on future premiums. If the rebate goes to the employer, it must be used for “the benefit of subscribers,” i.e., in the form of a cash check or a discounted employee premium.
  • I thought there was a cap on my out-of-pocket costs, but I’m getting billed for something that puts me well above the limit. How can that be?  All new (non-grandfathered) employer plans must limit out-of-pocket costs to $6,350 for individuals and $12,700 for a family in 2014 for services that are considered part of the essential health benefits and that are obtained in-network. There are a few possible explanations for why you are getting billed for something that puts you above the limit. First, if you obtained an item or service not considered part of the essential health benefits, or received care out-of-network, your health plan is not required to apply those costs towards the limit on your out-of-pocket costs. Plans can also exclude non-covered services. Second, it’s possible that your plan is grandfathered and doesn’t have to comply with this rule.  Finally, if your plan has separately administered benefits, for example, for prescription drug coverage, it can have separate out-of-pocket limits, as long as each of the out-of-pocket limits is no more than $6,350 for an individual or $12,700 for a family. In 2014, employer plans can also have no out-of-pocket limit at all on separately administered prescription drug benefits.  Check the details of your plan to see how the out-of-pocket limit is applied in your coverage. Your Summary of Benefits and Coverage will provide that information.
  • I had to complete a health risk assessment and now my employer is offering me a discount on my health insurance premiums if I will lose weight, stop smoking, and lower my blood pressure.  What are my rights? Your employer can offer rewards or penalties to encourage employees to take a health risk assessment, and there are no limits on employers that do just that. If, however, you must also meet a health standard, like losing weight or lowering your blood pressure, your employer must meet additional requirements. Those requirements are:
  1. Every individual must be given an opportunity to qualify for the reward (or avoid the penalty) once a year;
  2. The rewards or penalties can total no more than 30 percent of the cost of coverage (including both your share and your employer’s share of the premium) or 50 percent of your premiums for programs to reduce tobacco use; this can be in the form of lower (or higher) premiums, deductibles or co-pays (but the limit applies to the total value of all penalties/rewards);
  3. The workplace wellness program must have a reasonable chance of improving health or preventing disease and not just be a way to discriminate against workers based on their health; and
  4. Those individuals who can’t meet the health standard must be given a reasonable alternative standard to meet. Where the program focuses on activities related to a health condition – such as weight loss programs for people with high body mass indices (BMIs) – an individual may be required to show proof that their doctor has advised against the program. But programs that require individuals to meet the standard (for example, a BMI of 29) or pay more must make a reasonable alternative standard available to anyone who can’t meet the health target. Any plan materials that describe the program must also give you information on how to request an alternative standard.

If you have concerns about the program your employer is offering, you can contact the Department of Labor here or call 1-866-444-3272.

These and other FAQs in the Guide are part of a Robert Wood Johnson Foundation project to support Navigators and other consumer assisters. In future blogs we’ll continue to answer commonly asked questions about private health insurance and marketplace topics.

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