The ACA in 2014: Helping Consumers Transition to New Coverage

January 1st was the first day of coverage for those who enrolled in health plans through a health insurance marketplace.  All eyes were watching to see how successful the transition from enrollment to the use of new coverage would be. The good news? Unlike the first few days of the Medicare Part D program, the first few days of Marketplace coverage came with few horror stories about problems accessing health care services. But that could, in part, be because we’re only a few days into January. This new year will undoubtedly bring a new focus in ACA implementation: how will consumers fare as they start to use coverage that must meet new standards for adequacy and affordability?

Some consumers may be newly insured, with health issues that had gone untreated because of lack of insurance. Other consumers may have changed plans with the expectation that their new coverage would include their regular doctor and cover routine medications. In anticipation of the issues that may arise for both the newly insured and those who changed plans, HHS released several fact sheets that provide tips for consumers on common issues with coverage, including filling a prescription, going to the doctor, and getting emergency care.  And in an interim final rule released December 17th, HHS provided guidance to marketplace plans to help “smooth transitions” in two areas of coverage: access to providers and prescription drug coverage.

When I signed up for my plan the provider directory said my doctor was part of the network. But now I’m being told he/she is out of network and I’ll have to pay a higher co-payment. Can my plan do this?

Provider directories are notoriously hard to keep up-to-date. However, the HHS interim final rule strongly encourages marketplace insurers to protect consumers from out-of-network charges if the online provider directory was out of date when the consumer enrolled in its plan. Specifically, HHS encourages these insurers to consider services received out-of-network as having been received in-network, with in-network cost-sharing, if the provider was listed in the provider directory as of the date of the consumer’s enrollment in the plan.  However, such a policy is voluntary on the part of the insurer, and the HHS suggests that it need only be temporary – “for the beginning months of coverage.” To provide some encouragement for insurers to adopt this policy, HHS has said they will consider insurers’ practices in this area during the marketplace recertification process for the 2015 plan year.

I was in the hospital [or in the middle of an acute episode of care] on January 1, 2014, when my coverage changed from my old plan to my new, marketplace plan. My provider during that episode of treatment is no longer in my plan’s network and I’m worried I’ll face higher cost-sharing as a result. Is this allowed?

The recent interim final rule from HHS encourages – but does not require – marketplace plans to adopt policies “to prevent disruptions in treatment of episodes of care.” HHS suggests that insurers can do this by considering a provider as being in the plan’s network when there is an acute episode of care at the start of the plan year.  However, HHS further suggests that these policies need only be temporary, to help reduce problems with coverage transitions. HHS will consider insurers’ policies related to coverage transitions in its plan recertification process for the 2015 plan year.

My doctor says I need a prescription drug, but it’s not in my health plan’s formulary. I didn’t realize that when I enrolled in the plan. Shouldn’t my plan be required to cover a drug that my doctor says I need?

In its recent interim final rule HHS notes that the Essential Health Benefits rule requires plans to have procedures in place to allow enrollees to request and gain access to clinically appropriate drugs even if they are not on the formulary. However, new enrollees may not be familiar with what their plan covers or with the process for obtaining approval for drugs not covered by the plan, yet may need immediate access to drugs they are currently taking. Therefore, HHS urges marketplace insurers to temporarily cover non-formulary drugs (including drugs that are on the plan’s formulary but require prior authorization or step therapy) as if they were on the formulary. This policy, too, would apply for a limited time – the interim final rule suggests access be provided during the first 30 days of coverage – and is not required of insurers. But HHS expects this temporary policy will provide enough time for consumers to go through prior authorization or through the drug exception process.

What should I do if my plan doesn’t adopt these policies and I have to pay out-of-network charges or can’t get the drug I need?

As with any coverage denial, you can appeal the health plan’s decision, first for a review by the plan (known as an internal appeal) and then by an independent third party (known as an external appeal). The plan must notify you of their decision regarding your appeal within specific timeframes: within 30 days for services you have not yet received, and within 60 days for services already received. If you require urgent care, you can request an internal and external review at the same time, and you must receive a decision as soon as is required by your condition and at least within 4 days of your request.  You should also report the issue to your state insurance regulator.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.