Patience and Flexibility Needed as Those with New Insurance Start Using Health Care Services January 1

By Jack Hoadley, Georgetown University Health Policy Institute

Now that is working much better and enrollment numbers are rising, it is a good time to think about being prepared for the January 1 launch of new coverage.  Beyond counting enrollment, the media are already focused on what will happen to those who sign up for insurance effective on January 1.  If Sophie Smith shows up at a clinic or doctor’s office, will her new insurance status be recognized?  Will she have an insurance card to show?  Will the clinic or office know the right copay to charge?  Will she be treated or will she be asked to pay the full cost up front?

This question is not unique to insurance purchased in the federal or state Marketplaces.  Many of us who change employer-sponsored private insurance have at times waited to get a new insurance card or have faced confusion at a doctor’s office about the status of our new coverage.  As Sarah Kliff reported in the Washington Post earlier this year, there were concerns in 1966 that there could be long lines on the first day of Medicare coverage.  Fortunately, the concerns proved to be mostly unfounded.

But in January 2006, fears of a rocky start for new Medicare Part D drug coverage were justified, as colleagues and I described in a report earlier this summer.

When enrollees in the new Part D plans showed up at the pharmacy, some found that there was no record of their enrollment or of their Low-Income Subsidy status.  Others learned that a drug they had been taking was not on the plan’s formulary or that the plan required a prior authorization for a particular drug.  For some beneficiaries, this meant that they left their pharmacy without a needed drug.  What was done?

  • CMS had previously established policies requiring that enrollees, during the first 30 days of new coverage, be provided temporary supplies of medication for non-formulary drugs.  When it became clear that these policies were not working well, CMS sent out further guidance on January 6 and January 13.  Then in February, CMS required plans to extend the 30-day transition period to 90 days.
  • To help dual eligible beneficiaries whose subsidy status was not correctly recognized, Medicaid programs in 37 states implemented temporary coverage programs (without any guarantee of getting the money back) to pay for drugs needed by their citizens.  Ultimately, Administration officials used demonstration program authority to reimburse states for the money they spent to help out.
  • CMS had special call centers for inquiries by pharmacists.  But in January 2006 pharmacists calling the lines faced long waits.  CMS took steps to resolve technical issues, increased the number of representatives at the call centers from 150 to 4,500, and expanded operations to 24 hours per day.  CMS also instructed plans to expand their call centers for pharmacists.
  • CMS had created in advance a special process to help dual eligible beneficiaries who were not enrolled in a plan when their Medicaid coverage was terminated or whose plan assignment did not show up in the system.  The idea was that the pharmacy could provide a 14-day supply of a prescribed drug and bill the contractor for this special system.  When the system failed to function well, CMS initiated various administrative fixes.  Gradually the backup system did its job better.
  • To address problems unique to particular beneficiaries, especially those who were getting bumped from one entity to another in search of answers, CMS trained hundreds of its staff to serve as temporary caseworkers to identify both temporary and permanent ways to solve the problems of these individuals.  As late as August of that first year, some CMS regional office staffers continued to spend time on individual casework.

What are the lessons for January 1, 2014?  No matter how well prepared the system might be, start-up problems are inevitable.  It will be critical for all of us to be patient and recognize that things will improve.  In addition, exchange administrators, plan officials, and provider organizations need to be flexible in working through the problems as they come up.  As Part D problems arose early in 2006, the Bush Administration monitored them and used administrative authority to implement fixes.  Many pharmacists spent time and incurred costs to make sure their patients got needed drugs.  Next month we should expect HHS and state Marketplace officials to watch for problems and put forth fixes.  But we also need plans and providers to be flexible in ways that ensure that their patients get the care they need, for example by deferring billing until paperwork catches up.  And we need the public to be patient in recognizing that startup troubles do not signal system failure.

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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.