Insurers in health insurance exchanges have lots of rules to follow … an offer they can’t refuse.

2013

First we have a website disaster, then we have enrollment extensions linked to enrollment periods too short to effect proper enrollment in the first place. Now HHS has issued regulations placing the onus on insurers to provide coverage before receiving payment, to ignore use of participating doctors, to consider non participating doctors as in-network for a period of time, and to allow use of non-covered drugs.

These are not unique issues, employers changing carriers face them on a regular basis, but they also allow sufficient time between enrollment and the effective date of new coverage to communicate and resolve the issues. The federal government did not do that and will not do that in 2014 either.

Provider directories change constantly and there is no way to publish such directories that are always accurate … another fact known to everyone in the business except HHS. Employers tell workers to check with their doctor and to call the plan to verify participation before services are rendered. The federal government tells insurers to cover services as in-network if the online directory is not accurate. HHS seems to forget that many plans offered through the exchanges do not have out of network benefits, they are Exclusive Provider Organizations or HMOs and provide no coverage other than through a participating provider; something factored into premiums. Every exception that is made will be taken advantage of and will cost money.

Exceptions are also requested for use of non-formulary prescription drugs during the first 30 days of enrollment.

These transition requests are not totally unreasonable, but they would not be necessary if there were sufficient time between enrollment and the effective date of coverage allowing insurers to communicate with their actual new enrollees. All of this is a clear indication of a bureaucracy running a process. The regulations are dated December 4, 2013. This is stuff that should have been worked out with insurers month and months ago with the transition process included on healthcare.gov

Following are excerpts from the regulations. Note especially the paragraph I placed in red. Read it carefully. Do you still think you can keep your doctor or your health plan for that matter? Plans that don’t play by HHS rules will simply not be offered in an exchange in the future thereby disrupting coverage once again. Welcome to the world of government – run health care. Exchange plans may be private insurers, but it’s quit clear they will be regulated, taxed and feed into submission. I wonder why any insurer would want to participate.

Excerpts from HHS regulations:

However, we note that an effective coverage date of January 1, 2014 means that the individual must receive coverage for any services received on or after that date, even if the payment and enrollment are not processed by that time.

C. Other Policies to Smooth Transitions

In addition to the change in coverage effective dates outlined in this interim final rule, we also strongly encourage issuers to take other approaches to ease the transition to QHPs for consumers who may be switching from other coverage. Two areas of focus for a smooth transition are access to providers and prescription drug coverage.

When shopping for coverage on an Exchange, prospective enrollees may base QHP selection decisions on whether their provider is considered in-network using the issuer’s online provider directory. However, evolving provider networks may result in some issuer provider directories containing outdated information. As a result, an enrollee may later discover that his or her provider is considered out-of-network.

We are concerned that this could cause hardship to new QHP enrollees in the early months of coverage and could disrupt what could otherwise be a more seamless transition into a QHP. We strongly encourage QHP issuers to take any steps possible to ease this transition.

In particular, we interpret the requirement at §156.230(b) that issuers make their provider directories for QHPs available to the Exchange for publication online to mean that issuers must make current provider directories for QHPs available to the Exchange for publication online. Accordingly, issuers should ensure that provider directories listed with for the QHPs on Exchanges contain the most current listing of in-network providers so that consumers are relying upon accurate information to make enrollment decisions.

For those directories that cannot be maintained in a current status, we believe that it would be reasonable for issuers to consider services received out-of-network as having been received in-network (subject to in-network coverage and cost-sharing standards) with respect to any provider listed in the version of the provider directory as of the date of that enrollee’s enrollment for the beginning months of coverage. We strongly encourage issuers to adopt this approach.

We also encourage issuers to adopt policies in January to prevent disruptions in treatment of episodes of care (for example, considering a provider as in the plan’s network for an acute episode of care at the start of the plan year). Some states like Arkansas have adopted policies like this.

We are considering factoring into the QHP renewal process, as part of the determination regarding whether making a health plan available is in the interest of qualified individuals and qualified employers, whether consumers have up-to-date provider directories and how QHPs ensure continuity of care during transitions.

Prescription drug coverage is another area where we strongly urge issuers to take steps to ensure a smooth transition for new QHP enrollees.

In the Essential Health Benefits Final Rule at §156.122(c), we established that issuers providing EHB must have in place procedures that allow enrollees to request and gain access to clinically appropriate drugs not covered by the health plan.

We believe that the standard for issuers to have a drug exceptions process, as established in §156.122(c), will provide strong protections on an ongoing basis to enrollees with health needs that require drugs that are not on an issuer’s formulary, particularly if issuers use the process outlined in the 2014 Letter to Issuers on Federally-facilitated and State Partnership Exchanges.

However, we are also cognizant that new enrollees may be unfamiliar with what is covered in their new plan’s formulary and the drug exceptions process. Also, some enrollees whose drugs are covered by a QHP issuer’s formulary may need to obtain prior authorization or go through step therapy in order to have coverage for the drug.

Since new QHP enrollees may need more immediate coverage for drugs they have been prescribed and are currently taking, we strongly urge QHP issuers to temporarily cover non-formulary drugs (including drugs that are on a QHP issuer’s formulary but require prior authorization or step therapy) as if they were on formulary (or without imposing prior authorization or step therapy requirements) during the first 30 days of coverage, starting on January 1, 2014.

While not required, we encourage this approach because this policy would accommodate the immediate needs of QHP enrollees, while allowing the issuer and/or the enrollee sufficient time to go through the prior authorization and/or drug exception processes.