At NHF’s Social Worker Insurance Workshop in Baltimore on January 16, there were some great questions asked from the audience concerning the Marketplace. Social workers know they will most likely be the first line of defense for patients with bleeding disorders facing the many challenges of the ACA. Here are some questions asked and other snippets of information from the workshop.
|Very cool illustrator maps out the discussion|
Q. What if you don’t like the insurance plan options in the Marketplace. How do you file a special appeal [concerning coverage]?
Go to Healthcare.gov; there is a link for an appeal. Appeals are worthwhile because sometimes codes are entered in wrong, and sometimes people get approved for procedures and benefits that were originally denied.
Is there a limit to the number of appeals?
|Laurie with social worker|
Ed Kuebler, Texas
Q: But after you pick a plan and don’t like it, what if you just don’t pay the next month’s premium? Won’t you just get canceled and then you can choose another plan? Isn’t that easier than an appeal?
There is an open enrollment time, so you can’t choose to switch outside that time period. After March 31 you can’t get into a “QHP” (an insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements.)
Joanna Gray, of CRD Associates told us that the ACA says HTCs must be included in-network. But… plans don’t have to include any specific medical procedure. They only need to cover “sufficient” providers, and they don’t say who those providers are. The ACA hasn’t come through in its promise. NHF says be careful! Don’t pick a plan that doesn’t include your HTC or product, because now it’s legal for providers to avoid HTCs. We can’t change the policy for this year. Maybe next? We need to complain to get changes made.
|Mike Bradley (Baxter), Laurie|
Kelly, and Derek Robertson
NICOLE of NHF said that every state has its own definition of EHB (essential health benefits). So picking a plan is harder, because there are more plans, and picking one that covers what you need is hard.
Q: To use the Marketplace, you must be a legal resident. What happens to legal immigrants, who are not citizens? In Nevada, they are currently covered under high-risk pools but will lose this soon (the pools are closing). Are there alternatives? No. You can still get emergency medical through Medicaid; and of course, anyone can buy insurance in the commercial marketplace.
|Nancy Hatcher and |
Ed Kuebler again!
JoAnn Volk of The Center on Health Insurance Reform, Georgetown University Health Policy Institute, said that
six states will not enforce the ACA: Alabama, Missouri, Oklahoma, Texas, and Wyoming. The ACA gives primary responsibility to states to enforce the rules, but there are 10 state benchmarks (Essential Health Benefits) that must be followed, and will be reviewed by the feds.
If you find a QHB but it doesn’t include factor, JoAnn thinks that the appeals process will work, recommending that people get their drugs for 20 days, during the appeals process, even if they are not on formulary.
Q: How do I find the benchmark plan for my state?
All benchmarks are listed in the state insurance department website. www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/Vermont (for example)
Q: What’s the advantage of going into the Marketplace?
The advantage of going into the Marketplace is subsidies; you can be eligible for discounts within limits. To buy into a Marketplace, you have to be physically in the state, not incarcerated and be legally present. There are no other limits.
Q: When we couldn’t find what we were looking for (was our hematologist covered), and we called the website, we couldn’t get any help.
Don’t call the health.gov website. Call the plan provider. Sometimes it’s best to work with your HTC contracting department! They will know who is in network.
And there is so much more information! Be sure to keep reading your HemAware (from NHF), Pulse (from us), and tap into your chapter’s or your local hemophilia organization’s efforts to educate their families about insurance changes. Lots happening; don’t miss deadlines and opportunities by not staying on top!
Great Book I Just Read (Again)
Ada Blackjack: A True Story of Survival in the Arctic by Jennifer Niven [Kindle]
A secret exploration to Wrangle Island, in the Behring Sea, in September 1921 goes terribly wrong when food runs low and sea ice keeps a relief ship from rescuing the stranded four young men and one 25-year-old Eskimo woman trapped there. The trip sets off an international crisis when Russia, Great Britain and the US learn that the trips leader, the opportunist and greedy explorer Vilhalmur Stefansson, who never even went, was trying to claim the island for Canada. Only Ada survives the horrible conditions, and her return sets off a media firestorm. Did she kill her companions? How did she survive? Diaries are stolen, Ada is hounded and used by the press and her own sponsors. She becomes at once a hero and a villain. Fantastic read and Ada will amaze you with her spirit and ingenuity. Her real survival started when she returned home. Four/five stars