Welcome to the Jungle, I mean Marketplace! Part 2
Laurie Kelley
January 27, 2014
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.
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]?
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?
to the number of appeals?
No.
 |
| 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?
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.)
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.
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
(Apogenics, Inc.)
|
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.
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.
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
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.
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.
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?
state?
All benchmarks
are listed in the state insurance department website. www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/Vermont
(for example)
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.
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.
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!
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]
Jennifer Niven [Kindle]
A secret exploration to Wrangle Island, inthe 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
