HealthCare.gov canft handle appeals of enrollment errors
By Amy Goldstein
February 4, 2014 - The Washington Post
Tens of thousands of people who discovered
that HealthCare.gov made mistakes as they were signing up for a health plan are
confronting a new roadblock: The government cannot yet fix the errors.
Roughly 22,000 Americans have filed appeals with the government to try to get
mistakes corrected, according to internal government data obtained by The
Washington Post. They contend that the computer system for the new federal
online marketplace charged them too much for health insurance, steered them into
the wrong insurance program or denied them coverage
entirely.
Data from the Department of Health and Human Services about
the Affordable Care Act shows that nearly 2.2 million people selected a
health-plan from Oct. 1 to Dec. 28.
For now, the appeals are sitting, untouched, inside a government computer.
And an unknown number of consumers who are trying to get help through less
formal means — by calling the health-care marketplace directly — are told that
HealthCare.govfs computer system is not yet allowing federal workers to go into
enrollment records and change them, according to individuals inside and outside
the government who are familiar with the situation.
gIt is definitely frustrating and not fair,h said Addie Wilson, 27, who lives
in Fairmont, W.Va., and earns $22,000 a year working with at-risk families. She
said that she is paying $100 a month more than she should for her insurance and
that her deductible is $4,000 too high.
When Wilson logged on to HealthCare.gov in late December, she needed coverage
right away. Her old insurance was ending, and she was to have gallbladder
surgery in January. But the Web site would not calculate the federal subsidy to
which she knew she was entitled. Terrified to go without coverage, Wilson phoned
a federal call center and took the advice she was given: Pay the full price now
and appeal later.
Now she is stuck.
gI hope,h she said, gthey really work on getting this fixed.h
The Obama administration has not made public the fact that the appeals system
for the online marketplace is not working. In recent weeks, legal advocates have
been pressing administration officials, pointing out that rules for the online
marketplace, created by the 2010 Affordable Care Act, guarantee due-process rights
to timely hearings for Americans who think they have been improperly denied
insurance or subsidies.
But at the moment, gthere is no indication that infrastructure
. . . necessary for conducting informal reviews and fair hearings
has even been created, let alone become operational,h attorneys at the National
Health Law Program said in a late-December letter to leaders of the Centers for
Medicare and Medicaid Services (CMS), the agency that oversees HealthCare.gov.
The attorneys, who have been trying to exert leverage quietly behind the scenes,
did not provide the letter to The Post but confirmed that they had sent it.
A CMS spokesman, Aaron Albright, said, gWe are working to fully implement the
appeals system.h
Three knowledgeable individuals, speaking on the condition of anonymity about
internal discussions, said it is unclear when the appeals process will become
available. So far, it is not among the top priorities for completing parts of
the federal insurance exchangefs computer system that still do not work. Those
include an electronic payment system for insurers, the computerized exchange of
enrollment information with state Medicaid programs, and the ability to adjust
peoplefs coverage to accommodate new babies and other major changes in life
circumstance.
The exchange is supposed to allow consumers who want to file appeals to do so
by computer, phone or mail. But only mail is available. The roughly 22,000
people who have appealed to date have filled out a seven-page form and mailed it
to a federal contractorfs office in Kentucky, where the forms are scanned and
then transferred to a computer system at CMS. For now, that is where the process
stops. The part of the computer system that would allow agency workers to read
and handle appeals has not been built, according to individuals familiar with
the situation.
In the meantime, CMS is telling consumers with complaints about mistakes to
return to the Web site and start over. gWe are inviting those consumers back to
HealthCare.gov, where they can reset and successfully finish their applications
without needing to complete the appeals process,h said Albright, the agency
spokesman. The rationale is that, since the computer system is working better
now, itfs less likely to make mistakes.
Agency officials have no way of knowing how many people have taken that
advice, according to two individuals familiar with the situation. The computer
system containing the scanned appeals forms cannot yet communicate with
HealthCare.govfs enrollment database, so it is impossible to cross-check the
information.
Across the country, a few specialists trained to help people enroll in the
health plans point to examples in which withdrawing an application and starting
over has solved the problem. But that is not a solution for everyone.
Starting over would not help Addie Wilson, for example, because she has
already begun to pay for her new insurance and would have no way to get her
money back. A few days before Christmas, Wilson was hospitalized with what
turned out to be a gallbladder so infected that doctors inserted a drain so it
would be safer by the time they operated — the first surgery of her life. She
needed a health plan because her employer, the organization Home Base, was
cutting off the Blue Cross-Blue Shield coverage she and her co-workers had,
reasoning that they could find better choices on the new marketplace.
Given her salary, Wilson knew she was eligible for federal subsidies to help
pay for her coverage. She was discharged from the hospital on Dec. 23, the
insurance sign-up deadline; she did not yet know that CMS had quietly reset its
computers to give people one more day to enroll. It had been weeks since the
Obama administration had announced that the system was working smoothly, so she
could not understand why the HealthCare.gov screen on her laptop, which should
have calculated her subsidy, stubbornly refused to appear. She asked her
boyfriend to try on his computer and her father to try on his. Nothing
worked.
She called HealthCare.govfs toll-free number, where, she said, a woman on the
other end tried typing and then told her, gWell, itfs not working for me
either.h The woman recommended that she choose a health plan at the too-high
price and file an appeal. Since her Blue Cross coverage would end Dec. 31, she
went back onto HealthCare.gov and picked a plan.
A failure to compute a subsidy is among a variety of mistakes the computer
system has made. Another involves what some CMS and state Medicaid officials
refer to as gloopers.h These are people who applied for coverage on
HealthCare.gov and were told that their income was low enough to qualify for
Medicaid. But when they went to their state Medicaid agency, they were told they
were not eligible after all, and should get a private health plan through the
marketplace. So they have gloopedh back to the federal system, which is unable
to fix the mistake.
The letter from the National Health Law Program describes families who are
appealing for other reasons. In one instance, a North Carolina couple were told
that they were eligible for subsidies to buy private policies and that their son
was eligible for the Childrenfs Health Insurance Program, which is public
insurance for children of working-class families. But the computer told them
that their daughter was eligible for nothing — an obvious mistake. At the time
of the letter, the family was uninsured while waiting for a decision on its
appeal.
In Fairmont, Wilson is waiting, too. In early January, she contacted her new
health plan about her missing subsidy and asked what to do. She was told to pay
the full insurance premium — $215 a month. She did. The next day, Brandon
Williams, an enrollment counselor at a local health clinic, helped her check
HealthCare.gov again. This time, the computer worked properly and showed that,
with the subsidy, her monthly premium should be just $106 and her yearly
deductible $617, not $4,750.
Wilson and Williams called the online marketplace and, after three hours on
the phone, got only a promise from a supervisor that Wilson would hear from
CMSfs gadvance resolution teamh within five days. The call didnft come.
Wilsonfs scheduled outpatient surgery turned into an expensive, five-day
hospital stay after her doctors discovered her gallbladder had gangrene. Home
after the ordeal, and dreading the hospital bill and her big deductible, Wilson
called Williams, and they tried to reach the advance resolution team. They
couldnft get through. When the call from the team finally came, she said, a
knowledgeable-sounding man told her, gThe system is not set up to go into
someonefs account and correct a mistake.h
With Williamsfs help, she has filed an appeal. And she is waiting — waiting
to be healed enough to drive so she can go back to work, waiting for someone to
decide that she deserves her money back.
gThese little kinks should have been worked out prior to this thing being
launched,h she said. gThis is one more thing stressing me out.h