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HHS Secretary Kathleen Sebelius

HHS tells insurers to grant Jan. 1 coverage to late enrollees

By Paul Demko
Posted: December 12, 2013 - 6:00 pm ET

HHS officials announced a series of policy changes Thursday designed to ensure that everyone who signs up for private insurance exchange coverage that is supposed to be active on Jan. 1 will be covered on that date, even if they don't pay their premium until the day before coverage begins. The moves are designed to prevent problems for consumers—and another political fiasco for Obamacare—at the start of the new year.

Insurers now will be required to accept premium payments from subscribers as late as Dec. 31 for coverage that starts Jan. 1, 2014. Insurers and other observers are worried that many exchange plan subscribers may not realize they have to make their first premium payment to activate their coverage on that date.

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In addition, HHS made official a previous announcement that individuals can sign up until Dec. 23—eight days longer than originally allowed—for coverage that starts Jan. 1.

HHS also is giving people enrolled in the federal Pre-existing Condition Insurance Plan—a program that has covered people with severe health problems who otherwise wouldn't be able to obtain coverage from private insurers but that was supposed to end Dec. 31—the option of extending their PCIP coverage through January. That will allow them additional time to shop for standard coverage through the exchanges. Starting Jan. 1, individual-market health plans inside and outside the exchanges will not be allowed to consider pre-existing conditions in accepting applicants or setting premiums.

On a call with reporters, HHS Secretary Kathleen Sebelius stressed that there are still more than three months left in the open-enrollment period before nearly everyone will be required to have coverage or face a tax penalty. "The steps we're taking today will help ensure that Americans seeking quality affordable health coverage can do so with even more peace of mind and with even more confidence it will be there when they want and need it,” Sebelius said.

HHS is also leaning on insurers to make additional voluntary changes to ensure that individuals who signed up for plans are actually covered after Jan. 1. For instance, the federal agency is urging insurers to deem healthcare providers that have been dropped from their networks as in-network providers if they were listed as being in the network during the open-enrollment period. That would address situations where subscribers sign up for a plan on the basis that their doctor is in the network only to discover later that their doctor is not included.

In addition, HHS is strongly encouraging insurers to temporarily continue covering their subscribers' prescription drugs after Jan. 1 in plans that are being cancelled as of Dec. 31 if there is a gap in coverage.

The federal agency also is encouraging insurers to extend the deadline for paying premiums beyond the new required federal deadline of Dec. 31, and to provide coverage to individuals who have only made partial payments. HHS officials say Aetna has agreed to give customers until Jan. 8 to provide their first payment for coverage that starts at the beginning of January. There have been widespread concerns that consumers could face a chaotic situation when they seek to access their new coverage after Jan. 1. That's in part because the botched rollout of the federal exchange and some of the state-run marketplaces made it extremely difficult for individuals to obtain coverage during the first two months of operations. Less than 400,000 individuals signed up for coverage during October and November. That's barely 5% of the 7 million enrollees that the Congressional Budget Office projected will acquire coverage during the open enrollment period that closes March 31.

There also are major concerns about the accuracy and completeness of information being forwarded to insurers about enrollees. Some state-based exchanges have reported similar issues. That's raised fears that individuals will show up at the doctor's office after Jan. 1 only to find out there is no record of their insurance coverage.

Similar issues played out during the introduction of Medicare prescription drug coverage in 2006. In that instance, the federal government instructed pharmacies to fill prescriptions for elderly patients even if there was no proof of coverage, with the understanding that they would eventually be made financially whole. “We essentially said to pharmacists, 'Give them their drugs and we will work it out later,'” recalled Michael Leavitt, who was HHS secretary at the time, speaking at a conference organized by America's Health Insurance Plans on Thursday.

Michael Hash, director of HHS' Office of Health Reform, stressed that HHS is working closely with insurers to make the transition to 2014 as smooth as possible. “The steps that the administration is taking today are important to help ensure that consumers seamlessly transition from their current health plans into marketplace coverage without experiencing any gaps in coverage,” Hash said.

Follow Paul Demko on Twitter: @MHpdemko

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