Although enrollment for January 1, 2014 began with a whimper in October, 2013, it ended with a bang on December 24, 2013.  According to Julie Bataille, Director of CMS’s Office of Communications, had 2 million visits on Monday, December 23, and 880,000 visits on Christmas Eve.  The Marketplace call center received more than 250,000 calls on December 23rd and 317,000 calls on the 24th.

After 27,000 enrolled in qualified health plans through the federal exchange in October and 110,000 in November, 975,000 enrolled in qualified health plans in December, despite the fact that it was a short month.  Enrollment nearly doubled in the last few days of the enrollment period compared to earlier in the month.  Hundreds of thousands more have enrolled through the state exchanges as well: about 400,000 in California, more than 188,000 in New York, almost 60,000 in Connecticut.  And many more have been signed up for Medicaid.

Some of this heavy traffic is the predicted last minute rush of people who wanted coverage by January 1, 2014, at which time qualified health plan coverage with premium tax credits begins.  But it is also due to the fact that the websites are at last up and running.  It is now finally possible for consumers to sign up relatively quickly most of the time and to find the coverage they are entitled to.  Now the massive planned enrollment efforts that have been on hold for months as the websites struggled can begin.  Between now and March 31 we will see a continued surge as American’s uninsured get the coverage long denied them.

What’s next?  Individuals who enrolled in a health plan must now pay their premium.  Under federal regulations, enrollees have until at least December 31 to do so for coverage to be effective on January 1, 2014.  But some state exchanges allow payments to be made after January 1, and many insurers have agreed to make coverage retroactively effective for January 1 if payment is received by January 10.

The open enrollment period for 2014 also, of course, extends until March 31, 2014.  Individuals who apply between now and January 15, 2014 will have coverage for February, 2014.  Also, if a person attempted to enroll in coverage before December 24, but a problem with the Marketplace system prevented the applicant from getting coverage, the applicant may, according to an article on the website, be eligible for a special enrollment period and get coverage sooner.

For most enrollees, however, attention now shifts from getting coverage to using their coverage.  On December 26, 2013, CMS posted a number of fact sheets on its website intended to assist QHP enrollees in understanding how to access and use providers under their QHP coverage.

First, there is the matter of establishing the existence of coverage.  It can be expected that some health plan enrollees will begin showing up at emergency rooms across the country soon after midnight on January 1, 2014, the victims of excessive New Year’s celebration.  Many more will need refills for their prescriptions or seek primary care early in January.  These enrollees will need to establish for their health care providers the fact that they are covered.

If enrollees paid their premiums in a timely fashion, they may already have received an insurance card or other proof of coverage in the mail by January 1. Many insurers are also allowing enrollees to go to the insurer’s website to print out a temporary identification card.  Enrollees who need health services but have not yet received an ID card should contact, or have their provider contact, their insurer.  If the insurer does not resolve the eligibility question, consumers should contact or the call center for assistance.  CMS will work with insurers and providers to ensure that individuals who enrolled in coverage in a timely fashion will be covered.

Other newly released fact sheets on the website discuss getting prescription medicines, using provider networks, internal and external appeals, accessing physicians, and getting emergency care.  Much of the content of these sheets is general information about how to use health insurance, such as the difference between a PPO and an HMO or an in-network and out-of-network provider, but much of it is also specific to QHPs.

The prescription drug sheet, for example, informs enrollees that they should be able to determine information about the drugs covered by their plan from their insurer’s website, from their plan’s summary of benefits and coverage, from coverage material provided by their insurer, or by calling their insurer.  A QHP might cover a refill of an off-formulary drug on a one-time basis for a new enrollee.  QHPs must also offer an exceptions process for off-formulary drugs; under these processes, QHPs generally cover an off-formulary drug if the enrollee’s doctor certifies that the drugs included in the plan’s formulary are not as effective as the off-formulary drug, or that the on-formulary drugs cause adverse side effects.  A QHP must cover an off-formulary drug while the enrollee is awaiting a decision on an exception request. An exception denial is appealable.

The provider network sheet informs enrollees that the Marketplace provides a link to QHP websites, where a list of in-network providers can be found.  Enrollees who receive services from out-of-network providers will likely be responsible for extra cost sharing; indeed, out-of-network coverage expenses may well not count against deductibles or out-of-pocket limits. The “Seeing your Doctor” sheet states that an enrollee may appeal a plan decision not to cover a doctor, although it is hard to understand what the appeal would be about if the doctor was not identified by the plan as an in-network provider.

The emergency care sheet reminds enrollees that, under the ACA, no group health plan or insurer can require prior authorization for emergency services, or charge higher copayments or coinsurance for emergency services received through out-of-network providers than for in-network emergency services.  The appeal sheet describes ACA internal and external appeal processes.

Two other new question and answer sheets provide information of particular interest.  First, a sheet entitled “What You Should Know about Early Renewal of Health Coverage” informs enrollees who accepted their health plan’s invitation to renew their 2013 coverage early for 2014 that their plan may not cover all of the essential health benefits covered by 2014 plans, and will not be eligible for premium tax credit coverage.  This sheet notes that individuals who renewed in 2013 for coverage in 2014 may switch to a marketplace plan at any time during the open enrollment period through March 31, 2014.

Second, the information sheet on Helping Consumers with the Application Process provides valuable information on plan security.  This sheet notes that CMS may call consumers for additional information if their application is missing information.  If the call is from CMS, the consumer’s caller ID will read:

  • Health Insurance MP; or
  • 606-260-4191 (Kentucky); or
  • 479-877-3203 (Arkansas); or
  • 636-698-6320 (Missouri); or
  • 580-354-7707 (Oklahoma).

A CMS agent who calls for additional information will attempt to verify a consumer’s identity using information already provided by the consumer to CMS. A CMS agent may ask for additional information about earnings, but will never ask for an entire Social Security number, for personal health information, or for information about a consumer’s financial institution, like a bank account number.  A consumer who is uncomfortable with providing information over the telephone may ask to mail in the information.  Consumers who suspect that they are victims of identify theft should file a complaint with the Federal Trade Commission.

In other developments, CMS continues to post frequently asked questions and other policy guidance at its website.  Two FAQs posted on December 24 provide that insurers in the SHOP exchange may rely on attestations by employers that they employ 50 or fewer full-time equivalent employees, and that an insurer may waive SHOP minimum employee participation rates for 2014 if it is impractical for the insurer to determine a minimum participation rate for an employer and the insurer is implementing capability to comply with minimum participation requirements.