ObamaCare Appeals Process: Yet Another Failure

From The New American by Raven Clabough, February 3, 2014

Thousands of consumers who have signed up for a health plan through HealthCare.gov experienced significant errors that the government has not yet been able to fix. A government internal document revealed that approximately 22,000 people have filed appeals for errors they experienced during the enrollment process, but the appeals have gone unanswered.

Most of the appeals state that enrollees were charged too much for health insurance when signing up for the federal online marketplace, or that they were steered into the wrong program, or that the coverage was denied.

According to state Medicaid officials and those at the Centers for Medicare and Medicaid Services, consumers are dealing with what have been dubbed “loopers.” These are instances where individuals apply for health coverage and are told that they qualify for Medicaid, but when those individuals report to their state Medicaid agency, they are told that they in fact do not qualify for Medicaid and must pursue private health insurance through the marketplace.

A letter from the National Health Law Program cites other issues. For example, a North Carolina family was declared eligible for subsidies to purchase private policies and told that their son was eligible for the Children’s Health Insurance Program (CHIP), but that their daughter was eligible for nothing.

It appears, however, that these issues will not be addressed in the near future. The Washington Post reports, “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 healthcare marketplace directly — are told that HealthCare.gov’s computer system is not yet allowing federal workers to go into enrollment records and change them.”

Naturally, consumers are experiencing frustration.

One consumer, Addie Wilson, 27, earns $22,000 per year doing social work. Wilson asserts that she is paying $100 a month more for her health insurance than she should be and that her deductible is $4,000 too high.

Wilson was forced to sign up for health insurance on HealthCare.gov in late December by circumstance, as her old insurance was ending, and she was scheduled to have gallbladder surgery in January.

Struck with panic, she did her best to sign up for insurance on the website, but realized that the site was calculating a different federal subsidy than that which she knew she was entitled under the law. She called a federal call center and was told to pay the full price for now and appeal it later.

She took that advice, a decision she is now regretting.

“It is definitely frustrating and not fair,” Wilson opines. “I hope they really work on getting this fixed.”

Consumers are supposed to be able to file appeals through a variety of options, including computer, phone, or mail, but at the moment, mail is the only option. Those 22,000 people who have filed appeals have had to do so by filling out a seven-page form and mailing it to a federal office in Kentucky, where the forms are supposed to be scanned and entered into a computer system. At this point in time, that is where the process ends, since agency workers are unable to read and handle the appeals.

Officials who are faced without an option to address the appeals are instructing individuals to return to the website and start over.

“We are inviting those consumers back to Healthcare.gov, where they can reset and successfully finish their applications without needing to complete the appeals process,” said a CMS spokesman.

The failure of the healthcare appeals system is something which the Obama administration has been very discreet about, even as legal advocates have been calling upon officials to be sure to accommodate the due process rights of consumers who are entitled to timely hearings.

But at the moment, “there is no indication that infrastructure … necessary for conducting informal reviews and fair hearings has even been created, let alone become operational,” attorneys at the National Health Law Program said in a late December letter to leaders of the Centers for Medicare and Medicaid Services (CMS), which oversees the healthcare website.

A CMS spokesman, Aaron Albright, said, “We are working to fully implement the appeals system.”

Unfortunately for frustrated consumers, there is no clear end in sight.

The Post writes, “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 exchange’s computer system that still do not work.”

Issues that still require correction on the healthcare site include the electronic payment system, the exchange of enrollment information with state Medicaid programs, and the ability to adjust people’s coverage to accommodate changes such as new babies, marriage, etc.

Still, Albright assures that the appeals will be addressed.

“As we work to fully implement the appeals system, CMS is working directly with consumers to address concerns they have raised through this process,” he said.

However, he did not indicate when the computer program to process those appeals is expected to be completed, nor did he declare with whom each contractor was working to correct the problem, since the administration recently selected the consulting firm Accenture to replace CGI as the lead contractor responsible for the website’s continuing construction, reports CBS News.

Declaring that most of the front-end problems with the website have been resolved, the Obama administration has revamped its efforts to encourage more people to enroll in insurance via the site.

The Centers for Medicare & Medicaid Services “has been reaching out to consumers who applied for coverage but have not yet selected a plan by email, phone and hard mail, to let them know about the next steps to complete enrollment,” an administration official said. “Broader outreach and enrollment efforts will ramp up next year to help more Americans sign up for coverage throughout the open enrollment period, which goes through March 31, 2014.”

Meanwhile, President Obama adamantly defended his choice to keep HHS Secretary Kathleen Sebelius on the job in an interview with Fox News’ Bill O’Reilly, even after the healthcare website’s disastrous launch in October.

“We hold everybody up and down the line accountable, but when we’re midstream, Bill, we want to make sure that our main focus is how do we make this thing work so people are able to sign up,” the president told O’Reilly.


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