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PPACA eligibility: The flowchart

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Members of a National Association of Insurance Commissioners (NAIC) panel have tried to boil basic Patient Protection and Affordable Care Act (PPACA) program eligibility questions into a flowchart.

The panel, the Consumer Information Subgroup, has posted a flowchart discussion draft on its section of the NAIC’s website. 

The drafters have compressed the PPACA health program eligibility basics into a one-page chart that includes 17 pages and leads to nine ultimate program eligibility conclusions.

The questions range from practical questions about the consumer, such as, “Does caller appear English-language proficient?” to questions about whether the consumer is a legal resident of the United States.

The eligibility answers range from, “You may be eligible for Medicaid,” to a suggestion that some higher-income consumers might consider trying to either try to buy un-subsidized coverage through an exchange or try to get coverage through the non-group, non-exchange market.

The subgroup is responsible for helping state regulators and others involved with helping consumers understand and use the new PPACA health insurance exchanges, or Web-based health coverage supermarkets. The exchanges are supposed to open for business Oct. 1.

Earlier, the subgroup helped officials at the U.S. Department of Health and Human Services develop a health coverage glossary. A version of the glossary now on the subgroup website gives definitions of commonly used terms such as “co-insurance,” “medically necessary” and “usual, customary and reasonable.”

In addition to the eligibility flowchart, the subgroup is working on list of “frequently asked questions” (FAQ) that consumers often ask about PPACA. The questions include basics, such as “What is a health insurance exchange?” and potentially complicated questions that might eventually require a consumer to seek professional advice, such as, “Am I subject to the individual mandate?” and “What if my income changes during the year? What happens to my subsidies?”

At a recent meeting, Bonnie Burns, a California consumer advocate, suggested that state exchange managers should look to see what worked when states and others were helping to roll out the Medicare Part D prescription drug program back in 2006.

When the Medicare drug program came along, Burns said one problem was that entities in the same state would come out with different messages, according to an official meeting summary.

Burns “thinks it is very important that there be a consistent message throughout a  state,” according to the summary.

Another meeting participant, Beth Berendt of Washington state, the subgroup chair, suggested that one fear is that consumers will get lost because the people involved with explaining one part of the system, such as Medicaid eligibility, may not know much about other parts of the system.

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