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3 PPACA answers: What consumer reps want states to say

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State insurance regulators are talking at their meeting in Washington this week about how they will go about regulating the Patient Protection and Affordable Care Act (PPACA) exchange program and other PPACA programs now they really exist, and are no longer paper dream castles.

One panel at the National Association of Insurance Commissioners, the Consumer Information Subgroup, has been updating an existing PPACA document — a list of answers to consumers’ frequently asked questions (FAQs) about PPACA. The panel includes consumer group representatives along with representatives from insurance industry groups.

Members of the panel are trying to give state insurance commissioners and their employees ideas about how to handle PPACA-related questions.

The panel staff has created a draft that includes suggested revisions, and the panel has also posted comments from several longtime consumer reps. In the staff draft, for example, drafters have used red and blue ink to revise a question about the types of health insurance exchanges that exist, in an effort to explain the existence of state-run exchanges, exchanges run by the U.S. Department of Health and Human Services (HHS), and exchanges run by an HHS-state partnership is clearly as possible. At press time, the revised answer ended with a suggestion that consumers should to in-state regulators if they want to find out how their own state’s exchange is regulated.

The FAQ could affect agents and brokers by influencing what clients and prospects read when they visit insurance regulators’ websites and what they hear when they call consumer help lines.

For more information about the consumer reps said about the latest PPACA consumer FAQ revision, read on.

question marks

1. Are certain people paying for Medicare Part A able to enroll through the [insert name of exchange]?

Bonnie Burns, a Medicare specialist at California Health Advocates, has a number of suggestions about answers to questions about how PPACA affects Medicare.

She suggested, for example, that an answer to the existing question, “Are dental or vision benefits available through the [insert name of the state exchange]?” that the FAQ should discuss whatever options might be available to Medicare enrollees.

She also suggested adding a new question about how the PPACA exchange program relates to the basic Medicare Part A hospitalization program.

This was the answer she proposed:

If a person has to pay the premium for Part A because they are not entitled to those benefits they can buy coverage through [insert name of exchange] instead of Medicare, and they may also be eligible for a tax credit. This includes those beneficiaries who only enrolled in Medicare Part B because they couldn’t afford the Part A premium. In both cases these beneficiaries have to disenroll from Medicare A, if they have it, and from Medicare Part B. There are consequences to substituting a QHP for Medicare. A person may incur higher premiums for Medicare if they decide to enroll in the future and may have a gap in benefits. The [insert name of State Health Insurance Assistance Program (SHIP)] at [insert contact information] should be able to give consumers more information their choices.



2. How does a consumer find out what drugs a plan covers?

Kathleen Gmeiner of UHCAN Ohio suggested that the public exchange websites should link to each exchange plan’s formulary, or list of covered drugs.

“Questions have arisen in Ohio regarding whether an insurance company can change the formulary or tiering after the consumer has purchased the plan,” Gmeiner said. “Possibly this should be addressed with a blank for states to fill in their own rules.”

Dollar bill

3. Is there anything that consumers and their dependents who are already on Medicare and employer-based coverage need to do because of PPACA?

The existing FAQ says consumers who are already on Medicare and have employer-based coverage probably don’t have to do anything differently because of PPACA.

Medicare has complicated rules governing when it pays first and when another plan pays first.

Burns posed a question: “When the employer group is smaller than those covered by Medicare Secondary Payer rules, how will an employer plan coordinate with primary coverage through Medicare?”

When the employer group is small, Burns wonders whether the premium will be reduced, because the employer plan is now secondary coverage.

“Since there is no federal law on coordination of benefits for individual coverage, or for health coverage for employer benefits below a specified number or employees it appears that each state’s law will apply,” Burns said.


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