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3 must-have skills for finding ACA exchange liars

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Managers of the Affordable Care Act public exchange programs are now learning what you’ve always known: that insurers have flings with flashy distributors with big sales numbers.

But in the long run, insurers want to settle down with serious producers who send them profitable business.

Health insurers had ACA exchange stars in their eyes in 2014 and early 2015, when it looked as though the exchanges were magical rainmakers. Then, about a year ago, insurers noticed that their 2014 health claims were awful, and that their early 2015 numbers were worse. 

The ACA eliminated most of the defenses that health insurers once used to protect themselves against claim risk. Once insurers’ eyes cleared, they complained that exchange managers appeared to be doing little to enforce one of their few remaining defense mechanisms: the special enrollment period system.

That system is supposed to push healthy people to pay for coverage year-round. Consumers are now supposed to buy individual major medical coverage from Nov. 1 through Jan. 31, during an annual open enrollment period, or show they qualify for a special enrollment period.

Federal agencies developed a long list of reasons consumers could use to qualify for special enrollment periods. But as long as the list was, insurers reported finding signs that exchange programs were doing little to get consumers to show they actually qualified for special enrollment periods using any of the legitimate excuses.

In California, for example, representatives from San Francisco-based Blue Shield of California, a nonprofit carrier that has been a strong supporter of the ACA exchange program, said claims for enrollees who came in through exchange special enrollment periods were much higher than claims for special enrollment period enrollees who came in through agents, brokers or its own customer service representatives.

As issuers began to turn away from the ACA exchanges, ACA imposed a new special enrollment period application documentation rule. Special enrollment period sales fell 15 percent.

Related: New exchange screening rules slash sales

Managers of state-based exchanges are trying to win back the hearts of health insurers by setting up special enrollment period verification efforts of their own.

Related: Connecticut exchange OKs special enrollment verification

Managers of Covered California, California’s state-based exchange, posted a solicitation for special enrollment period verification vendor bids on the exchange website earlier this week.

You might want to apply to be an exchange special enrollment period applicant screener yourself. Or, you might want to use the information in the solicitation to show insurers, and clients, how you help keep health insurance costs down by keeping the individual major medical application system honest.

For a look at a tiny bit of what Covered California wants its new special enrollment period application liar finder to do, read on:

Jail (Image: Thinkstock)

Some people need special enrollment periods after losing access to health care services provided by a prison or jail. (Image: Thinkstock)

1. Incarceration

People can’t use Affordable Care Act exchange plan subsidies to pay for coverage while they’re in jail or prison.

The can qualify for special enrollment periods to apply for subsidized exchange coverage once they get out of incarceration.

Covered California wants its new liar finder to explain how it would figure out whether applicants have been released from incarceration, and whether they are using the incarceration-related data sources or methods to perform transactions today.

Related: Agency finds holes in an exchange program’s eligibility screening

Many exchange users apply for SEPs when they move. (Photo: Allison Bell/LHP)

Many exchange users apply for special enrollment periods when they move. (Photo: Allison Bell/LHP)

2. Relocation 

Insurers have complained that some consumers got covered by simply swearing that they had moved.

Covered California says it wants the liar finders to explain how they would determine whether special enrollment period applicants had recently moved to California, or within California, and about how long that process would take.

Related: What if your health client is new in town?

Some people need SEPs because they come to life outside the regular open enrollment period. (Photo: Thinkstock)

Some people need special enrollment periods because they come to life outside the regular open enrollment period. (Photo: Thinkstock)

3. Reproduction

People who have babies or adopt children can get coverage for the children through special enrollment periods. Covered California wants to know how a liar finder would verify special enrollment period application information regarding the birth or adoption of children.


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