WASHINGTON — The Affordable Care Act (ACA) remains a work in progress, even with the next open-enrollment period for health insurance under the law just six weeks away.
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Issues continue to crop up in the management of the online insurance exchanges as well as for people seeking to sign up for health plans and access their new health care and prescription drug benefits.
Plans bought under the ACA are covering 7.3 million people, the Obama administration reported in September.
While the president had said in April that 8 million people had enrolled, Marilyn Tavenner, administrator of the Centers for Medicare and Medicaid Services (CMS), told a House committee some of those may have gotten insurance through work or discovered they were eligible for Medicaid. Others may have not paid their premiums, she said.
The next enrollment period for ACA plans runs from Nov. 15 through Feb. 15. The Congressional Budget Office projects that 13 million people will get insurance through online exchanges, 5 million more than during last year’s bungled rollout of HealthCare.gov.
The U.S. Census Bureau last week reported that as of March 2014, 13.4% of Americans, or 42 million people, didn’t have health insurance for the previous year. For the 86.4% of Americans with health insurance in 2013, or 271.4 million people, 64.2% were covered by private health insurance. The largest single type of health insurance was employer-based health insurance, which covered 53.9% of the population. Government health insurance covered 34.3% of Americans, with 17.3% covered by Medicaid and 15.6% covered by Medicare.
In a speech Friday at the National Press Club in Washington, CVS Health president and chief executive officer Larry Merlo said the ACA has provided "a modest benefit" for the company. CVS is gaining more from Medicaid expansion under the law than from exchange enrollment, he said.
Estimates of how many enrollees are newly insured "are all over the board," according to Merlo, who cited a range from 25% to 80%. "I’m not sure we know the numbers in terms of what percent are really new to insurance," he said. "That’s not the same in Medicaid."
While the last open-enrollment period ended on March 31, some people have signed up for plans since then, capitalizing on extensions for those who married, divorced, had a baby or were thwarted by HealthCare.gov’s technical problems.
Just this month congressional investigators reported that the website risked a breach of personal information. Although the administration has taken steps to safeguard HealthCare.gov’s privacy, "significant weaknesses remain that put these systems and the sensitive, personal information they contain at risk of compromise," said Gregory Wilshusen, director of information security for the Government Accountability Office (GAO).
More than 20 security issues must be resolved, the GAO found.
"There’s very little that concerns me more on a daily basis than the security of this website," Tavenner testified. "I will always worry about the safety and security of the website." To date there has been no breach of personal information, she said.
Earlier this month, the National Association of Chain Drug Stores advocated administrative changes to help people seeking health care coverage in 2015.
Exchange call centers should remain open on Christmas and New Year’s Day, beneficiary eligibility files should be updated nightly, and pharmacists should be allowed one-time overrides in January, NACDS president and CEO Steve Anderson wrote in a letter to Tavenner.
Anderson said there were concerns last year that some state-run call centers were not open on holidays. New Year’s Day service is especially important for addressing confusion and transitional problems, he said.
Also, patients may visit a pharmacy in January, shortly after enrolling in a plan, only to find that their coverage is not yet active, according to Anderson. The likelihood of that happening will rise if plans fail to update patient eligibility files every night. Nightly updates will "provide for a smooth transition from coverage to care," he wrote.
"Finally, at the start of a plan year, there often can be confusion concerning coverage for specific medications for new plan enrollees," he explained. "Difficulties in adjudicating such drug claims can lead to continuity of care problems as patients are delayed or denied access to the medications they need."
To avoid repercussions, Anderson asked for overrides of prescription drug claim denials in January 2015.
"CMS should further make clear that the plans have the responsibility for paying for the overridden claim once the claim is approved," he wrote. "This will provide patients with access to the drugs that they need while they work through coverage issues with their insurer, or work with their prescriber to find a substitute covered medication."
