Carrier Not Recognizing Cost Sharing Limits on Subsidized Policyholder?

[yorkriver1]

Anyone have experience dealing with a large claim where the official parties involved might not be understanding the insurance coverage?

Yesterday I called a policyholder covered at the 94% cost sharing level on coverage through Marketplace, checking to see about how a close family member's MAPD was going. The conversation switched to the under 65 ACA subsidy client.

To shorten the situation, the doc says the carrier told his office: over $6k as the OOP for a new specialty pharma treatment. Under this client's 94% CSR that's impossible. Coverage not refused, just high OOP mentioned. Pharma co reportedly is absorbing all but a copay under a special program, but even that would most likely exceed the client's small max OOP and not contribute to meeting it if carrier doesn't pay. Sure, it would be good to not have carrier pay the $10k or so per treatment from a loss ratio hit POV. I am assuming this could come back to haunt all involved, if not handled by the book. I realize this is all filtered thru the client, but, still. Did not bring up my concerns with client...who is happy as is, thinking it's the only option.

I left a message with carrier, may be coming in late due to weather. Will see how this plays out.

 

[Yagents]

Anyone have experience dealing with a large claim where the official parties involved might not be understanding the insurance coverage?

Yesterday I called a policyholder covered at the 94% cost sharing level on coverage through Marketplace, checking to see about how a close family member's MAPD was going. The conversation switched to the under 65 ACA subsidy client.

To shorten the situation, the doc says the carrier told his office: over $6k as the OOP for a new specialty pharma treatment. Under this client's 94% CSR that's impossible. Coverage not refused, just high OOP mentioned. Pharma co reportedly is absorbing all but a copay under a special program, but even that would most likely exceed the client's small max OOP and not contribute to meeting it if carrier doesn't pay. Sure, it would be good to not have carrier pay the $10k or so per treatment from a loss ratio hit POV. I am assuming this could come back to haunt all involved, if not handled by the book. I realize this is all filtered thru the client, but, still. Did not bring up my concerns with client...who is happy as is, thinking it's the only option.

I left a message with carrier, may be coming in late due to weather. Will see how this plays out.

The phone reps have to dig another level deeper to find the CSR values. The problem lies in that the name of the plan, and the OOP expenses show on the high level screen as the normal silver plan name and deductibles. When claims are processed, they will be done at the lower CSR values. But the client needs to know what they own, and the pharmacy/provider reps need to go beyond the first level of questioning to find the real benefits.

 

[somarco]

Coordinating max OOP on Rx with the rest of the plan has been a challenge, especially where a PBM is involved. It doesn't matter if it is a subsidized policy or not.

 

[yorkriver1]

Thanks for these answers. Just what I need to ask & watch out for.

What usually happens when the carrier/PBM time lag for meeting max oop creates a delay in the carrier paying @ 100%?

In a more perfect world, the client would be able to hold off on paying out of pocket until the two providers synced the benefits. Not likely, I fear....

 

[somarco]

What usually happens when the carrier/PBM time lag for meeting max oop creates a delay in the carrier paying @ 100%?

It may take a month or more to catch up. Going to be a lot of unhappy campers that are heavy Rx users and paid for plans with $1000 - $1500 max OOP for everything. They may well end up funding for a couple of months after breaching the OOP on paper and then waiting on a reimbursement from the carrier.

Our clients can probably delay the doc and other medical providers, but if they want their meds they will have to pay on the spot.

 

[yorkriver1]

Thanks! Yes, going to do some active listening to customer concerns right there...feeling their pain...