Cost Sharing Info Sent to Carrier?

1. Client applies for ACA plan with Humana....chooses 4250 Silver plan, but due to low income cost sharing gets a $750 deductible with $1000 out of pocket max
2. Client gets card and plan info in the mail from Humana......card and all plan info says $4250 deductible
3. Client calls Humana Billing and Enrollment....asks about their benefits.....told they have a $4250 plan like it says on their card......knows nothing about cost sharing. Suggests they call the government to verify their deductible.
4. Client needs $40,000 surgical procedure....shows doctor insurance card with $4250 deductible clearly written on it....patient claims it really is $750 deductible.....doctor says 'yeah right...please prepay the $4250. Billing and Enrollment says you have a $4250 plan.

Glitch or mess? :goofy:

Anyone else experience this yet. Seems like cost sharing info has no way to get into the carrier system.
 
I have found similar problems with other carriers (Cigna/Aetna). If the carrier rep digs deeper in the carrier system, they'll see the CSR. Same goes when the provider calls to verify benefits, they need to ask and dig deeper.

Maybe this is the way the system is supposed to work that the carrier "cost shares" when the claim comes in according to the CSR. But with providers demanding cash up front, it's sure to cause problems for patients/clients.

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The other problem is getting your hands on a CSR brochure from these carriers.
 
There are so many administrative nightmares in this mess, and this has to be one of the worst. Even more so than collecting premiums from the PH and subsidies from DC.

This is essentially telling a carrier to administer each subsidized plan separately. I may have $10 copays and a $500 deductible while you (with the same Bronze plan) have $18 copays and a $910 deductible. In essence the carrier has to track what amounts to thousands of individually designed plans.

What *** came up with this scenario?
 
Somarco,

From the looks of it, this was never the intention. As we know, they never built a "back end" payment system, after struggling for months to make the "front end" website work.

This lack of back end has put all of the responsibility on insurers while CMS scrambles to build it (I'm sure you've heard about CGI going out, Accenture in, etc...). This is all part of the same missing system.

The temp fix is for carriers to just take what the gov't gives them as far as information, and re-submit it to the gov't in a different for payment, as we learned in that REGTAP/CMS presentation posted here last week (http://www.insurance-forums.net/for...s-you-cant-get-your-commissions-t61081-5.html Post #42, thanks to Duaine for the link)

We'll see how well that works, carriers have a whole lot more work to do.
 
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The claims side, and CSR, is not the same kind of backend mess as the premium and APTC. Yes, the carriers are essentially supposed to have each of these different CSR plans developed and administered directly. The cash feed from the feds to support carrier payment of the richer CSR plans has always been defined to occur upfront, and this is not too much of an issue as far as I know. All the eligibility related issues will of course bleed over and probably makes it a harder to know who to ask for money for from the feds.

In a vacuum with nothing else happening, carriers probably would be more prepared to execute this better. But in the current environment, they are spread way too thin and so the rollout continues to have flaws and is very, very slowly getting better.
 
The claims side, and CSR, is not the same kind of backend mess as the premium and APTC. Yes, the carriers are essentially supposed to have each of these different CSR plans developed and administered directly. The cash feed from the feds to support carrier payment of the richer CSR plans has always been defined to occur upfront, and this is not too much of an issue as far as I know. All the eligibility related issues will of course bleed over and probably makes it a harder to know who to ask for money for from the feds.

In a vacuum with nothing else happening, carriers probably would be more prepared to execute this better. But in the current environment, they are spread way too thin and so the rollout continues to have flaws and is very, very slowly getting better.

I appreciate your insight, but request that you speak dumb "english" to me.

First, I have read many times on RegTap that they have no idea about how much CSR payments to make, and it's being done on the honor system at the same time the APTC is sent.

Second, what should the carriers be showing on the client's cards, their computer systems, and who is paying the difference at the provider? The client, the carrier upon claim, or the feds?
 
What AG is saying is essentially confirming what I said and adding in the cash flow aspect.

The carriers have to administer claims as if they have thousands of individually tailored plans.

But the premium dollars they have to work with are minimal until the fed cough up their share. All this extra book work and floating claims until fed $$ come in, and then waiting even longer for reinsurance could create some serious reserve problems for some carriers.
 
The member above with a $750 deductible should only see their plan from that perspective; same for the carrier, same for the providers. The carrier is given an estimated amount of money, monthly and upfront, to cover the claims of members like this. The carrier just processes and pays more of the claim costs for the CSR plans than they would for the base silver plan. The process to get this money has always been defined as upfront. I think I was wrong earlier, and that this too is supposed to be automated, so it is correct that carriers have to make the request for this too just like the APTC. Sometime in 2015, carriers have to reconcile and see if they received too much or too little upfront from the govt.
 
Then will the government reimburse the insurers if they paid too much?

Yes if carriers prove that they did not receive enough upfront payment, they will receive the difference. Likewise if they did not use all the money received, they will return the difference.
 
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