On a good day, health insurance is a topic that can leave the average person and experienced Massachusetts hospital administrators scratching their heads.
January 1, the day the Affordable Care Act (ACA) transition went into effect, was not a good day. An inadequate state website and ongoing confusion and disconnects at administrative levels left many Massachusetts residents previously enrolled in one of the state’s sanctioned insurance plans unsure of where they stood.
Since 2006, by law, with some exceptions, all residents of Massachusetts were required to have health coverage that met state standards. For those residents not covered by an employer or commercial health plan, the state created an agency, the Massachusetts Health Connector, to act as a broker for qualifying insurance plans.
MassHealth covered the poorest residents. Low-income residents had a choice of private, state-subsidized commercial products made available by various insurers through the Health Connector’s Commonwealth Care program. The Connector also offered more expensive programs for the self-employed.
For all practical purposes, Islanders who subscribed to Commonwealth Care needed to choose an insurer that had a contract with the Martha’s Vineyard Hospital. In recent years, those insurers included the Network Health Plan, the Neighborhood Health Plan, Celticare, and for a time BMC.
When the ACA, also known as Obamacare, went into effect on October 1, the Massachusetts health care plan intended to provide health insurance for all since 2006 was required to retool and offer ACA compliant plans.
The state announced that as of December 31 it would end the Commonwealth Care program, which did not comply with ACA.
It was to be replaced by ConnectorCare, a new program for Massachusetts residents with incomes of three times the federal poverty level or less (about $70,600 or less for a family of four) who can qualify for help from the state and federal government to pay for their health insurance provided through a set of six new insurance plans, known as managed care organizations (MCOs), that meet ACA guidelines for health coverage.
One advantage of the change was that new federal qualifications allowed Massachusetts to expand the number of people covered under MassHealth through the Medicaid expansion plan, a federally subsidized program, by about 130,000 as of January 1, reducing the number covered under Commonwealth Care.
Law changed but website was not up to the job
By most accounts, the old state Health Connector website worked fine. The new site does not. State officials lay the blame on CGI — the Canadian contractor responsible for the federal Obamacare website as well as sites in several states — hired to deliver a $69 million upgraded website.
While CGI continues to work with the Connector to perfect and smooth the user experience on portions of the site that are functional, the Connector has halted work on the development of the remainder of the site, including an eligibility determination system, pending a consultant’s report.
While the Connector created alternative processes and tripled the size of its call center to process applications ahead of the January 1 deadline, very little has changed on the technical side since mid-December when CGI’s efforts to upgrade the site had to be aborted because the fixes were not working, according to the State House News Service.
Visitors to Massachusetts Health Connector web site still cannot use the website to determine their eligibility or select a plan, application data that is submitted through the website is not storing correctly, and small businesses are still using the old web-based system to shop for plans, the News Service reported last week.
“We still have an incomplete and inadequate IT functionality as a result of an underperforming vendor that has made it difficult for users to complete the application process,” said Roni Mansur, deputy executive director and chief operating officer at the Connector.
With the website unable to process applications, the federal government provided a waiver that allowed more than 124,000 Commonwealth Care subscribers to have their plans extended until March 31, 2014, by which time they will have to be enrolled in a new ACA-compliant plan.
Hospital officials struggle to keep up with insurance two-step
Behind the scenes, Martha’s Vineyard Hospital is working to keep abreast of the changes in the law and computer glitches on the state level, said hospital chief executive officer Tim Walsh.
Six MCOs will now offer a new ACA-compliant product. In all cases, the six previously offered plans through Commonwealth Care.
They are: BMC HealthNet Plan, CeltiCare Health Plan, Fallon Community Health Plan, Health New England, Neighborhood Health Plan, and Network Health. But not all MCOs cover all areas of the state, and not all hospitals accept every health plan. That decision depends on contracts between the MCO and the individual hospitals.
One complication for hospital officials across the state was the need to sign short-term contracts with Commonwealth Care insurance providers for a product that was originally scheduled to end on January 1, but will now cease to exist on March 31.
At the same time, the hospital has signed new contracts with specific managed care organizations for their new insurance products.
Further complicating matters for Islanders, in the transition from one plan to another, some MCOs auto-enrolled their existing Island patients, but assigned them to physicians on the mainland.
Mr. Walsh said that parent company Partners Healthcare, which is responsible for negotiating all contracts with the MCOs, is working with the MCOs to clear up the confusion and keep Martha’s Vineyard Hospital administrators up to date.
Mr. Walsh said there has been no shortage of confusion and disconnects, and patients are often caught in the middle. “We are doing our best to let patients know what they need to do to maintain their coverage, and in many cases, lead them through the process of switching plans so they will have coverage,” Mr. Walsh said.
He added that the county’s Health Care Access Program is also a good resource for people who need assistance, and it is working closely with the hospital.
For one letter writer, confusion and frustration
In a Letter to the Editor published January 16, Tiare Hess of Oak Bluffs wrote, “People who were before enrolled in programs like MassHealth Essentials and others, which are no longer offered as of January 1, were automatically enrolled in the BMC HealthCare Plus program, which no one on the Island — particularly the only hospital — accepts.
“Representatives and supervisors on the MassHealth call line can only tell people they can change their coverage to something the hospital and others will take starting February 1, which leaves many of us without needed medical services until then.”
Mr. Walsh said the hospital signed a contract with BMC effective January 1. The problem, he said, is that the BMC claims management system was not programmed in time for January 1, and the hospital is now working with patients to solve the problem.
Network Health is the largest MCO on the Island. Mr. Walsh said the hospital had to quickly sign a short-term contract when its Commonwealth Care plan was extended, but Partners has been unable to negotiate a new long term contract, so Island residents enrolled in that plan will need to make the switch if they want to continue to be covered in visits to the hospital.
In addition to BMC, the hospital has signed a long-term contract with the Neighborhood Health Plan. More contracts may be signed in the future.
Asked if it is understandable that patients would be confused, Mr. Walsh said, “Absolutely. We’re confused. There is an awful lot happening, and there is a lot that was supposed to happen that did not.”
Mr. Walsh added that “continuity of care” is his biggest concern. “We don’t want people unable to see their doctor because their plan is getting shuffled around in a lot of red tape.”
For one patient, frustrating roadblocks
The daily headlines, the jockeying for political gain on both sides of the aisle, and the health care punditry used to fill cable air time mean little to those who had insurance under the old system and are now struggling to find their way through the new system, which requires deciphering an often bewildering lexicon of insurance providers and plans.
“It’s incredibly frustrating,” said Sarah Young, 53, of Oak Bluffs, in a telephone call to The Times Friday to talk about her specific situation.
Ms. Young goes to Martha’s Vineyard Hospital on a weekly basis for allergy treatments in the office of her primary care physician. Last fall, along with thousands of others, she enrolled in one of the state-subsidized Commonwealth Care plans. Then she learned that she must determine her eligibility for one of a set of new ACA-compliant insurance offerings and enroll in a new state health plan.
The first hurdle was the Health Connector website. “I’ve gone online numerous times to the website and tried to do what I could do there, and I think everybody is pretty much aware now that that website has been having problems,” she said. “I have probably spent from eight to ten hours between trying to get on the website, calling for help, re-logging in; they finally are sending a paper application for re-enrolment.”
Ms. Young saw signs in the hospital on her weekly visits to her primary care doctor alerting patients that the hospital would no longer be accepting Commonwealth Care coverage as of January 1.
At the same time, acknowledging the many bureaucratic problems, President Obama extended the ACA signup deadline to March 31. The Massachusetts Health Connector followed suit and extended Commonwealth Care plan benefits until March 31, providing a grace period for those like Ms. Young who had so far failed to transition to a new plan.
It appeared that Ms. Young had time, but she did not. Her insurance provider was one with which the hospital did not hold a short-term agreement for extended coverage.
“My doctors office went out of their way today, Friday, to call me and let me know that they had received notice that they [MVH] would no longer be accepting Celticare which is the specific brand of insurance from Commonwealth Care that I subscribe to,” Ms. Young said. “They probably called me because I have an appointment on Tuesday, and I said, well cancel the appointment.”
Ms. Young said it is frustrating, not just because her insurance is essentially suspended and she is unable to pay out of pocket, but because she does not know how it will affect the treatment she has been receiving for well over one year.
Ms. Young said she went to the hospital website to see if there was any information that might be useful regarding the change in insurance policy but found no new information.
After receiving regular treatment and to suddenly be told that the hospital will no longer accept her insurance, Ms. Young said, throws her “into a bit of a panic.”
Ms. Young, who is self-employed and works two jobs, said the lapse in insurance coverage and the difficulty in finding a new plan is frustrating.
“I feel like I’ve trying to do what I’ve been told to do and I can’t do what I’ve been told to do, and now I’m told I have no insurance,” she said.
Told of Ms. Young’s predicament, Mr. Walsh said that in a case like this, where there is a pre-approved plan of care, the hospital would continue the plan of care and bill her insurance provider irrespective of the lapsed contract.
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