Column 44

Surprise!  Covered California has apparently just found out about HIPAA.  This is the Health Insurance Portability and Accountability Act of 1996.  

 

When calling to find out about our clients status and account, we were informed that they could not discuss the case unless we were on the file as "authorized representative".  Interestingly, when we first set up these accounts for our clients, there was discussion if we should or should not complete that section and we were advised it was not necessary.  This means the agent and any office staff that are involved in the case must be "authorized representatives". 

Since the inception of this program I have been intrigued by the fact that the normal protocols of insurance underwriting had not been included in the process.  So, now they will not talk to me or my assistants without each of us included in this status on this account. So, we will now have to go into each client's record and make that change.  All of us who have enrolled multiple accounts are delighted for some additional work on these accounts that have already been an administrative challenge. So in the interim, if your agent has been unable to assist you with Covered CA, please understand that this is why. 

So what is HIPAA?  As the name implies, this law covers many issues, but for this discussion, it is primarily about the individual's right to have their information kept private and only disclosed under certain circumstances. In the past when applicants were subject to medical underwriting, the medical history questions were comprehensive and covered the last 10 year's medical history.  Detailed records were often provided to determine if the individual were an acceptable risk. 

Under the ACA (Affordable Care Act) there is no medical underwriting, so health information is not required.  Covered CA however does ask for private information such as social security numbers, driver's license, income and tax information and documentation of this.  So it stands to reason that the applicant should have an expectation of privacy.  In fact, when the application is completed this is clearly stated and agreed to by the parties. 

Agents will have to give serious consideration as to how much involvement they can have with Covered CA after the initial enrollment. As this is the first year, we are doing everything we can to help our clients.  But I am also working to empower clients to have control and responsibility for this part of the transaction.  Simply stated, if an individual is granted a subsidy (and most are thousands of dollars per year) it seems reasonable to expect them to manage that part of the transaction themselves.  The agent can deal with the insurer and assist them with claims issues or choice of plan which has been our value all along.

Now that Open Enrollment is closed ,we are working with SEP  (Special Enrollment Periods).  These are folks that are now eligible because of an involuntary loss of coverage or a qualified life change event.  So far, I am not finding that the system is really set to fully accommodate those requests. 

For example, I had a client whose child would "age off" the group plan at her 26th birthday in May.  She came to see me in early April.  One would think we could apply at that time, indicate the future date of the qualifying event and her application would be in process for that effective date.  We were told that is not possible and to hold the application until after 4/15, so she would then automatically receive a 6/1 effective date. 

If the application is received before the 15th of the month, it will be effective the first of the following month; i.e received April 10, effective date is May 1.  But if received after the 15th the effective date is 1st of the following month: i.e received April 16, effective date is 6/1.  So be careful when applying for coverage.

Another surprise was a client who started an application, the child qualified for MediCal and the parent for no subsidy.  They chose not to proceed because the parent did not want the child on MediCal and purchased a plan off the Exchange for the child.  About 3 weeks later they receive a card in the mail showing the child enrolled in MediCal!  I will update you on the disenrollment process.

*Information provided in this column is "to the best of my knowledge based on press deadline. Submit your questions to This e-mail address is being protected from spam bots, you need JavaScript enabled to view it to be answered in the paper.