Highlights of the ACA Rollout

It has been about 4 months since the Health Insurance Marketplace rollout via Healthcare.gov. The much maligned launch of the program’s website was initially marred by frozen screens and long wait times. Exchanges at the state level unveiled more smoothly overall, but some still had their problems.

Now, most of the initial glitches have been fixed and enrollments into the exchanges, where consumers can compare and purchase health care insurance plans from different carriers, have been growing steadily.

Between Oct. 1, 2013 and Dec. 28, 2013, nearly 2.2 million individuals had selected a marketplace insurance plan. This number includes people who have already paid a premium, and those who have not yet paid. The total enrollment for December 2013, including enrollment in both state-based marketplaces (SBMs) and federally facilitated marketplaces (FFMs), was nearly a 5-fold increase compared with enrollment in October and November. This number reflects an improvement in website functioning as well as increased attempts by individuals to enroll by the first deadline of Dec. 24, 2013. The next open enrollment deadline is March 31, after which individuals may face a tax penalty if they are uninsured.

As of press time, about 800,000 more individuals signed up in January. About 3.23 million individuals are expected to enroll by the end of January, according to a statement from CMS.

According to an ASPE Issue Brief from the Department of Health and Human Services, a Gallup daily tracking poll showed 63% of Americans who currently lack insurance say they are likely to get health insurance this year. Also, 63% who are potentially eligible to enroll in an insurance plan through a qualified health plan or Medicaid said they were aware that the Health Insurance Marketplace offers options to buy that coverage.

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Additionally, between October and December more than 6.3 million individuals were determined eligible to enroll in Medicaid or CHIP through state agencies and through state-based Marketplaces, according to a statement by CMS administrator Marilyn Tavenner.

“These numbers include both Medicaid and CHIP new eligibility determinations in states that expanded coverage, determinations made on prior law, and in some states, Medicaid renewals and groups not affected by the health care law,” Tavenner said. “This does not include eligibility determinations made through HealthCare.gov.”

One of the major concerns with the overall success of the program is the enrollment of young adults, who are most likely to be without health insurance. Their participation in the marketplace is important to help ensure a favorable risk mix, according to the report. The general expectation was that older, less healthy individuals would apply earlier in the open enrollment period for 2014, and younger and healthier people would tend to enroll later. Thus far the enrollment figures bear this out. — by Carey Cowles

AOPA’s Take

Steve Custer

The recent creation of federal and state health care exchanges and the open market availability of health insurance will undoubtedly increase the number of insured individuals in the United States, a stated goal of the Affordable Care Act. The American Orthotic & Prosthetic Association (AOPA) has worked diligently to ensure that O&P is included as an “essential health benefit” and therefore a mandatory segment of the exchanges. While the specific inclusion of O&P as “essential” is not guaranteed in all exchanges currently, the benchmark model that has been adopted by the state and federal exchanges has effectively ensured that O&P benefits are available to those who purchase insurance through the exchanges.

The failure of Medicaid programs to expand their benefit offerings is disappointing as most Medicaid programs continue to limit coverage of O&P devices to certain demographic populations but is not a new issue for O&P providers. AOPA views Medicaid expansion as an important issue for its members and will continue to work diligently to achieve favorable coverage options for beneficiaries who require O&P services.

— Steve Custer

Communications Manager, American Orthotic & Prosthetic Association

What O&P Is Saying

From a consumer and patient perspective and my deductible being much higher than before, I can only imagine it being more difficult for patients to be able to afford high-dollar items such as artificial limbs. Therefore, more patients will be eligible for these services but not be able to afford them due to the high deductibles, which are required at the time of service.

— Brandice Richards

Comfort Keepers

I can definitely see more paperwork just because the government is involved and can potentially see more patients, but patients can’t afford to get a device due to how much is required up front even after trying to work out payments.

— Bill Truskey, COF

Owner and Vice President, Firstcare Orthopaedics Inc.

As with any of the changes we see taking place under the ACA, O&P will see its fair share of highs and lows.

For instance, according to the CMS final rule regarding a fingerprint background check, DMEPOS suppliers (which includes orthotists and prosthetists) who are subject to revalidation prior to 2015 will be classified as moderate risk and will not be subject to this.

However, newly enrolling DMEPOS suppliers will be classified as high risk, meaning they will be subject to the fingerprint analysis and background screening.

This change right here is going to bring the moderate risk supplier more business because they have already been deemed operational and have an advantage over the newly classified high risk supplier.

— Roni Pidcock

Vice President, QHS, Inc.

Medical Billing And Consulting

Since ACA has been put in place we immediately saw the state Medicaid not having to pay their 20% of the allowable, which results in a 20% decrease in pay. Even some commercial insurance won’t pay the 20% because “primary has paid at a higher rate than our allowable.” Result? Laid off employees and different strategies on daily operation.

[As for increased paperwork] these rules and regulations have been there all along and we continue to obtain the proper paperwork. The extra paperwork is mainly internal procedures to double check that the Ts are crossed and the Is are dotted. What is truly the added paperwork are the appeal and prepayment audits.

Maybe if Medicare would enforce the law that O&P professionals should be the only ones that can bill for O&P service, that would cut down on a large portion of the fraud that has triggered the current environment we are working in now.

— Al Garney, CPO

Prince William Orthotics and Prosthetics, Custom Fabrication

For more information:
ASPE Issue Brief. Health insurance marketplace: January enrollment report. Department of Health & Human Services. Available at: aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Jan2014/ib_2014jan_enrollment.pdf. Accessed Jan. 24, 2014.
Tavenner M. Milestone: 3 million in marketplaces. HHS.gov/healthcare. Available at: www.hhs.gov/healthcare/facts/blog/2014/01/three-million-in-marketplaces.html. Accessed Jan. 24, 2014.

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