With health insurance marketplaces about to open for 2015 enrollment, the Obama administration has told insurance companies that it will delay requirements for them to disclose data on the number of people enrolled, the number of claims denied and the costs to consumers for specific services.
For months, insurers have been asking the administration if they had to comply with two sections of the Affordable Care Act that require “transparency in coverage.”
In a bulletin sent to insurers last week, the administration said, “We do not intend to enforce the transparency requirements until we provide further guidance.” Administration officials said the government and insurers needed more time to collect and analyze the data.
When Juliana Kessler, 15, broke an arm, a clinic required her mother, Laura Gottsman, to agree to pay for a sling if her insurer refused.
“We expect this will begin after a full year of claims data is available,” said Aaron Albright, a spokesman at the Centers for Medicare and Medicaid Services, when asked about the government’s eventual plan to enforce the transparency requirements.
Consumer advocates said they were disappointed because the information would be helpful to millions of consumers shopping for insurance in the open enrollment period that starts on Nov. 15. The data will not be available before the enrollment period closes on Feb. 15.
In a new poll from the Kaiser Family Foundation, nine of 10 uninsured Americans said they were unaware that open enrollment begins in November, and two-thirds of the uninsured said they knew “only a little” or “nothing at all” about the marketplaces.
Arming consumers with information was a major goal of Democrats, who wrote the health care law. It was signed by President Obama in March 2010.
Under the law, consumers in each state have access to a public marketplace, or exchange, where they can buy insurance and apply for federal subsidies to help pay premiums.
The law says each exchange shall require insurers to disclose their claims payment policies, “data on enrollment, data on disenrollment, data on the number of claims that are denied, data on rating practices” and information on the use of doctors and hospitals outside a health plan’s network.
Moreover, the law says, insurers must allow consumers to “learn the amount of cost-sharing (including deductibles, co-payments and co-insurance) under the individual’s plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service.”
“At a minimum,” the law says, “such information shall be made available to such individuals through an Internet website” and by other means for people without access to the web.
Sabrina Corlette, a research professor at the Health Policy Institute of Georgetown University, said it was “disappointing and somewhat frustrating” that the disclosure requirements had been delayed.
“This is a critical tool,” said Ms. Corlette, who is also a consumer representative to the National Association of Insurance Commissioners. “It would provide the federal government and states with a wealth of coverage data — really important information to show if consumers are getting the full benefits of their coverage.”
Many people obtaining coverage under the Affordable Care Act have never had commercial insurance, and even experienced consumers are sometimes baffled by the intricacies of insurance policies, including provider networks and deductibles.
Insurers provide consumers with a “summary of benefits and coverage.” That document tells customers: “You must pay all the costs up to the deductible amount before this plan begins to pay for covered services.” Some insurers, however, help pay for some items and services before a consumer meets the deductible. It is not always clear which services are subject to the deductible and which are not.
A health maintenance organization offered by Blue Cross and Blue Shield of Florida illustrates the complexity. The plan has seven tiers of prescription drug coverage, including three just for generic drugs.
Under the plan, consumers pay only $4 for generic drugs used to treat certain chronic conditions like high blood pressure and diabetes. But for other generic drugs, as for some brand-name products, the insurance kicks in only after consumers have met the annual deductible ($2,100 per person and $4,200 per family for all goods and services).
Jon R. Urbanek, a senior vice president at Blue Cross and Blue Shield of Florida, said consumers had many questions because the pharmacy benefit “has all those tiers and some confusion to it.” To help answer the questions, Mr. Urbanek said, the company has 18 retail stores in Florida and will hold several thousand town-hall-style meetings.
More than 80 percent of people insured through the exchanges are entitled to subsidies. Contracts between the federal government and insurers include an unusual provision allowing insurers to terminate the agreements if the subsidies, under attack in several court cases, become unavailable in the federal exchange.