In a previous post, we outlined the recommendations made by the Department of Health and Human Services (HHS) last week to encourage health insurance carriers to take steps toward easing policyholders’ transition to new 2014 ACA-compliant health plans.
We want to provide clarification on a couple of the points, and dissuade anyone from believing their insurance carrier will simply cover any out-of-network care or off-formulary drugs throughout the month of January.
It’s a bit more nuanced than that.
Regarding in-network coverage and drug formularies, what HHS has asked insurers to consider is this:
- For any prescription medication being taken and covered under a policyholder’s current plan, allow that same medication to be covered during the month of January without requiring pre-authorization or step therapy (whereby the doctor must first try a certain drug before moving on to another, even if it is neither the doctor’s nor the patient’s first choice) to allow for transition to the new plan.
- In the case of a patient currently under treatment for an acute episode of care by an in-network physician, consider that physician to be in-network — even if he or she is not in-network on the patient’s new plan — for the duration of that episode of care.
- Through the beginning months of coverage, treat as in-network any provider that was listed in the carrier’s online in-network directory at the time the patient selected his/her coverage. This is due to the fact that many carriers had trouble maintaining accurate online directories during the early months of enrollment, meaning people may have been basing plan decisions on inaccurate information.
We should note again that these are simply recommendations made by HHS and are not required. Furthermore, we don’t know which of the recommendations may be acted upon, exactly how they will be implemented, and by which — if any — carriers.
For the full list of the HHS changes, refer back to our original post. We apologize if we caused any confusion!
Of course, we will continue to monitor this closely. When in doubt, please give us a call. We are here to help with these kinds of issues for our clients.
Please be patient as we manage a high volume of calls and emails.