“Please be sure to include MEDICAL URGENT in the subject line as well as a detailed description of the client’s situation in the message body,” the bulletin said.
There were six “medical urgent” emails sent to the exchange from the day the bulletin was sent out through Wednesday, April 6. The exchange has received 14 since the first of the year.
Your Health Idaho, the state’s exchange, is not an insurance company. It is a conduit, responsible for helping Idahoans buy health plans that comply with the Affordable Care Act.
This year, more than 100,000 people used the exchange to buy plans. Most of those customers qualified for federal subsidies, available only through the exchange, to help pay premiums because their incomes were too low to pay full price.
Idaho’s exchange operated with little turbulence and received praise for being lean and efficient after it opened in 2013, at first piggybacking on the federal exchange until Idaho built its own machinery to process tens of thousands of insurance applications each year. Now, however, some Idaho consumers and agents say the exchange is struggling to do its job.
IDAHOANS HAD FILED 907 APPEALS TO YOUR HEALTH IDAHO AS OF LATE MARCH. THOSE INCLUDE APPEALS ABOUT PROBLEMS WITH A PERSON BEING ENROLLED IN, OR DISENROLLED FROM, THEIR INSURANCE PLAN.
Your Health Idaho is months late sending hundreds of Idahoans a document they need to file their taxes this month.
“I cannot tell you how incredibly frustrated I am,” said Rose Penwell, a Boise resident. “It is an amazing system that’s happening right now. And by amazing, I mean incredibly broken.”
The exchange’s call center no longer can help solve problems. Instead, callers are being told to file support tickets by email. After calling five to 10 times per week, Penwell sent an email March 7 and got a response 16 days later.
In some cases, people with medical emergencies or ongoing health needs still have not been enrolled in insurance plans — months after they signed up for coverage.
“We are currently reviewing about 1,700 enrollment emails,” Your Health Idaho spokeswoman Karla Haun told the Idaho Statesman. “These emails range from questions regarding coverage dates and special enrollments to policy clarification. We are unable to categorize which of these are related to possible enrollment delays.”
22,892Emails seeking help from Your Health Idaho from Nov. 1, 2015, to March 31, 2016.
20,939Email requests Your Health Idaho says were resolved during that time.
Stanley Dean, an insurance agent in McCall, was in the middle of writing a letter to Your Health Idaho when the Statesman reached him by telephone at his office.
“Fix your screwed-up system immediately. People’s lives are at risk,” he had written.
Dean has a client with diabetes. In January the client wanted to enroll in a health plan that cost more than $1,000 per month at full price. The client’s income qualified him for subsidies to cover almost all of that premium. Under the Affordable Care Act, the federal government subsidizes premium payments by sending tax credits to insurance companies on a person’s behalf.
But something went haywire in the enrollment process. Your Health Idaho’s system will not recognize the man’s subsidy, meaning that in order to enroll, he must pay the full premium.
“He makes $24,000 a year. There’s no way he can make the payment,” Dean said.
Dean said he is spending hours trying in vain to resolve glitches and errors for his clients.
“Right now, I’ve got six cases that are virtually equal to this,” Dean said. “It’s just an absolute train wreck.”
Dean noted that Idaho’s exchange is not alone. “I’m licensed in six states, and believe me, in the other five states, it’s even worse,” he said.
Mountain Health CO-OP spokeswoman Karen Early said her nonprofit insurance co-op, which sold 2016 plans to about 16,000 people through the exchange, “occasionally” has had critical situations arise, such as when “people thought they had eligibility, and we had to work behind the scenes really quickly.”
Most often, that comes to light when someone goes to the pharmacy to fill a prescription, she said.
Early said Your Health Idaho has worked with Mountain Health CO-OP to fix each problem. In some cases, the problems were due to people not paying their premiums or assuming that incorrect bills — for example, showing they owe the full premiums when they do not — would be taken care of by the exchange or the insurer.
Blue Cross of Idaho enrolled about 42,000 people through the exchange. SelectHealth enrolled about 35,000. BridgeSpan enrolled about 7,000.
AS AN EXCHANGE CARRIER THAT HAS OPERATED IN FOUR STATES WITH FOUR DIFFERENT EXCHANGE MODELS, OUR BRIDGESPAN HEALTH TEAM GIVES YOUR HEALTH IDAHO GENERALLY HIGH SCORES FOR ITS OPERATIONAL PERFORMANCE.Lou Riepl, spokesman, BridgeSpan Health
Josh Jordan, spokesman for Blue Cross, said the company is “happy and impressed with how smoothly 2016 has gone.”
He said the Idaho exchange has been less problematic, and cost much less money, than the federal exchange.
“In any large-scale enrollment or implementation some things come up, but those have been uncommon, and [Your Health Idaho] has been responsive and nimble in working toward a solution with us and our members,” Jordan said.
BridgeSpan Health spokesman Lou Riepl said his company has “seen confusion from members from time to time when an issue does arise — whether it should be solved through Your Health Idaho or with the carrier.”
But that is less Your Health Idaho’s fault than it is due to consumers not understanding “where the roles and responsibilities of the carriers and exchanges begin and end,” he said. “This is an issue that exists in all our markets.”
WAITING ON A 1095
Some Idahoans are paying out of pocket for medications because their enrollment is stuck in limbo. Others are waiting on a piece of paper that stands in the way of thousands of dollars in subsidies.
This year, Your Health Idaho was required to send most people who bought insurance plans on the exchange last year a Form 1095-A. The one-page form is a month-by-month breakdown of a person’s health insurance for the year. It shows how much the plan cost; the amount of premium assistance the person received; and the cost for the second-cheapest, second-tier plan available that year on the exchange.
Shannon Murray and Rose Penwell are among those who have yet to receive their forms.
Penwell said she and her husband want to take a trip for their 10th wedding anniversary in July, but they are budgeting around whether they owe, or are due, money from the Internal Revenue Service. The Penwells’ accountant will not file their taxes without the 1095-A in hand, she said.
“I’m so frustrated, because there’s nothing I can do,” she said.
Shannon Murray and her husband are self-employed. The Nampa couple had insurance for two months last year, purchased through the exchange. For months, they waited anxiously for the 1095-A form so they could file taxes, anticipating an $8,000 refund they needed to pay bills.
Murray has called the exchange and complained to the Idaho Department of Insurance. The form still had not arrived as of April 5.
While it’s hardly rare for people to procrastinate on filing taxes, one insurance agent noted that many exchange customers may be more eager than average to get their refunds. They, like Murray and her husband, are more likely to be small-business owners or self-employed with modest incomes.
Recently, Murray gave up on the 1095-A and filed her taxes, using her best estimate of what the form would say.
“It [was] a real struggle for our family, knowing that we’re waiting on this money coming back to us, and because we didn’t have the form, I didn’t know if I could file,” she said. “It’s a really big financial struggle ... . An emotional struggle, too, trying to keep our family afloat.”
Your Health Idaho documents show that the organization had issued more than 5,000 corrections to 1095-A forms as of late March. It was required to send out the forms by Jan. 31 and had issued more than 69,000 of them by then, said Pat Kelly, executive director of the exchange.
ALL HANDS ON DECK NOT ENOUGH
Kelly said the exchange’s information-technology contractor is working around the clock to get consumers their 1095-A forms. There is no penalty for Your Health Idaho having missed its deadline, Kelly said.
The U.S. Department of Health and Human Services and the Idaho Department of Insurance have offered help, he said. Your Health Idaho has declined those offers because the problem “is very specific to Idaho’s technology and consumer experience,” he said.
WE UNDERSTAND HOW IMPORTANT AND VITAL THESE TAX DOCUMENTS ARE, AND THEY ARE OUR NO. 1 PRIORITY HERE, AND WE UNDERSTAND THE CURRENT SITUATION IS NOT THE WAY CUSTOMERS DESERVE TO BE TREATED.Pat Kelly, executive director, Your Health Idaho
Jody Olson, communications director and a spokeswoman for the exchange, said much of the hold-up for 1095-As is due to the forms showing incorrect coverage dates.
“This can be due to the [federal exchange] data migration and manual updates,” Olson said. “Controls have been and will continue to be implemented to mitigate these issues. This will ensure these issues don’t arise in the future.”
One member of the board that oversees Your Health Idaho downplayed the delay in issuing accurate 1095-A forms.
“This is the first time these forms have been required,” said B. Hyatt Erstad, who runs the Erstad and Co. insurance agency in Boise. “As everybody deals with these new reporting requirements, I equate it to the W-2s when they first rolled out.”
The exchange operated by at least one other state, Minnesota, also failed to issue 1095-A forms by Feb. 1 this year. And employers were given a two-month deadline extension to issue their versions of the 1095 to employees because the new process was daunting.
Erstad noted the great demand in Idaho for insurance sold through the exchange, with the highest per-capita enrollments in the nation.
“There are going to be hiccups as we implement a number of the rules that are out there,” he said. “I would say the exchange staff has done an exceptional job ... . They’ve had all hands on deck.”
Early, of Mountain Health CO-OP, noted that health insurance organizations have a unique staffing challenge because almost all of their business transactions are squeezed into a two- or three-month window.
“It’s difficult to have enough people on staff who are well-trained enough,” she said.
Dean, the insurance agent from McCall, said some operational decisions left him scratching his head.
The deadline to enroll in a health plan this year was Feb. 15. That coincided with Presidents Day weekend, so the exchange’s offices were closed Feb. 13-15, he said. The Idaho exchange, unlike the federal one, did not offer extensions to the sign-up deadline.
100,854People signed up for 2016 health insurance through yourhealthidaho.org.
90,632People who were enrolled by the end of February.
That was just the beginning, he said.
“I think it’s just incompetence,” Dean said. “I think they’re overwhelmed and they’re understaffed.”
There are 27 people on staff at Your Health Idaho, not counting the technology contractor that runs the website.
Ten to 20 people at the Idaho Department of Health and Welfare also answer phone calls to the exchange when needed.
Asked whether Your Health Idaho is understaffed or needs a larger staffing budget, Olson said no.
Kelly, the executive director, noted that Your Health Idaho has $6 million in cash reserves, which he attributes to “being very fiscally conservative and smart about our decisions in terms of long-term expenses.”
By law, Idaho’s exchange must be self-sustaining. It has received several million dollars in startup grants from the federal government for the past few years. After December it will no longer have that money, which this year made up more than half of its income.
$8.8 millionAmount of Your Health Idaho’s fiscal 2017 budgeted income that comes from a federal grant, which phases out in December.
$8 millionAmount of the budgeted income that is from user fees. Idaho’s is 1.99 percent; the federal exchange’s is 3.5 percent.
The exchange’s 1.99 percent fee on each insurance plan sold is up from the original 1.5 percent. Kelly said there are no plans to increase the fee again.
“And the promise of that is we’re delivering a much more cost-effective program to Idahoans than if we were on the federal marketplace,” Erstad said. “It saved Idahoans $10 million.”
Erstad said the board is aware of the problems with calls going unanswered, 1095-A forms being delayed and other complaints. He said Your Health Idaho might expand its call-center hours next year in the run-up to the enrollment deadline.
“Right now, I don’t think there are that many issues going on, now that we are past the big push. ... The brokers who have contacted us, I think their problems were resolved in a timely manner,” Erstad said.