A Healthy Blog

Massachusetts health care — wonky, with a healthy dose of reality

A federal escape valve for closed enrollment

A federal escape valve for closed enrollment

September 28, 2011

Today I spoke with a man who has been put into a desperate situation caused by a hole in our health care system. Jim has been on Commonwealth Care for the past couple of years. He recently completed an annual renewal form for his coverage. MassHealth determined that he was no longer qualified for Commonwealth Care.

The MassHealth Enrollment Center told him it was because he is now earning too much to qualify.

He figured that MassHealth had miscalculated his income and got to work trying to have them re-evaluate his case. After many conversations with MassHealth, it was determined that he was just a few hundred dollars over the limits (he is earning $33,000/year which puts him just over the $32,696/year limit). Unfortunately, because Jim had assumed that he would get back onto Commonwealth Care, he refrained from looking into his other insurance options. Jim had gone over the 30-day period which allows you to be eligible for a qualifying event for the private insurance options through Commonwealth Choice. Jim figured this out after he was out of time. At this point Jim, a diabetic who has prided himself on being on top of his care, had run out of insulin. He cannot afford the cost of insulin. He is facing having to go to the Emergency Room for his care. This is a health care advocate’s nightmare. Our mission is to educate our clients to utilize our health care system in the most cost-effective and quality driven manner. Spending hours (and moving the cost burden to the taxpayers) in the Emergency Room to get the medication he needs to be healthy is not that.

Due to the passage and implementation of the Affordable Care Act, I was able to tell Jim that once he hits the six month mark of being uninsured he could go through the federal Pre-existing Condition Insurance Plan (www.pcip.gov). The PCIP plans were created by the ACA as a temporary workaround before pre-existing conditions restrictions were eliminated nationally.

For Massachusetts residents this is becoming a welcome solution to consumers who are unable to purchase private insurance because of other restrictions. In Massachusetts state law does not allow insurers to restrict coverage or eligibility due to pre-existing conditions. But because of the limited-time enrollment procedures now implemented in individual coverage plans, some people are able to go through PCIP when they are denied coverage based on applying for insurance outside of their enrollment period. If you have been denied health insurance and have been uninsured for at least six months you now have the option of picking up a plan thanks to national health reform. I am hearing from more callers interested in looking into the PCIP plan, because they have missed the July/half-of-August open enrollment and are not able to get coverage. These are consumers that are not looking to scam the system; they are looking to pay for an insurance plan and did not understand the complex rules about going through private insurance.

For now, we need broader public education on the open enrollment rules. Consumers do not understand what limited open enrollment is and cannot comprehend how they would not be allowed to purchase insurance. They say to me, “But I am looking to pay them for the plan!” This will be no small task. The other solution is look at the impact of the state law closing down enrollment 87% of the year. Is this law helping or hurting? Do we need to build in more flexibility and access?
-Hannah Frigand