Enrollees at Health Exchanges Face Struggle to Prove Coverage

FORT WORTH - Paul D. Donahue and his wife, Angela, are among more than a million Americans who have signed up for health coverage through the federal insurance exchange. Mr. Donahue has a card in his wallet from his insurer to prove it. But when he tried to use it to get a flu shot and fill prescriptions this week, local pharmacies could not confirm his coverage, so he left without his medications.

Similar problems are occurring daily in doctors' offices and drugstores around the country as consumers try to use insurance coverage that took effect on Jan. 1 under the Affordable Care Act.

In addition to the difficulties many face in proving they have coverage, patients are also having a hard time figuring out whether particular doctors are affiliated with their health insurance plan. Doctors themselves often do not know if they are in the network of providers for plans sold on the exchange.

But interviews with doctors, hospital executives, pharmacists and newly insured people around the country suggest that the biggest challenge so far has been verifying coverage. A surge of enrollments in late December, just before the deadline for coverage to take effect, created backlogs at many state and federal exchanges and insurance companies in processing applications. As a result, many of those who enrolled have yet to receive an insurance card, policy number or bill.

Many are also having trouble reaching exchanges and insurance companies to confirm their enrollment or pay their first month's premium. Doctors' offices and pharmacies, too, are spending hours on the phone trying to verify patients' coverage, sometimes to no avail.

'The system wasn't really built to handle this kind of glut of new patients,' said Dr. Curtis Miyamoto, a radiation oncologist at Temple University Hospital who is president of the Philadelphia County Medical Society. 'So it's resulting in us having some delays in getting people verified, and therefore delays in their care.'

In Los Angeles, Hilary Danailova, who is almost eight months pregnant, said she had to pay $630 for an ultrasound on Thursday after failing to get an ID card or any confirmation of coverage from her new insurer, Anthem Blue Cross. Ms. Danailova, 38, said she signed up just before Christmas and sent her first month's premium of $410 by overnight mail on Jan. 3. She has repeatedly tried to reach Anthem to see whether the company has processed her payment.

'At this point I am facing the cold dread of not knowing whether Anthem ever recorded my enrollment at all,' she said.

A spokeswoman for WellPoint, whose plans are being sold on exchanges in more than a dozen states and include Anthem Blue Cross, said the company was 'experiencing an unprecedented level of questions from our members,' with one million calls to its customer service centers last Thursday and Friday alone. The centers typically receive a million calls in a month, said the spokeswoman, Kristin E. Binns.

'It's important to keep in mind that this is an unprecedented time of change for everyone in health care,' Ms. Binns said in a statement. 'Our goal is to ensure that our members can access their benefits as early as possible in 2014. We greatly appreciate their patience during this transitional time and apologize for any inconvenience they may have experienced.'

In Langley, Wash., north of Seattle, Erin Waterman was able to see a primary care doctor on Jan. 3 with a temporary identification card printed from the website of her new insurer, LifeWise Health Plan of Washington. But when Ms. Waterman, 47, tried to fill a prescription for a new asthma inhaler, the pharmacy could not verify her coverage even though she had paid her first month's premium on Dec. 23.

Ms. Waterman was given the option of paying full price - $187, instead of the $50 co-payment required under her new plan - and eventually being reimbursed. But she decided to wait, and hope that she does not have an asthma attack in the meantime.

'I didn't want to give them more money than I have to,' she said.

Some of the confusion stems from shifting deadlines that gave people more time to enroll and pay premiums.

Moreover, insurers are still trying to untangle problems that snarled the federal exchange in October and November. In some cases, the government has a record of a person's enrollment but the insurer does not. Insurers said they had received inaccurate or incomplete information - or no information at all - for some people who signed up through the federal exchange.

Chandra J. Leach, the office manager for Mr. Donahue's doctor in Fort Worth, said she spent 'well over an hour' on the telephone verifying that the Donahues were insured. The doctor has been seeing an average of five patients a day insured through the exchange, and the verification 'takes forever,' she said.

Despite the problems, Mr. Donahue, 58, a retired software engineer, is delighted with his new coverage from Blue Cross and Blue Shield of Texas. The monthly premium for him and his wife is $1,062, but the federal government pays a subsidy of $903. The couple pay the remainder, $159 a month.

'It's a superb deal,' Mr. Donahue said.

Another issue, doctors say, is that they often cannot determine which tests are covered by the new health plans or how much patients owe in co-payments and deductibles.

Dr. Austin I. King, an ear, nose, and throat specialist in Abilene, Tex., said he and his staff had spent five hours over two days trying to confirm coverage and gain approval from a company so a patient could get a CT scan of a tumor on the side of his face.

The problems are affecting some people who signed up for insurance well before the deadline. Judy Jacobs, 55, of Falls Village, Conn., has still not received a welcome packet or insurance card from Anthem Blue Cross and Blue Shield, even though she signed up for one of its plans through Connecticut's online exchange in early November.

On Dec. 9, Ms. Jacobs received a notice from Anthem that her application had been accepted, but she could not get through to the company to find out how to pay her premium.

'Everybody that I've talked to with Anthem is in the same boat,' said Ms. Jacobs, who runs an auto repair garage with her husband. 'They have not received their cards. They don't have any policy numbers. They don't know if they go to the doctor whether they will have insurance or not.'

Ms. Binns, the WellPoint spokeswoman, said the company had 'stepped up our operations,' with more than 1,000 representatives at its call centers and extended call center hours.

'WellPoint is committed to getting our members the assistance they need, when they need it,' she said.