Navigating a New Health Plan, After the Surge

YOU'VE no doubt heard about problems some people are encountering when they try to use the health insurance they've bought through the federal and state exchanges. A backlog of applications, the result of a surge in enrollments at year's end for coverage starting this month, has resulted in many people experiencing delays in getting insurance cards, policy numbers or authorization for treatment.

Keith Lichtman, an interior designer in Manhattan, knows the problems only too well. He had to pay out of pocket for treatment for strep throat because his doctor's office could not verify his coverage under a plan he enrolled in through New York's state-operated marketplace, NY State of Health. He hopes to be reimbursed, but he said a series of missteps since he enrolled has left him frustrated. 'There was a real lack of organization in the New York health exchange,' he said, adding that he also got confusing information from his new health insurer.

Mr. Lichtman had an individual health plan that, like millions of others, was canceled because it did not meet requirements under the Affordable Care Act. After a few false starts in November - he said he encountered shutdowns at the New York website, and long waits getting questions answered on the phone - he was able to enroll in a new plan through UnitedHealthcare. He paid his first month's premium through UnitedHealthcare's website on Dec. 20, and arranged to have his monthly premium automatically deducted from his bank account.

When he called to check on his coverage, he was first told that the plan had no record of his first month's premium, so he paid it again - only to have the first payment show up, resulting in an overpayment. (He requested a credit and has received it, he said.)

In early January, Mr. Lichtman developed a sore throat and went to his doctor, even though he had not received an insurance card. But the office could not verify his enrollment; a billing clerk tried unsuccessfully to contact both UnitedHealthcare and the New York exchange while he waited.

Mr. Lichtman ended up paying for the visit, as well as for a prescription his doctor gave him for strep. The doctor's office said it would resubmit his bill and reimburse him once his enrollment was verified.

After several tries, he was able to log into the New York exchange website late one night last week to verify his enrollment. Mr. Lichtman has since received his insurance card in the mail. But he said he ran into trouble getting his plan's computer system to recognize his choice of a primary care doctor, which is necessary before he can get referrals to specialists. He has been told it will become effective on Feb. 1.

Mr. Lichtman also said that he received an email notifying him of an additional charge of about $900, which turned out to be a bill for another patient that was mistakenly sent to him.

In all, he said, the process involved more than 15 frustrating phone calls. His advice? Use a speakerphone 'so you can multitask while you're on hold.'

The New York State Department of Health said it was aware that some people had experienced enrollment delays but that over all the site had functioned well. Officials said staff members were working closely with consumers who needed help and that an additional 325 trained representatives would be added to its call center in preparation for the March 31 end of open enrollment. That will bring the total number of call center representatives to 657, the department said.

UnitedHealthcare said it was working with the state to resolve the problems and suggested consumers could contact the company directly.

The New York exchange has generally had fewer problems than some other state marketplaces, and New York has been one of the most successful states in signing up people for new plans under the Affordable Care Act. The marketplace website said roughly 295,000 people had enrolled as of Jan. 12. The state's site has a list of frequently asked questions.

Here are some questions to consider about using health insurance benefits obtained through an exchange:

■ What should I do if my insurer isn't properly crediting my premium payments, or if my doctor can't verify my insurance coverage?

Be persistent in your efforts to resolve problems with your insurer, and document all of your interactions with both your health plan and the health exchange, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. Keep a log of phone calls. If you have to pay out of pocket for care, get written documentation of the date and treatment provided, so when your enrollment is verified you can request reimbursement.

And it doesn't hurt to ask your doctors if they will hold off charging you until you can come back with your insurance card. 'My general rule is save everything and, if possible, pay nothing,' Ms. Pollitz said.

■ Should I postpone seeking care until I have verification of my enrollment?

If you need urgent care, Ms. Pollitz said, you should see a doctor. But it might make sense to hold off on routine visits this month, to avoid a glut of newly insured patients seeking treatment. Kelly Alvord of the Patient Advocate Foundation noted that some pharmacies were bending the rules temporarily to help patients in limbo; Walgreens, for instance, is offering to provide up to a 30-day supply of prescriptions at no upfront cost to patients who do not yet have identification numbers from their health plans.

■What if I haven't enrolled in a plan yet?

You have until March 31 to enroll in a plan to avoid a penalty for lack of coverage. But there is likely to be another glut of people rushing to meet that deadline in March, so it makes sense to get started now, said Lynn Quincy, a health policy analyst with Consumers Union. 'Don't wait until the last minute,' she advises. 'Take advantage of this relatively quieter time and get it done now. Or, as Mr. Lichtman says, 'Start much earlier than you think you need to, and anticipate lots of red tape and miscommunication.'