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CMS Exchange Official Predicts Many 'Almost Immediate' Online Eligibility Reviews

By John Reichard, CQ HealthBeat Editor

May 1, 2013 -- A top federal official overseeing exchange implementation recently said that in many cases those applying for insurance coverage in the new exchanges will receive almost immediate eligibility determinations if they enroll online.

"If they are submitting online, in many instances they will receive their eligibility review almost immediately, including the amount of the premium tax credit they can expect to receive for a qualified health plan, or learn if they qualify for Medicaid and CHIP," said Chiquita Brooks LaSure. The new marketplaces are scheduled to start enrolling consumers on Oct. 1.

Brooks LaSure is deputy director for policy and operations at the Center for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services (CMS). She spoke during an afternoon session at the first "Health Insurance Exchange Summit," held in Crystal City, Va.

Doubts about the how smoothly the enrollment process in exchanges, or marketplaces, have lately dogged CMS officials. In March, a CMS official emphasized that implementation experts are in a mode of trying to complete operations. Some of the niceties will have to be sacrificed for a while given tight implementation time frames, Henry Chao told a group of insurers. He also said the aim at this stage of the process is to avoid "a third world experience" for exchange shoppers.

Insurance applicants can apply online or use paper applications. CMS unveiled a streamlined three-page application for some individuals last week that can be filed either online or through the mail.

Brooks LaSure was asked how long the enrollment process might take if a determination is not made immediately. "There are certainly going to be times when individuals will need to provide more information," she said. "A lot of it is going to depend on whether the issue that needs to be resolved is something where there is some sort of paper transaction between us and the individual, or whether this is something that is going to be handled completely electronically," she said.

Asked if determinations aren't almost immediate whether the process would take days or weeks, she said that someone trying to apply online in the middle of the night but missing a piece of information might be able to submit it electronically the following morning, but other cases will involve an exchange of mail "and that might take longer."

Brooks LaSure also said that brokers will be able to assist consumers with enrolling in the federal exchange that will serve many states. CMS recently released a "frequently asked questions" document on how that process will work. That document in turn is raising questions.

"One of the options is to come in through the [insurer's web] portal and if that happens does the enrollee still get to see the whole menu of choices out there," asked Washington and Lee University Law Professor Tim Jost.

Brooks LaSure said it's important for people to know that there other options. She suggested that there would be a way for consumers to see those options. But Jost said afterward that he's nervous that consumers working through brokers won't necessarily see all the options, thereby undermining the principle of "managed competition" in exchanges that is supposed to control costs and improve quality.

Jost said he's more comfortable that web-based brokers will provide the full menu of choices. The CMS guidance document says that "Web brokers must display all Qualified Health Plans (QHP) available through a Marketplace, irrespective of compensation or appointment arrangements in Federally facilitated Marketplaces," the document says.

"CMS expects that the sort order of, or sorting algorithm for, Qualified Health Plans will not steer a consumer to a particular QHP based upon financial consideration to the web broker," the document states.

"CMS also expects that a web-broker will disclose to the consumer the specific source and nature of web broker compensation and that the compensation does not affect the display of QHP options or the premiums charged."

But in other cases, brokers might work individually with a consumer by going to the website of a specific insurer in order to assist that individual. The CMS document says that "as part of the discussion with the consumer, CMS expects that the agent or broker will inform the consumer that the agent or broker will provide information for certain QHPs with which he or she has a business relationship, but that the consumer could directly access the Federally-facilitated Marketplace website, where additional QHP information and choices are available."

That language suggests the possibility at least that the consumer won't actually see all the choices he or she has.

Brooks LaSure fielded questions on a variety of other topics – and one complaint.

She said, for example, that no guidance on federally facilitated exchanges is forthcoming and that CMS has addressed questions concerning that marketplace in regulations and other documents relating to other types of marketplaces. She said additional "frequently asked questions" documents could be issued, however.

A call center CMS plans to open in June will answer questions 24 hours a day relating to exchanges and insurance coverage options and be opened at the same time the agency relaunches its HealthCare.Gov site to handle many functions under the health law, she said.

The call center will have English and Spanish speakers available to field questions and a "language line" that can arrange to provide answers in more than 150 other languages, she said. She was unable to say, however, where the center will be located and how many employees it will have.

Brooks LaSure also was asked whether she expects any state-based exchanges to drop off the conditionally approved list. She didn't answer, saying only that "we continue to work with all the state-based marketplaces."

The head of the Connecticut exchange had a pointed request to make of Brooks LaSure. He said it was "kind of interesting" to get the news of the option of a three-page enrollment application. "Unfortunately, for states like Connecticut that are fairly far along in development this is a real problem for us because our system integrator is now saying" that it will be hard to go back and make that change.

"Anything that HHS or CMS could do to just sort of stop making changes right now would be very much appreciated," he said.

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