Insurance Disasters: How You Can Avoid Them: Part 3 – Where, Oh Where has my Little Plan Gone?

You did it right the first time. You even have a screen print of your enrollment page proving you have an enrollment – and four months later, you still can’t get your insurance company to pay for an office visit because they say you haven’t got an enrollment with them. What gives?

Multiple computer systems have to play well together in order to get your enrollment squared away. Depending on your state, there can be as many as three separate systems all involved – and they don’t necessarily like each other.

Some, older Medicaid systems for example, were never built to play in a sandbox with other computers – quite the opposite, they are built to stand-alone – and now they have to talk to other, newer, and probably not compatible, systems. In the last four years, a lot of the finicky stuff has been worked out, paved over or otherwise fixed so that the enrollment actually gets done and gets to the insurance company where it belongs – BUT even the best systems can fail or run into trouble.

And it would be way too sensible for the systems to double check themselves. Granted, some do – if your state is one of those, you can stop reading now because this likely won’t happen to you – and if it does it’ll get fixed before you know about it. For the rest of us…

The first indication of a problem to the Marketplace is when you call and say ‘I have a problem’ – in some states, it’s literally the first the Marketplace knows that something went wrong and the enrollment wasn’t received by the insurance company. ¬†Leaving alone that it shouldn’t be this way, you have to be alert in order to ensure not only that you have an enrollment but that you get to use it.

First: know the process – find out from the call center or the website what to expect after you enroll. As a basic, one size fits all answer the one thing everyone should expect is to receive a Welcome Pack from your insurance company, generally within ten business days. If on Day Eleven ¬†you haven’t got the Welcome Pack, call the Marketplace FIRST.

Second: be proactive – make sure payment is received, you got your cards and the insurance is active. So, when you get that Welcome Pack, read it! Know when your cards should arrive if they aren’t included. Log in to the company’s website and confirm yourself that you have active coverage – or call their call center and get that confirmation verbally.

Third: Don’t expect the Marketplace to ‘take care of it’. In a perfect world, you should be able to trust that the Marketplace would ensure that the enrollment was received and everything they control is fine – but that’s not reality. Once you’ve called the Marketplace and reported the problem, call them back weekly.

They detest this – too bad. Don’t be rude and don’t get angry with the poor rep who can’t fix the problem but do call each week and do make sure that your call is noted on your account. If things go way far south, no one will be able to say you didn’t follow up. That’s critically important. The truth is, calling weekly won’t speed things up and may annoy the call center – but it insures that if they fail to resolve the problem, they cannot say you didn’t follow up and therefore they didn’t need to continue pursuing the issue.

Yes, that can happen. No, it isn’t common – but neither is it common for the enrollment not to be received by the insurance company. Calling weekly is insurance against having to go to the DOI just to get the problem fixed – which is rare and not likely to happen.

Fourth: Keep detailed notes – and screen print relevant parts of your account if necessary. If your account lets you review open work orders then absolutely keep screen prints of those – it proves positively that the Marketplace was aware of the issue and when.

Fifth: Keep in touch with your insurance company – and consider three way calls between you, the marketplace and the insurance company. Your insurance company is your ally here – make sure they know you should have an account and that they notate any calls you make to them (ask them how that’s done and what you need to reference the call if you call back). Some insurers can go ahead and extend coverage while they are waiting on the Marketplace – some can’t. Find out from your insurance company how claims will be handled if you have medical issues while you are waiting.

Also, make your payment – if necessary, pay it to a savings account of your own until this is resolved and you can pay the insurance company. $125 a month might be manageable – but it will not be so nice if five months come due simultaneously!

Sixth: There comes a time to do something else. If the Marketplace can’t give you a good timeline as to when this should be fixed, then give them ten business days. Professionals know their time frames so it’s a poor organization that doesn’t know how long it takes to fix a problem. If they have given you an explanation then give them a reasonable amount of time to fix it. Two months is NOT reasonable. Two months isn’t ‘this is hard’ -it’s ‘we didn’t hire enough people’.

The sole exception is if your account really has got a technical issue that requires a programmer or IT to correct – this is exceptionally rare.

Anyway, don’t wait forever – they may get it done but then again, they may not. If it’s been at least ten business days – or the time frame you were given has passed – call them back (. Get a reasonable explanation, a hard time frame and probably an apology. If you don’t get one of the first two, it’s time to complain formally.

The Marketplace website will have the information for filing a complaint – or the call center can outline it for you. Follow the directions – getting mad and doing it your way only messes you up now – and file a formal complaint. This will probably start with the agency – that’s fine. If they fail to follow up or to do so satisfactorily, file a complaint with the Department of Insurance in your state (the Marketplace website may have this information as well).

Only in extremely rare cases does it really take more than 14 days to resubmit your enrollment back to the insurance company – and the Marketplace should be able to inform you if something is that far wrong that they need more than 14 days. Most commonly, they are simply understaffed – which is not going to get better if everyone sits around waiting for months for their insurance companies to find out they are enrolled.

The absolute last resort is call your congressman. If you’ve done your part and they STILL can’t get that enrollment straightened out, a call from a congressman’s office may be just what it takes to get someone to actually fix it.


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