Health Consumer Advocates, beyond ACA enrollment

Health Consumer Advocates, beyond ACA enrollment

Posted March 21, 2014 by Kevin Knauss

As the ACA open enrollment winds down, attention now turns to helping individuals and families in the new health plans actually get health care from their insurance. While there have been significant challenges just getting people signed up for health insurance, there will surely be additional hurdles as households now try to use the new health plans. For most people, they have no advocate to help them maneuver through the maze set up by health care professionals and insurance plans. Who will be the health insurance advocates for these families?

Health insurance gets more complicated

Regardless of the improvements to the new health plans brought about by the ACA, health insurance is still complicated. As with any insurance policy, many of us quickly forget the details of how the plan works, what is covered and what we have to pay beyond the monthly premium. The nitty-gritty details of deductibles, copayments, coinsurance, networks, and drug formularies become a fog when a family is faced with an accident or illness. If a household enrolled directly online or with the help of Covered California staff or Certified Enrollment Counselor, they will have no one to lean on to sort out the issues of their specific health insurance plan.

Advocates help with insurance problems

It isn’t a complete certainty that delegating a certified insurance agent will provide you with the advocate that you need. But here is the singular difference between a Certified Enrollment Counselor and a Certified Insurance Agent: Agents are appointed by the health plans to represent their plans AND the agent’s clients. Outside of the member of the health plan, only the designated agent can talk to the health plan to handle issues such as billing, charges, appeals, switching plans, adding a dependent, and grievances. To a limited extent, the insurance companies rely on the arduous process of contesting a charge because they understand most people will just give up and never fight.

Agents can be advocates

Unfortunately, not all health plans have made it easy for Certified Insurance Agents to become the broker of record for their members. This was a topic of my recent letter to Peter Lee, Executive Director of Covered California (see entire letter below). In short, without a designated agent or advocate most families will have no one to help them through the insurance maze when they have problem. It is deplorable that health insurance has become so complicated and convoluted that individuals and families need an advocate to fight for health care. But this is the situation we are in.

ACA complicated process

As a nation we need to move to either a simpler health insurance model with more transparency or we need to empower people to assign a health insurance advocate to help them navigate through the system when they are in rough waters. We have already experienced major issues with the open enrollment process where the carriers never received the application from the exchange, they were enrolled in the wrong plan or small application errors resulted in denial of the Advance Premium Tax Credit.

Denial and reimbursement of health care expenses

There are lots of organizations that will advocate for people in the Medi-Cal system but relatively few for people with private health insurance unless they are filing a lawsuit or have a big claim dispute. One company, AVYM, works with doctors and health plan members to get reimbursed for health care that should have been covered. With proper health insurance advocacy we can prevent denied and delayed care by working with the health plan, member and physician.

Fighting against profits before people

I can’t say that I’m overly optimistic that the current system will make room for health insurance advocates. Part of the issue with being appointed with a health plan is to acquire a small commission to compensate for such advocacy work. But the whole health care system is getting squeezed as providers and insurers look for ways to save money and keep premiums low. Ultimately, it is the plan members that suffer from cost cutting as they find themselves without proper representation when fighting the health care machine that puts profits before people.

Letter to Peter Lee of Covered California

March 21, 2014

Peter Lee
Executive Director, Covered California
560 J Street, Suite 270
Sacramento, Ca 95814

Dear Mr. Lee,

As a Certified Insurance Agent for Covered California I have not been able to live up to the agent agreement that I represent all the Qualified Health Plans fairly. My inability to represent many of the health plans beyond just the Covered California summary of benefits and quoted monthly premium results from several of the carriers failing to have any mechanism to properly appoint agents. Through the first three months of open enrollment the health plans of Alameda Alliance, Contra Costa Health Plan, L.A. Care, Molina and Valley Health Plan wouldn’t even return phone calls or emails on how to become appointed.

As an independent agent that is certified to represent Covered California plans through out the state, getting an appointment with these regional health plans shouldn’t be this difficult. A fellow agent was able to get appointed with Contra Costa Health Plan but he had to sign an agreement specifying there would be zero commission paid for his enrollments. L.A. Care is now working with a General Agent to process appointments, but they require attendance for an orientation meeting in Los Angeles. My California Health and Life license and Covered California Certificate should be enough to show that I’m capable to represent their plans. Do Certified Enrollment Counselors and Covered California staff face the same challenges in enrolling people in these plans?

When an individual, family or small business asks me to be their agent they are also asking me to be their advocate on health insurance related matters. If I’m not appointed with the health plan I can’t be of service to the member in matters such as disputing a health care charge, requesting member ID cards or resolving premium issues. Without being appointed I usually don’t have access to the important Evidence of Coverage which spells out how the health plan will be administered and other marketing collateral that might help my clients make an informed decision on which health plan to select.

The issue of appointment is directly tied to Covered California’s mission to “… improve health care quality, lower costs, and reduce health disparities through an innovative, competitive marketplace that empowers consumers to choose the health plan and providers that give them the best value.” I think you would agree that health insurance is not a topic most people want to delve into and become experts about. There are times when the most educated among us need help unraveling the various puzzle pieces of deductibles, copayments, coinsurance and networks when an illness or accident happens.

While I believe the efforts of the Covered California staff and Certified Enrollment Counselors have done an admirable job enrolling Californians in the new health plans, they can’t be advocates for the members when disputes and questions arise. If I’m not appointed with the carrier one of my clients selects, they are essentially on their own if they have to fight the health plan. Even the proposed Certified Application Counselors and Navigators will be little more than enrollment entities with no follow-up responsibilities.

I guarantee you that most people will forget my discussion with them on the differences between PPO, EPO and HMOs, tiered networks, tiered drug formulary, “in” verses “out” of network deductible, copayments, coinsurance, and annual maximum out-of-pocket expense. When a parent or child gets sick the last thing they want to do is hassle with the insurance company. I will happily carry that burden for my clients, but I can only do it if I am appointed by their respective health plan.

I hope Covered California will consider the following suggestions as we move from enrollment to implementing quality health care in California.

1. All carriers offering health plans in Covered California should automatically appoint any licensed and certified insurance agent upon receiving the necessary appointment documents such as a signed agent agreement and E&O insurance verification.

2. No health plan should be able to stipulate a zero commission rate as a condition of appointment.

3. Agents, along with CECs and any other enrollment entity, should be able to demonstrate that they understand the various parts of the health insurance plans including, but not limited to, the differences between a PPO, EPO, and HMO, deductibles, copayments, coinsurance, in-network verses out-of -network, tiered facilities, tiered drug formularies, in-patient verses out-patient designation, and the Evidence of Coverage.

4. No agent should discriminate, with respect to enrollment, between an APTC eligible individual or family and those who may be Medi-Cal eligible.

5. Agents should sign a pledge not to cross-sell any other products while discussing health plans with consumers such as home, auto, life, disability or indemnity insurance.

The easy part is enrolling people in health insurance. The difficult part will be helping these individuals and families make the most of their health plans especially when a health emergency or chronic illness strikes. I understand it is not Covered California’s mission to be a health insurance member advocate. But I would appreciate any consideration you and the Board might be able to give to the agent community to be better advocates for our clients by making the appointment process easier so we can fulfill our responsibilities of representation.


Kevin Knauss

CL# 0H12644



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