Obamacare's 'Orphans' and 'Ghosts' May Have Trouble Getting Care in January

Health insurance companies are spending the last week of the year searching for orphans and ghosts—the people who tried to buy health plans through healthcare.gov but have had their files mixed up or lost en route from the government website to the insurance company’s database.

The insurance companies dub “orphans” the people who selected a health plan on healthcare.gov but whose enrollment never got transmitted. “Ghosts” are the opposite: Customers whom insurers have counted as enrolled but aren’t on the government’s list of people who chose that plan—perhaps because they cancelled their plans or switched to a different company.

Patients with mismatched files may find that their doctors or pharmacists can’t confirm that they have insurance next year. Such problems were widespread in 2006, when the government created a new drug benefit for Medicare patients, and the health-care industry is bracing for a replay of those chaotic days.

To reduce that risk, the Centers for Medicare and Medicaid Services (CMS), which runs healthcare.gov, is sending weekly batches of enrollment files to the 300 insurers selling health plans on the site. Insurers check those files against the data the site transmits automatically, looking for inconsistencies. CMS last week reported that the rate of missing files was down to less than four of every 1,000 enrollments between Nov. 25 and Dec. 5. The total number of missing files was fewer than 15,000 from the debut of healthcare.gov on Oct. 1 through Dec. 5, the administration said in a blog post.

Both the administration and the insurance industry are trying to identify errant files and contact consumers to straighten out the mess before people seek medical care. Differences between insurers’ lists of enrollees and the government’s list often have to be reconciled by hand. “We are double and triple checking all enrollment data across systems,” a spokeswoman for CMS said in an e-mail Dec. 20. The agency is also reminding everyone who selected plans on healthcare.gov to pay their premiums and contact their insurers, she says.

Insurers have been calling for the government to set up phone lines to help people whose enrollment may be in question, so any problems they discover at the doctor’s office or pharmacy in January can be fixed promptly. “There needs to be a dedicated hotline at CMS to help consumers in this situation,” Robert Zirkelbach, a spokesman for industry lobby group America’s Health Insurance Plans, said in an interview Dec. 11.

The White House’s decision to extend deadlines complicated the job for insurers trying to verify who’s enrolled for coverage on Jan. 1. Because of the problems that crippled healthcare.gov in October and November, the administration gave people through Dec. 23 to enroll, instead of the original Dec. 15 deadline.

The White House also pressed insurers to give people extra time to pay their first month’s premium. The insurance industry responded by announcing that health plans would give people through Jan. 10 to pay for policies beginning Jan. 1, though certain states and insurers may have earlier deadlines. That extension is good for consumers, but it also makes it difficult for health plans to know who’s enrolled by checking whether they’ve paid their premiums.

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