How do I navigate this health insurance hell?
August 1, 2016 9:36 PM   Subscribe

I applied for health insurance within the time allotted for my special enrollment period, but since they did not receive the (online) application until 63 days after my eligible event, they say I am ineligible. What are my next steps?

I am in Washington State. I recently turned 26 and aged out of my parent's health insurance plan. Washingtonhealthplanfinder said I had until July 2nd to apply for coverage, which would be 60 days after I turned 26 and aged out of my plan. I applied for coverage on July 1st.

I chose Regence, and they are saying that since July 1st was a Friday, and I applied late in the evening, they did not end up receiving my application until after the long weekend and therefore I am ineligible for coverage.

I do not agree with this decision. The website did not say anything about applying before the close of business, and I absolutely did APPLY during the correct time period, and since it was an online application I do not really understand how they didn't receive it until the 5th. Nothing I read said anything about the date the application is received being important.

I tried to appeal it but I just received a notice in the mail saying that they are not able to offer me a plan, and I guess I can send in another appeal? I am confused honestly as to whether this most recent notice is in response to my appeal or if it is something else entirely.

WAhealthplanfinder has some sort of ticket in that hasn't been resolved yet regarding this, but after talking to them on the phone today I don't have a lot of faith in them. Since Regence sent me this letter, I am worried that is their response to the ticket.

I have a few medical conditions for which I really needed insurance a month ago (I didn't realize that by applying on the 1st of July that would push back the day the insurance was supposed to start until August).

So, I have many questions.

a. My insurance through my parent was a BCBS company. I am supposed to be taking a few expensive medications plus I have some durable medical equipment I need parts for, and I need to see a few specialists. Since Regence is also a BCBS company, and since they have received claims for me when I was on my mom's insurance, could this refusal to insure me have anything to do with my pre-existing conditions? Is it possible they knew about all that stuff, and are trying to figure out any way possible to deny me insurance because they think/know I will be expensive? I believe this is illegal, right?

b. Should I get a lawyer? How/who/what type? This is causing me a lot of strife and my quality of life is suffering because the medications my doctor prescribed are too expensive without insurance. But, I am not even sure this is a legal issue or I have legal recourse. Is it the law that I have 60 days after my qualifying event to apply for coverage? Is it legal for them to deny me coverage if I applied in the correct time period? My medical conditions include ADHD, anxiety, and sleep apnea, all of which make it difficult for me to make and execute decisions, which is why I procrastinated until the 59th day to apply. Do I have recourse under the Americans with Disabilities Act, maybe? Plus, since I don't have health insurance won't I have to pay a big fine at tax time? In which case I feel like maybe a lawyer can help me, because I really really want health insurance, I am not trying to not have it, and I thought I did all the right things. Could a lawyer help me make a better appeal since apparently the first one didn't work out?

c. It says on the sheet I can also file a complaint with the Washington State Office of the Insurance Commissioner. Will that help me at all? I was also thinking of contacting the Better Business Bureau since they have helped me before when a company was treating me unfairly. Would this make the health insurance company mad at me and make it even harder? I feel like I have nothing to lose at this point, but I don't want to make this any worse.

Basically, I just want to know what I can do at this point to get health insurance coverage so I can get my medications and my health conditions dealt with properly and how I can avoid paying that big fine for not having health insurance. This is very frustrating and if I call Regence tomorrow I don't want to say anything I will regret. Help please!
posted by tweedle to Law & Government (11 answers total)
I strongly suspect Regence is full of it (special enrollment periods usually run 60 days from the qualifying event), but unfortunately the ACA scheme is very complicated so I can't research it completely on the fly. You should:

(a) file another appeal; and

(b) definitely call your state insurance commissioner. While I can't speak to WA specifically, states with functioning governments (which is unfortunately not all of them) are used to dealing with these kinds of issues and know how to resolve them. You should at least be able to get a well-informed answer about the special enrollment period from them. I would try calling first, since your issue is fairly urgent. Unless you have money to burn, I would hold off on consulting an attorney until you've spoken with the commissioner. They won't be able to act as your lawyer, but if Regence is just plain wrong about the enrollment period, that's the kind of thing a call from them to "mediate" will usually clear up.
posted by praemunire at 10:33 PM on August 1, 2016 [2 favorites]

My understanding, but not necessarily definitive, is that your application must be submitted to the exchange by the deadline. The time it takes the insurance company to receive and process the application should not matter.

The insurance company is simply going by their own rules. They do not necessarily know when you submitted the application, only when they received it. The exchange must clarify this information for them.

You should work with your exchange and pursue the ticket you submitted. A the same time you should call your insurance commissioner's office for assistance. You should also contact an exchange navigator, which you should be able to find on your exchange website.

One of the special qualifying events, according to the HHS, is "An error or problem with enrollment (or non-enrollment) that was the fault of the exchange, HHS, or an enrollment assister. In this case, the exchange can properly enroll the person (or change plans) outside of open enrollment in order to remedy the problem."

You are going to have to be persistent is pursuing this. I suspect that you will prevail, although it may take a while.
posted by JackFlash at 12:02 AM on August 2, 2016 [6 favorites]

Also, you should be able to print out a receipt from your exchange account that indicates the date of your application. Have you sent this receipt to the insurance company?
posted by JackFlash at 12:09 AM on August 2, 2016 [1 favorite]

You should contact the WA state insurance commisioner for all of these questions.
posted by the agents of KAOS at 1:04 AM on August 2, 2016 [1 favorite]

I would also talk to a local insurance broker to see if they have anything to offer.

Once upon a time, I covered a gap in health insurance with a six-month, non-renewable policy. Don't know if that's available to you, but chances are there is a solution out there.
posted by SemiSalt at 4:42 AM on August 2, 2016 [1 favorite]

Having exhausted all other avenues, this sounds like the type of case that could benefit from throwing a public floodlight on it. Consider contacting your congressman or the local TV station to see if they can help.
posted by CathyG at 7:39 AM on August 2, 2016

Following up on my previous answer, it looks like short term insurance is still available. For instance here.

I know that I would be happier taking the solution offered by the marketplace to railing at The Man.
posted by SemiSalt at 8:59 AM on August 2, 2016

Short term plans without a qualifying event do not cover pre-existing conditions. They are not a viable solution for the original poster.
posted by JackFlash at 9:45 AM on August 2, 2016 [1 favorite]

I work on these issues for a living, although I work with the NY Exchange, and have done some work on the implementation of the ACA.

Regence is absolutely full of it.

Enrollment is handled at the exchange/marketplace level and an enrollment file is then sent to the insurance company. Insurance companies don’t actually handle enrollment or disenrollment for marketplace/exchange plans, they are dependent on the exchange to generate those files.

The Washington exchange will move slowly to resolve this, although they absolutely have the power to resolve this, because they can generate and send a new enrollment file. Keep pressure on them, and ask that the issue be escalated because of high health needs, and don’t hesitate to request to speak to a supervisor.

Nthing the suggestion to contact WA state insurance commissioner. It doesn’t look like you have a Consumer Assistance Program, so your best bet is the state insurance commissioner. Here in New York they work resolve consumer complaints and can be helpful.

Both of the above options are slow moving however, and will require you to put pressure on them and follow up.

Appealing to Regance is up to you, I think you are more likely to get a response by working with the exchange and the insurance commissioner.

I’m not really sure what legal recourse is available to you. If this was an eligibility determination you could appeal to the exchange, and if it was in reference to Medicaid or another public health program you’d like have more clearly defined rights.
posted by gnar_gnar at 12:49 PM on August 2, 2016 [2 favorites]

To follow up on gnar_gnar's excellent response, Regence cannot legally refuse to enroll you. If you enrolled through the exchange, met the proper deadlines and follow up with the required premium payments, an insurance company must accept your enrollment and can never cancel your policy. This is one of the primary features of the ACA.

Without further evidence I don't think that Regence is trying to mess with you. I think this is just a typical bureaucratic glitch in the coordination between the exchange and the insurer. You should be able to work it out.
posted by JackFlash at 1:13 PM on August 2, 2016 [1 favorite]

Response by poster: Thank you everyone for the advice! And the inadvertent reassurance that I am not crazy/wrong.

I did a bunch today, so hopefully someone with some power can help me.

I contacted the office of the insurance commissioner, filed another appeal with Regence that included more documents, contacted a navigator, contacted a broker, and applied for medicaid insurance for workers with disabilities since I also happen to make less than 220% of the poverty level (although I am not sure how far that will get me as I have never documented any of my issues as disabilities before, although it seems like they should count, especially since due to lack of insurance right now I am off some of my meds and my functioning is not great compared to before).

Next step is to contact some local hospital systems I know will provide care free of charge if you don't make a lot of money, and see what I can do to get a few of my medical problems taken care of even if I don't have insurance.

Thank you so much everyone! I cannot tell you how reassuring all of your comments are, and helpful in that I went from not having any clue what to do, to actually doing stuff. I will wait to mark best answer until I figure out which suggestions get the best results.
posted by tweedle at 2:39 PM on August 3, 2016

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