Long delays, broken Web sites and ongoing political battles. The biggest problems of the implementation of the Affordable Care Act have been widely covered by national media. But there are plenty of smaller issues buried in the details of the landmark act.

The devil remains in the details of the law as insurers, providers, agents and brokers discover unexpected complications in implementation.

Plan design changes for previously unmandated pediatric dentistry, reimbursement structures for behavioral health treatment and a poor spread of risk are just a few of the hidden flaws in the new law, according to a panel of health providers and underwriters organized by the Association of Health Care Journalists (AHCJ) in Chicago.

The panel was held in late November at Columbia College, Chicago, for the Chicago chapter of AHCJ.

John S. Rutkauskas, DDS, chief executive officer of the Chicago-based Academy of Pediatric Dentistry, told journalists that new pediatric dentistry coverage—required to be offered by exchanges under heath care reform—was a good addition to health care plans, but the structures of the care available from health plans could be confusing and disruptive to consumers.

An estimated 8.7 million children could get dental care under the new law from a combination of employer plans, exchange-sold plans and Medicaid expansion, increasing coverage for kids by as much as 55%. The association is using the opportunity of the new law to promote dental hygiene and preventive care that will be more available than ever under the law.

Most individuals are used to stand-alone dental plans provided by dental specialty insurers featuring separate deductibles and coverage terms. However, under health care reform, employers and individuals will be most likely offered three types of dental coverage, including stand-alone plans provided by dental specialty insurers, bundled coverage provided  by large health plans and dental insurers with separate policy terms and deductibles but sold together, and embedded plans in which dental coverage is rolled into one health plan under a single policy and high deductible from a single insurer.

All three models comply with the law but can be confusing and disruptive, says Rutkauskas. For example, individuals are likely to notice that embedded plans will appear to be the least expensive of the choices, with a single premium that is lower than the combined premiums of the other choices. But the actual care is likely to cost more out of pocket as it will be subject a single, much higher deductible.

When policyholders notice that their health plan deductible applies to dental as well as medical coverage, they may delay the preventive care and early intervention that is the hallmark of successful dental care, he says. Many children might not get dental care until their deductible is satisfied by other medical charges.

Behavioral health care for alcohol and drug addictions will be available for privately and publicly insured individuals under health care reform and, thanks to health care parity laws, no longer subject to lower limits and caps on medical coverage, says Dan Lustig, PsyD, vice president of clinical services for Haymarket Center, an alcohol and drug treatment center in Chicago.

However, the management and payment of benefits for alcohol and drug treatment may be more confusing under reform and limiting in new ways. While the cost of medical care is no longer capped, some components of care may be limited under guidelines from expanded Medicaid.

Residential care is critical to positive outcomes of treatment, he explained, and in most cases of addiction, multiple periods of treatment are common as patients move in and out of remission from their addiction.

Many patients receive care under state-funded Medicaid and, while the medical treatment is no longer limited, room and board payment may be restricted under Medicaid guidelines. These restrictions may prevent patients from receiving residential treatment when they needed to respond to relapses.

“Alcohol and drug addiction is the number one cause of death in the United States,’ Lustig says,’ and it is important that we focus on positive outcomes, not just payment procedures.’

Land of Lincoln Health is the first Illinois underwriter created as a Consumer Operated and Oriented Plan (CO-OP), a new nonprofit insurance model allowed under health reform. The new company was created by the Metropolitan Chicago Health Care Council, an association of 150 health care providers in the Chicago area, with a $160 million federal loan facilitated by the health care reform law.

In April, the health plan was licensed as a mutual insurer in Illinois and prepared to underwrite group and individual health insurance through the health insurance exchanges in Illinois. Jason Montrie, vice president of networks channels, says the company is off to a good start, despite a series of challenges created by the delayed launch of the online health exchange processing.

Web-site shopping and registration was planned for an October 1 launch, but the failure of the processing system to accept the flood of new participants led the new health plan to create a “reservation system’ for Illinois residents seeking coverage.

One of several health plans available through the exchanges, Land of Lincoln began taking calls and preparing customers by asking them to fill out information application forms. The applicants were then given reserved appointments with enrollment specialists to discuss plan options, pending more successful operation of the health exchange Web sites.

The process allowed the health plan to assist applicants until the technology caught up with the sudden demand, Montrie  said. The health plan also had to accept responsibility for communicating the range of health plan options and clarifying differentiations between the plans that may have changed under health care reform.

The health plan also had to develop targeted marketing to reach a critical audience, Montrie noted. Appropriate spread of risk is critical to success of health care reform, noting that participation of a young, healthy pool of insureds would be necessary to offset the claims produced by an older, less healthy group of policyholders in order to establish a financially healthy spread of risk.

However, the law did not work particularly well to attract young, healthy participants, he said. While the law provides for penalties for individuals who do not sign up for health coverage, the penalties are much less than the annual cost of coverage.

“When you are dealing with young, healthy individuals under 40 years old, who believe they are invincible, it can be a challenge to convince them to purchase health insurance,’ he said. As a result, the health plan is targeting applicants under 40 in its marketing and advertising as well as general individual purchases and purchasing executives for small businesses.

The health plan is also creating broker accounts at its Web site www.landoflincolnhealth.org to allow agents and brokers to submit coverage requests for small businesses directly to the company.

The author
Len Strazewski has been covering employee benefits issues for more than 30 years. He has an M.S. in Industrial Relations from Loyola University in Chicago.