The Association of Washington Healthcare Plans – an alliance of licensed health maintenance organizations (HMO) and health care service contractors (HCSC) in Washington state – said Wednesday that problems with thousands of consumers’ health claims have resulted in delays of service or in claims payments to an estimated 15 percent of enrollees in the state’s online insurance exchange.
In a letter to the Washington Health Benefit Exchange, which operates the state’s exchange, the association listed five main problems it said the exchange needs to address:
• Delays by the exchange in sending premium payment files to issuers.
• Incomplete premium payment files to issuers.
• Lack of receiving termination files from the exchange.
• Problems with invoices, including inaccurate or missing invoices.
• Dual eligibles for APTC Exchange coverage and Medicaid. (Many of these enrollees will churn between Medicaid and tax credit status multiple times throughout the year, resulting in the need for recoupment of premium payments, further exacerbating 5h3 problems.)
“The issuers request the exchange provide a ‘roadmap’ describing how and when all the identified defects will be resolved — which must be well before 2015 open enrollment.” The letter, signed by the association’s executive director, Sydney Smith Zvara, also called on the exchange to forgo implementation of new features or system projects until the current problems are resolved.
“We cannot function in the current environment as is and support open enrollment activities at the same time,” wrote Zvara. “It is not appropriate to continue to confuse members and make it difficult for them to navigate the system and access the coverage for which they have paid.”
We have asked for comment from the exchange.