ACA Consumers Tell Their Stories

March 08--Margaret Hungerman was no neophyte to health insurance when she went in search of a new policy last year.

She had been covered while working as a manager during a 15-year career at D&B, and after the Macungie woman left the company in 2009, she bought an individual policy with Capital BlueCross. Then she learned last year that she'd have to find a new plan because her old one didn't comply with the new federal health-care law.

She went in search of coverage through the Affordable Care Act and, like so many, got stuck in the black hole of the law's troubled rollout.

Her application -- she actually filed two at the suggestion of a Capital BlueCross aide after her original application seemed lost in cyberspace -- would not be completed until January.

But the troubles for Hungerman, who sees a doctor for a thyroid condition, were hardly over. She went a month without coverage, nervously hoping to avoid a pricey emergency room visit. Once she got approved for coverage beginning Feb. 1, her doctor took her insurance, but her pharmacy did not.

Going back and forth with the insurance company, the federal government and the pharmacy, Hungerman finally tracked down the problem: The Capital BlueCross aide apparently wrote down the wrong date for her birthday on one of her applications. It would take several more days and hours on the phone before Hungerman got her identity straightened out. Frustrated, Hungerman said such sloppiness wouldn't have been tolerated at her old job.

"If I had rolled out a software implementation like this in such a chaotic manner, I would have been fired," she said.

Capital BlueCross Senior Vice President of Business Development Aji M. Abraham said the company cannot discuss individual cases. However, Capital BlueCross is intent on "getting it right" for all customers, he said.

The fumbles would cost Hungerman, who saw a neurologist in January when she was uninsured.

Last week, she got the bill: $950.

The back-and-forth mess Hungerman dealt with illustrates the next set of trials for new Obamacare insurance enrollees, whether they're first-time insured members or longtime policy holders like Hungerman.

Beyond the botched technology that stymied Obamacare in its first several months, a new slate of troubles emerged: lost coverage; months of red tape that leave the policy holder either without care or paying full price; new rules that require families to go from a single plan to multiple policies.

And sometimes, a happy ending resulted after it all clicked seamlessly. The consumers signed up, got the coverage they wanted at a reasonable cost and were able to use it without incident.

Since the health-care law took full effect Jan. 1, The Morning Call has interviewed a number of Obamacare policy holders. Here are some of their stories:

'A very frustrating experience'

It hasn't been an easy life for Maureen Hirochek. The Nesquehoning woman says she hasn't been able to work since 1989 after back surgery didn't relieve her of pain. She wrestles with a degenerative disc condition and, like her husband, has diabetes.

For years, the Hirocheks have been hanging on, waiting to reach age 65 when they'll qualify for Medicare. Hirochek's husband, Lewis, qualifies this year, but she has to wait another five years.

In the meantime, they were paying for a Special Care policy, a low-cost plan for low-income people who didn't qualify for Medicaid and had no employer-based coverage. Their plan provided a helpful if thin level of benefits, such as a limit of four doctor visits a year and no drug coverage.

With little income, the Hirocheks got by on insulin and medications donated by pharmaceutical firms. But Maureen Hirochek's insulin pump broke years ago, and her policy would not pay for a replacement.

"My diabetes has been out of control for about 14 months now," she said in January.

With her Special Care plan phasing out, Hirochek called the federal government's Obamacare phone line multiple times in December. On Dec. 26, she spent nearly two hours trying to get out of "the loop" with a government operator before finally breaking through.

The Hirocheks' new coverage, after subsidies, costs them $59 a month, about $260 less per month than the Special Care plan, and has comprehensive benefits. On the other hand, because they now have full-fledged coverage, they no longer will get free pharmaceuticals. Maureen Hirochek said their premium savings may very well be eaten up by their new prescription costs.

She's willing to take the trade-off. One of the first things Hirochek did with her new coverage was order an insulin pump. It came in mid-February.

"It was a very frustrating experience," she said of the transition to Obamacare. "My husband and I both have health problems, so this better coverage at a lower price will be very helpful to us, but it should not have been this difficult."

She's getting payback for her troubles. Since she got the insulin pump, her blood sugar levels have been normal or near normal 75 percent of the time, she said last week.

"That," Hirochek said, "is fabulous for me."

'I didn't want to wait'

Jonathan Strickland in one sense could qualify as a desirable "young invincible," the relatively healthy young adult demographic group critical to balancing out the more costly Obamacare enrollees at the other end of the age spectrum. But while the 27-year-old Coplay resident says he's "never been sick or hurt," he did spend some time in an inpatient rehabilitation program last year and still uses outpatient services.

He's unable to get coverage from his employer, an Allentown caterer, he said, so it was important to him to find health coverage. With his mother's help, he enrolled in December in a Highmark Community Blue plan that costs $163 a month and has a $2,100 deductible.

Initially, some of his outpatient services were billed to the wrong account, a problem he said was resolved easily.

Strickland also said he was eager to see a dentist, whom he had not visited in five or six years. But his insurance cards were slow to materialize, so he shelled out about $200 for a cleaning.

"I didn't want to wait," he said.

He said he's delaying further appointments until the paperwork gets straightened out. The frustration, he said, doesn't seem worth the cost.

"I'd almost rather pay more if I'd get better service," Strickland said.

Highmark spokesman Leilyn Perri said insurers are doing their best to deal with many new customers and a new and sometimes complicated process.

"Because of the changing rules and deadlines for enrollment on the health insurance marketplace, and the significant volume of applications received, we experienced some operational delays in sending bills to members," he said. "Highmark is working hard to enroll members to ensure they have active coverage as quickly as possible, and we appreciate their patience."

Capital BlueCross' Abraham said the transfer of information between the insurance companies and the federal government initially was "very challenging," and that the volume of complaints has shrunk significantly, but the process is still "a long way from being perfect."

The glitches he experienced left Strickland believing the federal government promised more than it is able to deliver.

"They probably should have took a lot more time before unrolling the whole program," he said.

'A dog walking on its hind legs'

The possibility of more affordable health insurance appealed to Richard Cuff and his family in South Whitehall Township. Cuff, who was laid off from a consulting job a year ago, said he had been paying around $1,100 a month for family coverage with a "very high" deductible.

Cuff said he tried to apply for coverage seven times until he got through in December and enrolled.

"Healthcare.gov is like a dog walking on its hind legs," he said this year. "It may not do it very well, but the fact that it does it at all is very impressive."

After subsidies, the Cuffs pay about $500 a month for better coverage, he said.

But as the weeks went by, Cuff still didn't have a plan for his teenage daughter, Caroline. Obamacare rules, he said, determined that she either go onto the state Medicaid plan called Medical Assistance or the children's health insurance plan called CHIP.

The Cuffs put off a few visits to the doctor and dentist for her and did not refill a prescription for her while they waited for a determination on her eligibility for CHIP. Earlier this year, Cuff said he was leaning toward buying a separate private policy for her if she doesn't qualify for CHIP, since many physicians don't accept Medicaid. That way, Caroline would be able to stay with her doctors.

"I'd be happy to pay for the up-charge that CHIP would require versus Medical Assistance," Cuff said. "But the law does not allow us that option."

More than two months after applying, the Cuffs learned that their income is too low for Caroline to qualify for CHIP. They're checking now about Medicaid before making a final decision about how she should be covered.

'Simple'

Barbara Wentz has always handled her family's health-care plans. So even though her son is a 40-year-old engineer living in Washington state, she agreed to investigate options for him. The Zionsville woman selected four "gold"-level plans with low co-payments and monthly premiums ranging between $327-$383.

He chose the most expensive option and within a day received payment confirmation, she said.

"This is how easy getting Obamacare should work," Wentz said, noting that Washington state runs its own health-care marketplace, unlike Pennsylvania, which chose the federally run marketplace.

Wentz said her son, who last year was paying premiums of $565 a month, was able to use his new coverage with no hesitation when he visited her in January. He paid a $10 co-payment for an office visit and used his coverage for a prescription, Wentz said.

"That was it," Wentz said. "Simple."

Not so for Debbie DeNardo. The Plainfield Township lawyer, worried that she might be without coverage Jan. 1, brought a completed application and payment to the Highmark store in Lower Nazareth Township in December.

"I thought at that point I was home free," she said, "but no. I never received a card. I did, however, receive two more notices telling me my insurance would end on Dec. 31, 2013, and a statement for some other plan that they had apparently selected for me that I did not want."

DeNardo said she finally got proper cards in late January and a correct invoice in mid-February. Since she doesn't qualify for subsidies, DeNardo is paying the full price for her coverage. Her premium is up by $6 a month to $527, and she now has co-payments for office visits and emergency care that she didn't have previously.

"I had been hoping that the Obamacare might result in a decrease," she said. "Silly me."

'Not well thought through'

When Carol Smith-Nichols slogged through the Obamacare sign-up process last year, she couldn't understand why her college-age daughter was denied coverage under her plan. After all, a widely supported element of the federal health-care law is a provision that allows children under 26 to be covered by their parents' plans.

Not taking a chance, Smith-Nichols, who was profiled in a December story in The Morning Call, bought a low-cost, high-deductible private plan for her. That meant her family of three would have three plans -- hers, her daughter's and her teenage son's CHIP plan.

Smith-Nichols, of Hanover Township, Northampton County, filed an appeal to Washington to reverse the decision for her daughter. After several weeks of no contact, she called Healthcare.gov's toll-free phone number and was told operators could not access appeals information. She sent another appeal early last month and got confirmation that her letter had been received a little over a week ago.

Meanwhile, she and her daughter received two sets of cards and explanations of benefits from their insurer, Highmark. The company's instructions indicated that the first mailings were incorrect, although Smith-Nichols said the cards were identical.

Smith-Nichols thinks the responsibility for the ongoing mix-ups belong to the insurance companies and the federal government, which had well-documented troubles transferring information to the companies.

"I think all the changes have got companies just ... being driven in all different directions," Smith-Nichols said. "It seems like the companies are not nimble enough to keep up with all this."

As for her daughter's appeal, Smith-Nichols will have to be patient.

The U.S. Centers for Medicare and Medicaid Services, which administers Obamacare for the federal government, still has not completed building its automated appeals process. It has a manual process in place and is working to help consumers who want to pursue appeals.

But CMS would prefer if consumers -- yet again -- reset their applications.

"We have found that the appeals filed are largely related to previous system errors, most of which have since been fixed," CMS said in a statement. "We are inviting those consumers back to Healthcare.gov where they can reset and successfully finish their applications without needing to complete the appeals process."

But Smith-Nichols wants an appeal, and on Thursday, she finally learned she'll get her wish. She received a letter saying she will at some point be offered an "informal resolution." If she doesn't agree with it, she can demand a hearing, which will allow her to testify over the phone. A decision would be presented to her by mail, she said.

"There is, most importantly, no mention of a timeline for the appeals process, but I have been assured that if my appeal about my daughter's eligibility is decided after the upcoming end of the open enrollment period, she can still be added on to my policy," Smith-Nichols said.

After having spent countless hours trying to sign up for coverage and then trying to get the attention of a stubborn bureaucracy, Smith-Nichols has learned to be patient.

"At least the wheels have inched forward a bit," she said.

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YOUR EXPERIENCE WITH OBAMACARE

The health-insurance marketplace, a key component of the nation's new health-care law, opened for business Oct. 1. At first, many had trouble applying for coverage, which went into effect Jan. 1. If you have acquired coverage through the marketplace or tried to, The Morning Call would like to hear about your experience. The newspaper also is interested in knowing about your experience using a policy purchased through the marketplace. We ask that you include your name as well as a phone number where a reporter may contact you. Please email your response to [email protected] with "Obamacare" in the subject line.

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