Monday, August 16, 2010

Some reflections on the "Pool" [UPDATED]

[Please scroll down for update]

I've been giving more thought to the whole process of the new Ohio ObamaPool©, and have come to two conclusions (thus far):

There are some rather stringent requirements put on me as an agent (see below), a relatively meager "finders fee" associated with steering folks to the Pool, and the likelihood that this will be a fairly labor-intensive process. So, I've decided to charge a non-refundable $50 retainer, upfront, before I will answer any questions about the Pool or help folks through the process of accessing it. As this is a "non-commissionable" product, I feel justified in doing so.

And what's so "labor intensive" about it? Well, consider that, in order to "sell" one of these, I need to complete and submit a special Broker Verification Form with each "application," and that this will require some fairly heavy pre-screening on my own part. And there's this rather daunting verbiage to which I am required to attest:

"I certify that I understand the eligibility, enrollment and anti-dumping requirements required by Section 1101 of [ObamaCare©] and I have explained these requirements to the applicant ... and that the enclosed application is complete and meets these requirements."

Okay, that seems pretty straightforward, but, as FoIB Rick B wondered:

"[O]ut of curiosity, as an agent, if a pregnant woman came to you and knew the high-risk pool would allow her to get immediate coverage. Assume she already has coverage, but her plan excludes maternity, how would you advise her?"

Under "normal" circumstances, it's up to the applicant/insured to prove prior coverage (via a Certificate of Creditable Coverage). It seems to me, then, that the carrier acknowledges that it has no way to independently verify prior cover. So, if someone comes to the new Pool, and is otherwise eligible (denied or waivered, pregnant, etc), how would Medical Mutual (MMO) prove that this individual had previous coverage (assuming it wasn't with MMO)?

For example: Sally is insured with Humana under an individual plan with no maternity coverage. She's now 3 months pregnant. Why not submit an app for the Pool, mark "no" for prior insurance, and have immediate cover for the pregnancy? Marking "no" means that MMO would have to prove a negative; i.e. how would they be able to prove she DID have coverage? And if I was not her agent for the Humana plan, how would I be any the wiser?

One answer might be for MMO or HHS Secretary Shecantbeserious to contact Sally's doctor. But if she's preggers, especially early on, why not just switch doc's? At $5000 or $6000 (or more!) for the claim, there's a pretty powerful incentive to be "creative."


UPDATE [8-19-10]: A colleague with whom I was discussing this pointed out - correctly, I think - that in this instance Sally isn't really lying when she answers "no" to prior coverage. After all, her Humana plan does not cover her for maternity; therefore she is, technically, uninsured.

That's what "is" means, right?

blog comments powered by Disqus