[UPDATED] DHS confirms that insurance companies will reinstate pharmacy coverage for cancelled private option beneficiaries | Arkansas Blog

Tuesday, August 18, 2015

[UPDATED] DHS confirms that insurance companies will reinstate pharmacy coverage for cancelled private option beneficiaries

Posted By on Tue, Aug 18, 2015 at 11:16 AM

The Department of Human Services confirms our report earlier this morning that insurance companies will reinstate coverage (at least for pharmacy services) for private option beneficiaries who had their plans cancelled via the state's troubled Medicaid verification system. The gist: insurance companies will pay if the person turns out not to be eligible for the program; DHS will reimburse the insurance companies if it turns out the beneficiary was in fact eligible. 

*** UPDATE: There are a few wrinkles in terms of the details: only pharmacy coverage is immediately reinstated. In other words, if beneficiaries try to get medication, they will be able to. If someone turns out to be eligible, the insurance companies will pay for all claims, both pharmacy and non-phamaracy (and DHS will reimburse via paying back the August premium). If someone turns out not to be eligible, the insurance companies will cover pharmacy costs but not non-pharmacy claims. In that scenario, the provider would bill the patient for non-pharmacy services (again, this would only come up if it turns out that the patient is found not Medicaid eligible). 

The insurance companies believe that most providers will provide services to patients in this limbo situation (covered for pharmacy services but only retroactively covered for non-pharmacy services once they're found eligible). Again, the insurance companies believe that the large majority of these folks are actually eligible; if providers make the same bet, they know that they'll be paid by the insurance companies for all claims as long as patients are found eligible. And of course, the interaction with the provider is a flash point that could prompt the eligibility determination to go through; providers in this situation will be highly motivated to push patients to get in touch with DHS as soon as possible.

Note that this deal covers only August coverage for those whose coverage was terminated on August 1. That still leaves the question of what will happen on September 1, when thousands more are set to lose coverage, but the insurance companies appear to be open to the possibility of continuing this policy. ***

DHS spokesperson Amy Webb said that DHS has been working on this arrangement with the insurance companies that offer private option plans as well as the Arkansas Insurance Department 

Webb provided the letters sent to DHS by Blue Cross Blue Shield and Centene (selling in Arkansas as Ambetter), two of the three carriers offering private option plans. 
PDF Here
is the Blue Cross letter and 
PDF here
 is the Centene letter. 

QualChoice, the third company offering private option plans, is not participating in the deal. 

The state still deserves questions and criticism about the policy decisions that got us in this mess in the first place, as well as ongoing policies still in place. And this doesn't solve everything: this should provide relief for the majority of those whose coverage was terminated, but it won't help people covered by QualChoice plans or by the traditional Medicaid program. All of that said, let's be clear: this is very good news. At least for many beneficiaries, this deal between insurance companies and the state will stop the nightmare scenario: a gap in coverage that makes it impossible for an eligible beneficiary to get vital medication while the verification mess gets sorted out. 


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