A Health Insurer Calls, With Questions

Not long after she signed up for health insurance under the Affordable Care Act, Judy Shoemaker received a phone call that puzzled her.

The caller said she was welcoming new members to the insurance network and then asked Ms. Shoemaker to take a survey about health care issues, so information could be provided to her physician. Ms. Shoemaker declined, saying she didn’t understand why her insurer would be seeking medical information to give to her doctor. “I thought it was strange,” said Ms. Shoemaker, a consultant to nonprofits in Indiana. “I can talk to my doctor myself.”

James Tuck, who runs a dog care business in Chicago, got a similar call after signing up for insurance through the Affordable Care Act in March. The caller said he was contacting Mr. Tuck on behalf of his new insurer, Blue Cross Blue Shield of Illinois, to go over his benefits and ask him some questions. Mr. Tuck hadn’t yet received his insurance card and was hesitant to answer questions, especially after he consulted a private health advocate, who had helped him evaluate insurance options. She advised him not to answer the queries. “She said their goal is to find a reason to get you booted off your insurance.”

Insurers say they are doing nothing of the sort. Lauren Perlstein, a spokeswoman for the Health Care Service Corporation, parent of Blue Cross Blue Shield of Illinois and plans in four other states, said in an email that the company contacted new policy holders to help “new members get the proper coverage and medical assistance they need, by helping guide them through the health care system.”

The company’s “experts” contact new members to explain benefits and answer any questions, she said, as well as to “identify members who can benefit from our personalized medical management program so they can best manage their health.”

Medical management options include, for example, programs for expectant mothers, to help make sure they get prenatal care. They are an outgrowth of disease management programs, which aim to improve care and lower costs by helping patients with chronic conditions adhere to treatment regimens.

As of April 30, the company has identified about 38,000 new members who would qualify for medical management programs “and, by working closely with providers,” has helped them more easily navigate the health care system to get proper care, she said.

Members aren’t terminated because of responses they may give on the calls, she said. Rather, “this outreach is only to help our members by providing assistance and tools to best manage their health.”

David Nash, dean of the school of population health at Thomas Jefferson University in Philadelphia, said Mr. Tuck had received “inaccurate” advice, since the Affordable Care Act bars insurers from considering your health status when enrolling you in coverage.

“It’s against the law to deny coverage for any prior conditions,” Dr. Nash said. Insurers commonly conduct such surveys, known as “health risk assessments,” to help make sure members with specific health needs receive proper treatment, as well as to help predict costs so insurers can accurately set premiums. It’s understandable, he said, that someone who hasn’t had workplace-based insurance, where such assessments are very common, might be taken aback by being asked questions about personal topics, like their exercise habits. But gathering such information helps insurers design sustainable policies, he said.

Yet Sarah O’Leary, who advised Mr. Tuck, said such insurer-initiated calls were reminiscent of those that insurance contractors made before the Affordable Care Act, to help vet applicants for individual policies for pre-existing medical conditions. (One such company contacting consumers on behalf of insurers, she said, is RSA Medical, which previously helped insurers underwrite individual applicants). Her firm, ExHale Healthcare Advocates, advises patients about medical coverage and negotiates medical bills, for fees ranging from $25 to $500 depending on the complexity of the situation.

Ms. O’Leary said she was not aware of any consumers who had been improperly terminated from coverage, but that she considered the calls a “red flag.” She advises clients not to answer health questions from their insurers unless they have an active claim.

Here are some questions about keeping your coverage under the Affordable Care Act:

■ What should I do if I get an unsolicited call from my insurer asking health-related questions?

Dr. Nash noted that answering insurer surveys was voluntary, but if you decline you can miss out on programs that may help you

Cheryl Fish-Parcham, private insurance program director at Families USA, which helps consumers, said health insurance companies were most likely trying to better understand the health profile of new enrollees as a group, to help them design their offerings for next year. Or, they may be trying to get on top of patients with complex needs, such as those who suffer from multiple illnesses. It is up to consumers if they want to answer any questions from their insurer, she said, but consumers “can rest assured” that their policies can’t be canceled because of their health.

Ms. O’Leary suggests that if you get a call from your insurer that you didn’t initiate, you should at the very least hang up and call the number on the back of your insurance card, to make sure the caller is legitimate.

■ Is there any way I can lose my health coverage under the Affordable Care Act?

You can be terminated if you don’t pay your monthly premium, so it’s important to get your payment in on time. If you get assistance through premium tax credits, or subsidies, you’ll have a grace period before your policy is actually canceled, to allow you to catch up. Ms. Shoemaker, the Indiana consultant, said she paid her premium online several days before the due date and then telephoned to confirm her payment was properly credited.

Another way to lose coverage is if you fraudulently filled out your application. It’s not entirely clear yet what would be considered fraud, said Karen Pollitz, a health policy expert at the Kaiser Family Foundation. But one classic example might be listing a nonrelative on your application for a family policy in order to gain coverage for them; if the insurer learned the truth later, coverage could be rescinded. Saying that you don’t smoke on your application, when in fact you are a smoker, isn’t grounds for termination of coverage under the law. But if your status as a smoker is discovered, insurers can retroactively impose higher premiums and cancel you if you don’t pay.

■ Can disease management programs be beneficial?

A study by RAND researchers found that disease management programs, which help patients with conditions like diabetes stick to specific medical and drug regimens by, for example, having a nurse call them to remind them to refill prescriptions, can help patients and may save money. (In contrast, generic “wellness” programs focusing on, say, weight loss, didn’t save money, the study found).