The Sentinel Project: The ACA's Marketplace Reforms and Access to Care

Abstract

The Patient Protection and Affordable Care Act (“ACA”) is intended to connect Americans with affordable, medically necessary health care. The first step toward achieving that goal is insurance expansion. The ACA’s first year of insurance expansion has allowed millions of Americans to newly obtain insurance. The second step recognizes that the content of health coverage matters, as appropriate insurance connects consumers with necessary care. The ACA therefore requires most plans offered in the individual and small group markets to cover a slate of ten essential health benefits (“EHBs”).

There is a third necessary step in fulfilling the promise of the ACA. Once people are connected with insurance plans covering essential health benefits, it is vitally important that the plans deliver on the promise to provide necessary care in a timely, appropriate manner. The Sentinel Project of Seton Hall Law School will address this third step by assessing the market behavior of plans as consumers seek access to appropriate health care. This Report describes the history of health plans’ behavior in fulfilling their contractual obligations, the regulatory structure designed to assure the smooth functioning of the health insurance markets, and the Sentinel Project’s plan to assess the ACA’s effect on those markets.

The Sentinel Project will examine the interactions among consumers, insurers, and regulators in the individual and small group markets. With our partner, New Jersey Appleseed, we will provide advice and representation when plans deny coverage to consumers; interview health care providers, health insurers, regulators, advocates, and consumers; and review the emerging literature on health coverage disputes. We anticipate that the information we garner will raise issues in four categories of concern: contract exclusions; medical necessity; network adequacy, and discrimination.

The Sentinel Project will use the information it obtains through consumer representation, interviews of stakeholders, and independent research to create a feedback loop that circulates important indications of the functioning of the insurance market. We will provide information on market behavior to insurers, consumers, regulators, providers, and advocates. Our goal is to contribute to the success of the implementation of the ACA by assisting in the smooth performance of the market for individual and small group insurance. The Sentinel Project’s efforts are intended to:

(1) Inform insurers of emerging concerns as consumers negotiate new insurance products;

(2) Assist consumers as they seek to obtain and understand services covered by their health plans, and to advise and assist them as disputes with their health plans arise;

(3) Enhance consumer understanding of the structure and functioning of health plans in the individual and small group markets;

(4) Inform federal and state regulators of concerns that arise as consumers and plans respond to market and regulatory influences;

(5) Assess the efficacy of existing consumer protections in assuring appropriate coverage of necessary care in the reformed markets; and

(6) Assess the need for amendments to the regulatory structure that guides the operation of this vital market for health coverage.

Keywords: Affordable Care Act, ACA, PPACA, essential health benefits, medical necessity, contract exclusions, discrimination, parity, network adequacy, appeals. coverage denials, access to care, covered benefits