Problems? Turning to Congress can help

State and federal lawmakers can expect to hear from a few constituents soon.

Whether they are individual consumers looking for help on a coverage-related problem or insurance experts trying to massage some policy changes, Nevadans are looking to reach out.

We’ll start with a senior who is seeking help to fight a change in what treatments Medicare is willing to pay for.

■ Joyce of Mesquite wrote to us about a change in how Medicare covers her medical condition. The 80-year-old had her stomach removed about 15 years ago after a bout with cancer. Although Medicare used to pay for four cans of her liquid diet daily, as well as catheters and other supplies, Joyce says that’s no longer the case “since the Obama medical reform.” She says Medicare now tells her that if she can swallow two sips of water, the federally run insurance program no longer will cover her liquid meal supplements or supplies.

So Joyce, the law is a mixed bag for Medicare — it requires the program to cover annual checkups and preventive screenings, even as it cuts annual increases in reimbursements for hospital cost and home health services.

But we couldn’t find anything in the Affordable Care Act that would have cut your specific benefits. That means we can’t say whether the changes you are seeing result from the law.

Regardless of why your coverage stopped, your approach should be the same as it would be for any consumer who is experiencing your issues: Len Barend, an insurance and benefits specialist with The Barend Agency in Las Vegas, recommended that you appeal Medicare’s decision.

Start by asking your doctor to write a letter to the Centers for Medicare and Medicaid Services explaining why your liquid diet and supplies are a medical necessity, Barend said. But don’t stop there: Write your U.S. congressman — in your case, that’s Rep. Steven Horsford, D-Nev., — and Sens. Dean Heller, R-Nev., and Harry Reid, D-Nev., and let them know your situation.

“When a congressman calls and says, ‘What kind of crap is this?’ Medicare jumps,” Barend said. “If a recipient calls, (Medicare) doesn’t care.”

When we asked Barend how long an appeal to Medicare can take to draw a response, he laughed.

“It depends on how fast they want to react. The solution is a simultaneous appeal from your doctor to Medicare and from you to your congressmen,” he said.

Barend knows from personal experience. As a Medicare recipient himself, he saw coverage of an arthritis medication he receives in his doctor’s office shift from Medicare’s Part B supplemental program to its Part D prescription drug benefit. That meant the drug, if given in his doctor’s office, was no longer covered. Barend had his doctor appeal, and he reached out to Rep. Joe Heck, R-Nev., for help. Heck’s office looked into the situation; two weeks later, Barend’s doctor called to tell him he could be treated in-office again.

“Congress will jump on a case for a constituent,” he said.

■ We always listen when industry insiders talk about the future of the Affordable Care Act in Nevada.

Earlier this month, Jim Wadhams, an insurance attorney and lobbyist with Fennemore Craig Jones Vargas and former commissioner of the Nevada Insurance Division, spoke at a breakfast meeting of the Clark County Association of Health Underwriters about how the law might continue to roll out.

Wadhams talked about what needs to happen to boost sign-ups through Nevada Health Link when open enrollment comes in November, and he pulled back the curtains for a look at how behind-the-scenes political machinations might play out as Nevada’s 2015 legislative session draws near.

First, about those health link enrollments. The site’s issues, from inaccurate subsidy calculations to billing snafus, have been well-publicized. Xerox, the site’s contractor, got the heave-ho in May and won’t be running Nevada Health Link after November, when the Silver State Health Insurance Exchange begins borrowing the federal system’s eligibility and enrollment functions while it looks for a replacement system.

And a replacement system is what’s needed, Wadhams said.

“Certain technologies can be fixed, but I don’t think the system as it was designed can be fixed. It’s going to have to be altered in order to make it work,” he said.

Meanwhile, if you’re waiting for a fix via congressional repeal, forget about it. Wadhams said a repeal isn’t likely. What you might have, though, is a “major overhaul of many issues.” Especially ripe for change are rules that have raised costs for younger consumers, such as community ratings that eliminate premium breaks for the healthy and age bandings that prohibit charging older people substantially more than the young.

As for the law’s political consequences, Nevada has an unusual dynamic in its Republican governor and Democratic attorney general. That, in turn, could make things interesting here through the fall elections and into the legislative session.

As a signature policy of President Barack Obama, the Affordable Care Act is a “litmus test for Democrats,” Wadhams said. “But the fact that Gov. (Brian) Sandoval chose to control the exchange process locally made him a bit of a renegade as a Republican. Now it becomes an issue for Republicans who want to support the governor. It’s created a very strange confluence from both sides of the aisle. It’s blinded legislators to the problems now staring them in the face.”

But early bipartisan effort on implementing the Affordable Care Act here also could mean across-the-aisle cooperation on fixing today’s problems, Wadhams said.

Wadhams is working to convince Sandoval’s office and the Insurance Division that a Centers for Medicare and Medicaid Services decision to let small businesses and individuals keep noncompliant plans through 2015 would be legal here. Without the rule change, premiums could jump dramatically this fall for about 100,000 Nevadans.

“We’re not going to stop the ultimate development of the (law). We’re just going to get a smoother glide-path into the future,” he said.

“These problems need to be fixed irrespective of whether they’re fixed by Republicans and Democrats. They need to be fixed for the people who live and work here,” he said. “Those (candidates) who survive the primary are going to get our information, plus hopefully a small check to defray campaign expenses.”