Sentinel Project Hopes to Help Newly Insured Get What They’ve Paid for

Andrew Kitchenman | November 3, 2014 | Health Care
Seton Hall law professors, NJ Appleseed work together on adequate and equal access to needed healthcare

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The Affordable Care Act guaranteed that hundreds of thousands of New Jerseyans are covered by insurance, but a new project aims to make sure that the insurance they receive gets them the healthcare they need.

The Newark-based Sentinel Project is intended to fill the gap left when Gov. Chris Christie opted against pursuing federal funding for a state-based health insurance exchange or consumer assistance program.

The project, a joint effort of Seton Hall School of Law and New Jersey Appleseed Public Interest Law Center, will gather information from insurance customers to determine whether insurers are providing them with the services they are entitled to under the law.

“One of the things that I thought state exchanges would be helpful in was just exactly this sort of thing — that is, there would be professionals who would be knowledgeable about the state’s insurance market” monitoring insurers’ compliance with the law, said John V. Jacobi, project leader and Seton Hall health law professor.

While the state Department of Banking and Insurance provides consumer assistance, Jacobi said that the Sentinel Project would supplement the state’s efforts at a time when the number of insured residents is soaring.

The project is focused on New Jerseyans who receive insurance through the individual or small-group markets, although it will refer Medicaid recipients to organizations that can represent them. It will keep track of people’s experiences in several main areas, including whether insurers are approving care that is medically necessary; whether insurers are maintaining adequate provider networks; and whether all types of patients are treated equally — for example, whether those with mental or behavioral health problems are receiving equal treatment to other patients.

The lack of state involvement in overseeing the marketplace “made this kind of project all the more important, as New Jersey has fewer resources than some other states have in monitoring the activity of insurance carriers,” Jacobi said.

Renee Steinhagen, New Jersey Appleseed’s executive director, said she sees the project as a way to make sure that residents receive the healthcare they need and to which they’re entitled. She’s also hopeful that the project will inform federal discussions about how the ACA’s essential health benefits should be revised.

A crucial part of this work is making sure that residents with concerns — and those who work with them — are aware of the Sentinel Project. While the project began accepting consumers though a hotline in April, it only began widely publicizing itself this fall, beginning with the launch of its website.

The project will also be able to reach a wide range of consumer groups through New Jersey for Health Care, a coalition of community, research, and advocacy organizations that supports expanded access to healthcare. New Jersey Appleseed is a member of the coalition.

Nearly 162,000 state residents enrolled in insurance through the individual marketplace in the first open enrollment period, which ended in April. The second open enrollment is scheduled to start on November 15 and last until Feb. 15, which Sentinel Project staff members believe could lead to a wave of concerns as residents try to use their new insurance.

Jacobi said his goal is to approach insurers as quickly as possible when residents have concerns about their services, so that the companies can remedy the problems. He said he’s already approached major insurers about this approach and they’ve been receptive.

“I’d like to think of this project as really trying to make sure that this expansion works and not as a project where we’re trying to point fingers at anyone,” Jacobi said.

For health plans to be compliant with the ACA, they must offer a series of essential benefits. While most of those were already required under New Jersey law, the ACA did add some new requirements, including providing dental care to children.

Jacobi said the Sentinel Project intends to make sure that health plans don’t wrongly reject essential benefits that are prescribed by patients’ insurers. While he said it’s appropriate for insurers to make sure that the prescribed care is appropriate, “consumers can be harmed if an insurance company is too aggressive.”

Even when insurers approve a service, it can inaccessible to patients if the provider is too far away. That’s why the Sentinel Project will also focus on whether insurers are following appropriate guidelines in maintaining adequate networks of providers.

Jacobi added that there are benefits to insurers maintaining their own networks, since they can choose providers who agree to follow effective and efficient methods. But with many consumers frequently choosing less-expensive plans, Jacobi said the Sentinel Project will also work to ensure that the plans are clear with consumers about what they’re buying, including which of the consumers’ current providers are in the plan network.

“We have had some concerns with how insurers have made their networks available on their website,” Jacobi said, adding that it’s not always clear from insurers’ sites which providers are in the marketplace plans, leaving consumers confused.

“The name of the plan on doesn’t always match up with the name of the plan on the insurers’ website,” he said. “It is confusing and it can make a difference because insurers have products that have different networks.”

This is particularly sensitive for patients with behavioral health issues, since insurers in other states have used different procedures to approve services for those patients than they use for nonbehavioral healthcare services. Jacobi emphasized that he hasn’t found this problem in New Jersey, but it’s important to track.

“Insurers are permitted to test whether something is medically necessary or not, but they are not permitted to create hurdles,” Jacobi said.

The Plainsboro-based Robert Wood Johnson Foundation is funding the project. Jacobi said it doesn’t appear that there is any similar work being done in other states that didn’t seek federal funding, so the Sentinel Project’s work could provide lessons that could be used across the country.