Every day for weeks, Kathleen Bayly checked the mailbox at her Pleasanton, Calif., home for the bill from her new insurance company.
But Bayly, 61, who signed up in November for health coverage through California's insurance marketplace, didn’t receive anything from Anthem Blue Cross.
With her insurance set to expire on New Year's Eve, she became increasingly anxious. She cut short a vacation to make sure she didn’t miss the packet. She repeatedly called both Covered California, the marketplace, and Anthem Blue Cross. She wrote letters to local politicians.
On Dec. 13, nearly a month after enrolling, Bayly finally reached someone at Anthem who gave her a way to pay online. "It certainly hasn't been easy," she said.
For all the attention paid to the troubles at the front end of the enrollment process in the nation’s new insurance marketplaces, the back end can be just as fraught. The path to receiving an insurance card, the key to receiving non-emergency medical care, can be tortuous.
Once someone signs up, the insurance exchange still has to give the information to the insurer, which must send a confirmation packet and, even more important, a bill.
Insurers and others are concerned that even highly motivated consumers will run out of time to seal the deal. Many consumers don't know they have to pay their first month's premium to be covered. And with the back-and-forth mail required, the paperwork can be easily overlooked in a pile of packages and holiday cards.
Enrollment glitches also may keep insurers from getting the applicant’s information, including a Social Security number and contact information. And some people, though they applied for coverage and have time to pay the premium, may not have the money.
"There are so many twists and turns before this [system] is humming," said Micah Weinberg, a senior policy advisor at the Bay Area Council, an employer-backed public policy organization.
Among the biggest issues, he said, is, "Will the money get where it needs to get by the deadline?"
In the end, even if consumers enroll and pay, they still could face delays in getting the all-important card. Insurance companies have up to 10 days to issue a card once they receive the payment.
If aspiring beneficiaries don’t manage to get on insurers’ rolls by the New Year, many people could show up at doctors' offices and hospitals in January believing they are insured when they're not.
Glenn Melnick, a health care finance professor at the University of Southern California, said the number of steps and agencies involved in the sign-ups is a problem. "When a single entity doesn't control all of the details of an enrollment process, there is lots of room for mistakes and handoff errors," he said. "It is going to be messy."
California, one of 14 states running its own exchange, has been praised for its progress compared to other states and the federal government in enrolling consumers in new insurance plans. More than 156,000 have enrolled in coverage statewide. Roughly a third of enrollees in new marketplaces nationwide are in California, and officials are expecting a rush of applications over the next several days.
California consumers have until Dec. 23 to enroll in coverage and until Jan. 6 to pay their first premium – with Christmas and New Year's holidays in the middle. Other states have even earlier deadlines for payment.
Getting coverage immediately is most important for people who have pre-existing conditions and chronic illnesses. Others may be able to wait: People can apply for coverage in 2014 until March 31.
For those anxious to get insured quickly, Peter Lee, executive director of Covered California, underscored the importance of paying the first bill on time.
"Your coverage won't be effective until your payment is received," he said at a news conference on Thursday. "There is a lot of talk about enrollment. When we come into January and February, we are going to talk about one thing – who has insurance."
Federal officials also are concerned about the time crunch. The administration asked insurers last week to let consumers pay later in January for coverage that would still begin Jan. 1 and to allow partial payments for the first month. Insurers have not yet responded.
In California, insurance companies have sent out more than 60,000 invoices but few customers have paid, Lee said. Covered California is running radio advertisements reminding people about the payment deadline, and insurance companies are adding staff and expanding hours to process applications and payments.
Sharp Health Plan, based in San Diego, is allowing consumers to pay by phone, online and in person, and plans to stay open every day but Christmas and New Year's.
"We are all on call and we are all trained to accept payment," said Melissa Hayden-Cook, CEO of the company.
Blue Shield of California spokesman Steve Shivinsky said the company is sending out letters reminding applicants to pay. “It is going to be quite clear to the consumer that we have received their application and now it is time for them to write their first month’s premium payment,” he said.
Covered California didn't start transferring applicants' information to insurers until several weeks into open enrollment. Spokesman Dana Howard said the exchange was making sure the system worked and that the insurance companies were set up to receive the data.
Insurance companies said they are now receiving the data daily and the information is largely complete and accurate, in contrast to the problems in the federal exchange.
But people are submitting new applications at an ever-faster clip, and Covered California is making its way through a backlog of paper applications. California Association of Health Underwriters president-elect Patrick Burns said he anticipated an onslaught of applications before Dec. 23 that could test the system even further.
Agents say the state’s helpline isn’t helping. Insurance professionals with questions have to call on the same line as regular customers, lengthening everyone’s wait for answers.
The wait time for help reached 36 minutes last week.