En­roll­ment anx­i­eties

Com­plex con­sumer choices pose chal­lenges for out­reach groups, plans and providers

Modern Healthcare - - NEWS - By Paul Demko

Dur­ing the 2014 open en­roll­ment for Oba­macare cov­er­age, Mary Den­son, 21, a stu­dent at Columbia (Mo.) Col­lege, qual­i­fied for a fed­eral pre­mium sub­sidy that re­duced her pre­mium con­tri­bu­tion for buy­ing health in­surance to less than $20 a month.

But she fears that when she re­news her cov­er­age for 2015, she won’t have enough in­come from her nanny job to reach the sub­sidy in­come thresh­old of 100% of the fed­eral poverty level and con­tinue qual­i­fy­ing for pre­mium tax cred­its. She isn’t el­i­gi­ble for Med­i­caid be­cause Mis­souri hasn’t ex­panded that pro­gram for low-in­come adults. Den­son says she’s con­sid­er­ing look­ing for another job to reach the $11,670 in­come thresh­old but wor­ries she may have to drop classes. With­out the sub­sidy, her cov­er­age would cost nearly $400 a month, far more than she can af­ford.

“I’m just go­ing to have to re-ap­ply and pretty much hope that I make the cut again,” Den­son said.

The sole fo­cus dur­ing the 2014 open en­roll­ment pe­riod was on sign­ing up as many peo­ple like Den­son as pos­si­ble in ex­change and off-ex­change in­di­vid­ual-mar­ket plans. But when the three-month open en­roll­ment pe­riod for the sec­ond year of cov­er­age un­der the Pa­tient Pro­tec­tion and Af­ford­able Care Act opens on Nov. 15, the task for health plans, in­surance bro­kers and thou­sands of en­roll­ment work­ers at hos­pi­tals, clin­ics and com­mu­nity or­ga­ni­za­tions will be more com­plex.

The roughly 8 mil­lion peo­ple who en­rolled in ex­change plans this year will need to re­new their cov­er­age, and ex­perts say many will need to re­port up­dated in­come in­for­ma­tion and re-eval­u­ate their plan choices. Beyond that, it’s pro­jected that an ad­di­tional 5 mil­lion peo­ple will sign up. In the com­ing weeks, ex­change-plan en­rollees will be­gin re­ceiv­ing no­tices from the CMS and their cur­rent

in­surer about their cov­er­age op­tions for next year.

Many ex­perts pre­dict that per­suad­ing Americans who are still unin­sured to sign up will be harder than it was last time be­cause that pool may in­clude health­ier peo­ple who don’t think they need in­surance, along with those who ei­ther don’t want to pay for it or don’t think they can af­ford it.

The CMS an­nounced this month that in­di­vid­u­als who take no ac­tion will be au­to­mat­i­cally en­rolled in the same plan for 2015. This could cre­ate many prob­lems for con­sumers. If they don’t re-ex­am­ine their plan choices, they could get stuck in a plan that doesn’t meet their med­i­cal needs or cur­rent fi­nan­cial sit­u­a­tion. Many dis­cov­ered after sign­ing up for 2014 cov­er­age that their pre­ferred providers weren’t in­cluded in the plan’s net­work, or they based their decision on a lower pre­mium and found them­selves fac­ing de­ductibles and coin­sur­ance that were too much for their pock­et­book.

In ad­di­tion, some con­sumers will face a sig­nif­i­cantly higher pre­mium con­tri­bu­tion un­less they switch plans. That’s be­cause in­sur­ers are rais­ing and low­er­ing rates for 2015, and the fed­eral pre­mium sub­sidy likely will be re­based in most mar­kets. If a con­sumer was in the sec­ond-low­est-priced sil­ver-tier plan in the mar­ket for 2014 and another plan un­der-prices that prod­uct for 2015, the sub­sidy will no longer cover as much of the pre­mium and the cus­tomer will have to pay more out of pocket. On top of that, if their in­come has changed in 2014 and they don’t pro­vide the in­surance ex­change with up­dated in­for­ma­tion, con­sumers may re­ceive too large a pre­mium tax credit and have to re­pay the In­ter­nal Rev­enue Ser­vice for the ex­cess sub­sidy.

Help­ing con­sumers un­der­stand

All of this raises anx­i­eties among ex­perts who say that too many choices and vari­ables could over­whelm con­sumers, most of whom have limited com­pre­hen­sion of the sys­tem.

“The ques­tion is, how will con­sumers un­der­stand what they should do?” said Mara Youdel­man, man­ag­ing at­tor­ney with the Na­tional Health Law Pro­gram. “There will need to be a tremen­dous amount of ed­u­ca­tion and out­reach to help con­sumers un­der­stand the mul­ti­ple no­tices they may be get­ting, the new choices they may have and the ben­e­fits of com­ing in and up­dat­ing their in­for­ma­tion.”

De­spite the chal­lenges as­so­ci­ated with au­to­matic re­newal, most con­sumer ad­vo­cates and health plans ap­plaud the CMS pol­icy decision be­cause it will max­i­mize the num­ber of Americans re­main­ing in cov­er­age with­out those peo­ple hav­ing to take ad­di­tional ac­tion. Jodi Ray, project di­rec­tor of Florida Cov­er­ing Kids & Fam­i­lies at the Univer­sity of South Florida, said the his­tory of sign­ing up fam­i­lies for Med­i­caid and the Chil­dren’s Health In­surance Pro­gram shows that au­to­matic en­roll­ment is the most ef­fec­tive ap­proach to max­i­miz­ing cov­er­age re­ten­tion.

“When the in­di­vid­ual has more steps at re­newal, we tend to lose them,” said Ray, whose or­ga­ni­za­tion re­ceived fed­eral fund­ing to do en­roll­ment as­sis­tance through­out Florida for 2014.

But au­to­matic re­newal almost cer­tainly will cre­ate headaches for con­sumers and en­roll­ment work­ers. “We are brac­ing our­selves for some con­fu­sion,” said Emily Sut­ton, out­reach and en­roll­ment man­ager for One World Com­mu­nity Health Cen­ters in Omaha, Neb., which fo­cuses on en­roll­ment of Span­ish-speak­ing res­i­dents. “A lot of peo­ple we serve have a very low health lit­er­acy rate.”

What con­sumers need to know

One World has drafted let­ters and fliers to dis­trib­ute to clients de­tail­ing five things they need to know about re­new­ing cov­er­age. “Call or visit the plan’s web­site to make sure your doc­tor will be in the net­work next year,” the let­ter ad­vises. “Also, make sure any pre­scrip­tions you take will be cov­ered.” Sim­i­larly, En­roll Amer­ica, which played a ma­jor role in pro­mot­ing Oba­macare cov­er­age op­por­tu­ni­ties na­tion­ally, is cre­at­ing a check­list it will dis­trib­ute to part­ner or­ga­ni­za­tions work­ing in lo­cal com­mu­ni­ties.

In­sur­ers that dom­i­nated ex­change sales in 2014 ex­pect that au­to­matic re-en­roll­ment will ben­e­fit them.

For in­stance, for 2014 Blue Cross and Blue Shield of North Carolina signed up 232,000 peo­ple via the state’s fed­er­ally run ex­change, which rep­re­sented about two-thirds of all en­roll­ments in the state. But when open en­roll­ment for 2015 starts, the North Carolina Blues will face a ma­jor new ex­change com­peti­tor, Unit­edHealth Group. Still, the North Carolina Blues has a built-in ad­van­tage. Ex­change plan en­rollees who take no ac­tion will be au­to­mat­i­cally re-en­rolled in their cur­rent plan. If that plan is no longer of­fered, the in­surer can en­roll them in the most sim­i­lar plan it of­fers.

That makes it likely the Chapel Hill-based in­surer will re­tain much of its mar­ket share.

“The eas­ier that it can be made for them to keep (their plan) if they like it, that’s a good thing,” said Brad Wilson, CEO of the North Carolina

Blues. Web-based in­surance bro­kers are seek­ing to play a larger role dur­ing the 2015 open en­roll­ment. They were largely stymied in try­ing to sign up sub­sidy-el­i­gi­ble in­di­vid­u­als for 2014 cov­er­age be­cause of tech­ni­cal prob­lems in­ter­act­ing with Health­Care.gov. Gary Lauer, CEO of eHealth, said dur­ing a re­cent in­vestor call that his Moun­tain View, Calif.-based company has set up a sys­tem that will al­low it to en­roll “large vol­umes” of sub­sidy-el­i­gi­ble con­sumers dur­ing the 2015 en­roll­ment pe­riod. “If we had th­ese pro­cesses in place dur­ing the last open en­roll­ment pe­riod, we be­lieve we could have gen­er­ated sig­nif­i­cantly higher ap­pli­ca­tion vol­ume based on the de­mand that we ob­served but could not ad­dress,” he said.

Still, one of the big­gest con­cerns of en­roll­ment groups is that con­sumers won’t re­al­ize they need to up­date their in­come data through the ex­change web­site, and there­fore might not have ac­cu­rate in­for­ma­tion about how much they are el­i­gi­ble for in pre­mium tax cred­its and how much they will have to pay out of pocket in pre­mi­ums for a par­tic­u­lar plan. A lot of con­sumers need to up­date their in­come in­for­ma­tion be­cause lower-in­come fam­i­lies of­ten see their in­comes fluc­tu­ate sig­nif­i­cantly from year to year. “We don’t want them to get to the point where they’re go­ing to owe those sub­si­dies back to the IRS,” Sut­ton said.

There also are lin­ger­ing con­cerns about the re­li­a­bil­ity and

us­abil­ity of the ex­change web­sites given the chaotic roll­out of Health­Care.gov and many state-based ex­changes last fall. Some in­sur­ers are wor­ried about the fed­eral ex­change’s ca­pac­ity to han­dle the del­uge of re­turn­ing cus­tomers and an un­known num­ber of new en­rollees. Re­new­ing en­rollees will have only from Nov. 15 to Dec. 15 to make changes in their re­ported in­come and their plan choice if they want those changes to be ef­fec­tive Jan. 1. Some ob­servers fear that could over­load the sys­tem dur­ing the first month.

“We won’t know how good it’s work­ing un­til it’s time for it to go live,” said Wilson of the North Carolina Blues.

“No con­fi­dence” sys­tem is fixed

Mean­while, some state-based ex­changes con­tinue to strug­gle with tech­ni­cal prob­lems. Christo­pher Sch­nee­man, pres­i­dent of SevenHills Ben­e­fit Part­ners, a bro­ker­age firm in St. Paul, Minn., said ap­pli­ca­tions filed through the MN­sure web­site con­tinue to dis­ap­pear, and some clients have no idea whether they’ve suc­cess­fully en­rolled in cov­er­age. “We have no con­fi­dence that those is­sues have been fixed,” he said.

Another is­sue is whether en­roll­ment as­sis­tance groups will have the abil­ity to di­rectly con­tact peo­ple whom they helped sign up for 2014 cov­er­age. There was con­fu­sion among out­reach work­ers about how much per­sonal in­for­ma­tion they legally could keep about their clients. Many work­ers erred on the side of cau­tion and did not keep con­tact in­for­ma­tion, par­tic­u­larly in states where Repub­li­can-elected lead­ers were hos­tile to Oba­macare. That will make it a chal­lenge to con­tact peo­ple about their op­tions for 2015.

Jeremy Milarsky, nav­i­ga­tor pro­gram man­ager at Pri­maris, which helps peo­ple sign up for cov­er­age in Mis­souri, said his or­ga­ni­za­tion opted not to keep per­sonal in­for­ma­tion on clients to make sure that it did not run afoul of state or fed­eral law. That means 2014 clients will have to take the ini­tia­tive and con­tact his group if they want help.

En­roll­ment out­reach lead­ers say one les­son learned from the 2014 open en­roll­ment is that it’s im­pos­si­ble to pre­dict what types of new prob­lems will arise and when a so­lu­tion will turn up un­ex­pect­edly. For in­stance, in the four-county area around Tampa, Fla., a church serv­ing the area’s Ethiopian com­mu­nity turned out to be a boon for the Fam­ily Health­care Foun­da­tion’s en­roll­ment ef­forts. The church con­tacted the foun­da­tion, which led to out­reach events at the church and a con­nec­tion to the lo­cal net­work of Ethiopian taxi driv­ers, who spread the word about ex­change cov­er­age op­tions, said Melanie Hall, the foun­da­tion’s ex­ec­u­tive di­rec­tor.

With the 2015 re­newal sea­son loom­ing, Hall said her group plans to re­con­nect with the Ethiopian church to help peo­ple slog through their in­surance op­tions. “In cer­tain com­mu­ni­ties it’s very much a word-of-mouth ex­pe­ri­ence,” Hall said.

Den­son, the Mis­souri col­lege stu­dent, dis­cov­ered the im­por­tance of hav­ing health cov­er­age this sum­mer when a se­vere kid­ney in­fec­tion landed her in the hos­pi­tal emer­gency depart­ment. She racked up more than $4,000 in med­i­cal bills but had to pay only $200 to meet her de­ductible. She plans to con­sult with Pri­maris, which helped her find her plan this year, to help her nav­i­gate the re­newal process. “It’s pretty dan­ger­ous not hav­ing health in­surance,” she said.

Maria Elena Ve­las­coFon­taine, right, a nav­i­ga­tor with the Fam­ily Health­care Foun­da­tion, as­sists a con­sumer at an Ethiopian church in Tampa, Fla., dur­ing the first open en­roll­ment pe­riod.

Sources: Con­gres­sional Bud­get Of­fice; staff of the Joint Com­mit­tee on Tax­a­tion

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