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Transcript: ACA Enrollment Round II: Do consumers have the help they need?

The following is an edited transcript of a meeting with reporters that explored the availability and usefulness of in-person assistance programs (navigators, assisters and brokers) that are intended to help individuals search and apply for coverage. The speakers were:

  • Trey Sivley, division director in Georgia’s Division of Insurance and Financial Oversight Office of Insurance and Safety Fire Commissioner

  • Lisa Stein, vice president of work and family supports at Seedco, a navigator program in Atlanta

  • Dorian Martindale, certified navigator and community outreach and enrollment specialist at Meridian Education Resource Group, Whitefoord, Inc

  • Andy Miller, editor and CEO at Georgia Health News

Q: What are the differences between the 2014 and the 2015 enrollment period?

Trey Sivley: I spent about an hour before our meeting today reading the most recent guidance from [The Department of Health and Human Services]. And so this is the guidance that came out December 1. And although it is guidance to issuers it has significance to enrollees. And I want also to make note of a few of the more significant items from this most recent guidance that I think do have an impact on how navigators need to communicate or at least be aware of some of the pitfalls that may befall some of the folks who are going to be renewed.

If you are not familiar with the 2015 enrollment process, the real difference between it and the 2014 process is that if you were enrolled in 2014 and you did nothing, and assuming you were still active and paying your premiums or at least were still within the grace period, or you had not been terminated, if you have not gone onto the exchange and made an active selection of a different plan by December 15, you will be reenrolled into that policy or a similar policy with the same qualified health plan issuer. And that is not a permanent process but it's kind of the auto enrollment. So in other words you can be passively enrolled into a policy but still make an election during the open enrollment period of a new policy or a different policy. But it would be a weird situation where you may end up having kind of the auto enrolled policy for one month and then you’d move into a different policy.

The thing that is most significant out of the guidance as I was reading through it and kind of the distinctions from some of the earlier rules if you’re familiar with them is around the premium tax credits and the cost share reduction. If you did not make an election to allow the exchange to obtain some of your tax information in years subsequent to 2013 you may be auto enrolled but you won’t have your premium tax credit or your cost share reduction potentially. And that, as I understand it, that may not be as significant issue as it sounds because most people did elect evidently to allow the exchange to obtain that subsequent tax information. But those who didn’t could be in a situation where you may have a fairly significant tax credit associated with the 2014 plan year but you are auto enrolled in the 2015 plan year. And you wouldn’t have that tax credit. So that’s significant and it's something that I think everybody should pay attention to.

Additionally, if you, in the 2013 tax year, if you have household income that showed at 500 percent of the poverty level or more, you may even still be auto enrolled in a policy. But again, you would not have a tax credit. So you would really—for folks who may be eligible for a tax credit but would not get the auto enrollment tax credit because they happen to have more income than they’ve estimated for the 2014 plan year - you would need to go through the re-eligibility process if you thought that you should be entitled to a subsidy during the 2015 period. I think those are fairly significant issues as it relates to an enrollee.

There were other things that I suppose stick out from the guidance to me. One of the concerns with the auto enrollment process in my mind was because of the way it works. Starting December 1st and going through the month of December, every day it's going to send a list to all of the qualified health plan [QHP] issuers, kind of a strike list of enrolled switch list. In other words, if I am a QHP issuer and I may have some folks who are going to be auto enrolled in a plan from the 2015 year, which means I need to enroll them in a plan I need to know whether or not they switched because I don’t need to be debiting their account. Because if somebody may have [made a choice] and somehow it got lost in the fray, there’s the potential that someone’s account gets hit twice. There’s urging in the guidance that I read for the QHP issuers who are in that situation where they may or may not have folks who’ve auto enrolled or may have people who make an active choice subsequent to 12/15 to kind of delay the premium debit. So that’s interesting and may delay some of the issues that could arise if you don’t have good coordination between the exchanges and the QHP issuers.

Q: What navigation assistance is available in Georgia?

Lisa Stein: For Seedco, this is our second year operating as one of two federally-funded navigator-sponsoring entities in Georgia. We have a coalition this year of 12 community partners throughout the state. And we work really closely. There’s a second entity this year, Insure Georgia, who is based out of Macon and is also is the second federally funded navigator entity. And Seedco is also a certified application counselor sponsoring entity, which a CAC or a certified application counselor is doing the same things as a navigator but it's a different funding stream. So we really benefitted from having the first open enrollment under our belt. We spent a lot of time with our partners really evaluating how things went, what worked well, what didn’t work as well. Seedco operates, as Marilyn indicated, in New York, Maryland, Georgia, and Tennessee. And so we sort of had our own lab. We had two federally funded marketplace states, two state-based marketplace states, two states to expand in Medicaid, two states that did not, urban territory, and rural territory.

So we commissioned the University of Georgia to do an evaluation across the four states. And so they looked at data we had collected in all four states. They interviewed consumers who had consented in all four states. And they interviewed navigators in all four states. A full report is available on our website. But some key findings that really came through across all of those states and was pretty consistent was that people really appreciated in person assistance. Often navigators were the only human interaction someone might have with the marketplace. Folks who are not—the assumption might be that they were being driven there because the technology was not working so well. However, most people hadn’t even attempted an online before they came to a navigator. In general, health literacy is really low. Seedco has really invested a lot of training of our navigators on how to do health literacy communication. And so, for example, in year two we’re developing a visual graphic tool to use with consumers to help explain terminology and concept.

And what we find is that the point that a consumer gets enrolled that there’s two major questions. What do I do with this card? How do I use it? And how do I pay for these services? And so I think the importance and the value of that interaction and that assistance, and I think what also became clear in the study and a role you all can play, is that people were generally not aware that there was free assistance available. And I think an important distinction about navigators and some CSCs is that it is unbiased, free assistance, and that anybody if you’re applying for a  subsidy, not applying for a subsidy, have a complicated situation or not is eligible for the service. And people just didn’t know. And I think we were so concerned in the first open enrollment and we weren’t sure about traffic and resourcing and capacity, there’s a lot of driving people to the website and the call center versus making sure people were clear what a navigator was and what they could do for them. So I think a big piece of what you all can do is to continue to get that message out there.

To kind of spin off of what Trey indicated, what’s different this year is there are some folks that need to renew. And a big piece of the messaging we’ve been doing around that there’s more choices in the marketplace. You could potentially probably get a better plan and a better deal. So we’ve been trying to market it that way. But again, you’re sort of fighting against human behavior to sort of default to the easiest solution.

I think another challenge we’re facing this year in open enrolment is that it's significantly shorter. It's three months instead of six. And it will be the first year that some people will face a potential financial penalty for not making a choice. Their income may have varied and they may find out that they have to make up for some of the tax credit or subsidy at the end of the year. And then for some people who made no choice in year one the penalty will increase in year two and probably the point of education on that will be tax time. And open enrollment ends February 15th and taxes are due April 15th. So default human behavior is to wait till the last minute. Those first two weeks of April will be too late for the open enrollment period. So I think you all have a really big role to play around that.

Q: As a navigator, how are you reaching consumers, and what are the challenges?

Dorian Martindale: At Whitefoord, in our family medical center, in our elementary school clinic, in our middle school clinic as well. There’s a lot of things going on under the Whiteford umbrella but particularly with our primary care providers. We train them to be able to ask the proper questions and to look at our scheduling system because everything is switching now from paper records to electronic records to see if the patient that they’re going to enter the room with is insured or uninsured.

So their role basically is to ask questions of the patients that they see to determine whether or not they are consumers that we as navigators need to see. You know that there are income guidelines and that income is based upon the number of people who are in the tax household. These are some of the things that we had to educate our providers to be able to ask about and to sort of prescreen them. Some of our providers jumped on board. Some of them were, I guess I could say, uncomfortable. So we learned a couple of days later, if you will, that it's probably the best thing for our providers to do is to have something that they can put in patients’ hands that sort of go over those guidelines, over the income requirements, go over the tax penalties, if you will, to make sure they understand. If you can afford coverage and you elect not to have coverage this is the penalty that you could be subject to. If you earn this much money and you have this many people in your house this is what you may qualify for a subsidy. Just to give them a one pager, quick hit to be able to, if the patient has to wait for the provider to come in they’re there in the room waiting for them. They’re in the lobby. They can have access to them. And so those that were not as comfortable as others with regard to our primary care providers with discussing the information they still had a way to bring up the subject with this one pager that we provided for them.

Q: What should reporters pay attention to in 2015?

Andy Miller:  I look at this from a reporter standpoint. And the one thing I caution everybody to think about is people tend to blame Obamacare for just about anything regarding health insurance and health care. And I just want to caution reporters to be thinking about that when they talk about—when people talk about, well, my doctor is no longer in my insurance company. And I can’t see my favorite hospital. And they may not even be in one of the exchanges. But the fact of the matter is that some of the problems that are happening with insurance in the exchange are happening in the private marketplace. And so it's important to make distinctions. But in general, as a reporter I look at some of these issues and I come up with questions and I come up with story ideas that I’d like to either write or that I’d like to read. And one story I’d like to know is from what I’ve seen and what I’ve heard anecdotally that the enrollment so far has not been as robust as a lot of people were hoping it would be or thought it would be. And that’s one question I have is if enrollment is down why is that, because we’ve only got three months this time.

Another big difference this year is the penalties. And the more I think about this, Dorian talked about this earlier today, and the fact is that people are facing big penalties this year versus last year for not having insurance. When people get their statement or their tax returns this year it's only—if you don’t have insurance - it's only 95 dollars which is like what, the price of a traffic ticket or one percent of income, whichever is greater. Now for this coming year, 2015, if you don’t have coverage it's two percent of income or $325, whichever is greater. And for most people it's going to be the two percent. And that’s going to be hundreds of dollars. So my question of navigators is, are they explaining that to people who are reluctant to sign up for coverage because that’s a big amount of money?

We talked earlier today about the networks involved and whether doctors - your doctor - is going to be in there in terms of the insurance company that you choose. And if you go online and you get to the insurance company’s provider list and you read the list of doctors, and you see your doctor on that list it may in fact not be a current list. And so what consumers should do and what journalists should look for is that issue because a lot of these networks change all the time. It's happening in private insurance as well as in the ACA. And consumers need to really call their doctor’s office to make sure that they are actually part of the plan that they choose. We have a lot more competition in Georgia in the exchange among insurers. It is supposedly leading to lower prices. Is that really pumping demand for these products versus last year where we had—in Southwest Georgia we had the second highest premiums in the country. The only area that was higher was the ski resort areas of Colorado. And so one thing I would like to know is how are enrollments going in that area now that they have three or four insurance companies selling products?

I’d also like to know what the outreach is to ethnic groups that were hard to reach the first time. What’s the outreach to rural areas that didn’t have many signups at all last year in Georgia, and in other states. And one big thing that’s in my mind that I don't know if it's in consumers’ minds is the Supreme Court. And the question is, is that entering people’s mind at all in terms of both the people that are guiding consumers and also consumers themselves? Do they think that this thing is going to—the whole thing is going to get thrown out? Does that dampen demand? So those are some of the stories that I would like to read and I’d like to write. And I think there’s plenty of material here and we’ll find out a lot more certainly when HHS gives us some numbers in terms of the first month in terms of how many have signed up and how many Georgians have signed up and whether they’re new people and were uninsured this past year or whether they’re so-called the people that had formally got the policy last year. So thank God we don’t have to write about a broken website this year. So we got rid of about 20 stories there.

Q: What are the different kinds of consumer helpers out there? We hear the words navigator, in person assisters, we hear brokers. And when we’re talking about navigators I believe all of them have to be licensed.

Lisa Stein:  So navigators are federally funded in person assistants and we are in the federally funded exchange states. Every state at least chooses two organizations to be the sponsoring entity and receives funding based on a formula of number of uninsured and provides assistance. Specifically a navigator is to conduct outreach in education and enrollment assistance in an unbiased [manner]. We are not working on commission. We are not working for insurance companies. And we are not telling people what to choose. We are helping people make an educated choice. A certified application counselor can perform all of those same duties and is commonly referred to as a CAC. CAC’s are housed in many different organizations. The qualified health centers, hospitals often have CACs on site. In addition, Seedco, we’re also a CAC sponsoring entity. And so from our perspective those folks are doing the same work as a navigator. They’re just receiving—we’re receiving private funding to sponsor those efforts versus federal dollars to sponsor those efforts. But on the interface with the consumer it's exactly the same. In hospitals and in health centers it's obviously part, as my colleague spoke to, about an integrated approach to working with patients and making sure they have what they need, and that they can get their healthcare. And obviously in healthcare and hospitals there’s obviously a financial incentive to making sure that people are enrolled in some sort of medical coverage.

Insurance brokers can also be licensed to operate and sell products in the exchange. And certainly my colleague Trey can speak more to that. Specifically there’s sort of—for Georgia - there’s two licensures. So any one who is either a counselor or a navigator does receive a federal training and a federal certificate. The sponsoring entity can choose to provide additional training, which Seedco did because we knew low health literacy was going to be a big issue. In addition, in Georgia we received a state license where we do some additional training and background checks are conducted and we received a Georgia license.

Q: Dorian, you said that you are less busy this year. Why?

Dorian Martindale: Unfortunately, this time last year and in the months preceding the beginning of open enrollment, which was October 1st last year my calendar was booked solid with churches and community centers and radio forums, TV appearances. I mean anything you can imagine. I remember turning on my TV one day and taking my phone and recording the fact that Magic Johnson was on TV talking about the health insurance marketplace. So it sort of seems like the newness has worn off for this go around. So really it's you guys that I guess we’re sort of depending on to help, as you said, bridge that information gap. We’re still doing outreach where we’re invited. Some places we go to initiate outreach. So there’s still those of us who are committed to getting it out there. I just personally wish more of the people who had the platform for getting it out there to the masses in one fatal swoop. We’re still as interested in it as they are in Kim Khardashian’s butt going viral as you put it.

Lisa Stein:  We are working constantly to do better outreach. And I think we have to think about non-traditional points of entry. Our study did find that across all four states about 63 percent of folks had deferred two or more healthcare visits in a previous year because they couldn’t afford it. So you’re right. If you’re not going into the doctor because you can’t afford it sometimes navigators also help people do a hardship exemption especially in Georgia where there’s a Medicaid gap. It just might not be an option. But it's also our challenge to then go find those non-traditional points of entry. It might be a church. It might be a shopping center. We’re certainly trying to push ourselves out of our box and find creative ways to do it.

We’re two weeks into open enrollment. So we’re just starting to get our data and get our group going. I mean I think that there’s some percentage of folks for whom urgency is there. They want their coverage to continue. They know that they want it active on December 1st. And then I think that there’s still a huge piece of the population that just, again, it isn’t in their scope of this is what I need to have. I haven’t ever had it. My parents have never had it. It's not something we’ve grown up having. And so there’s a consumer learning curve. And I think we’re working with that. But I do think it will be a problem. I mean we’re hoping to try to generate the buzz ourselves in these other creative ways so that we know that there will be a last surge. There was a last surge last year. It's going to happen sooner. It's going to happen quicker. And it’ll be less time to really deal with it.

Andy Miller:  I was going to suggest, you know, journalists are looking for good stories. And people like yourselves will come across a good story, a good sign-up story, whether is reaching Asian Americans, which I guess was a low enrollment ethnic group last time. In other words, a navigator goes to an Asian American church and signs up a bunch of people that would be a good story. Or, we talked about the penalties. If a navigator comes to somebody and says, look, if you don’t get insurance you’re going to be paying hundreds of dollars next year. And they sign up. And maybe that person would talk to a reporter. So we can go to all these enrollment events from now until February 15th but if there are good stories that kind of sift their way through that you guys can contact us. And say I’ve got a good story that I think will help us tell a story as a person in the media, but also help get the message out to your community.

Q: Georgia has one of the highest rates of uninsured residents. And of course, [Insurance Commissioner] Ralph Hudgens famously said that he was going to do everything possible to obstruct the implementation of Obama Care. So I’m wondering, what is the state doing to try to educate consumers or to assist them? And if you have consumers who call the state insurance commissioner to try to get information about the exchange what happens to them?

Trey Sivley:  It’s not something that I can really comment on. Regarding the mechanics of how the ACA works and when it comes down to consumer interactions we inform them where to go.

Q: Do you send them to the navigators?

Trey Sivley:  Yeah. If that is the appropriate place to go, yes. So, let me give you a for instance, and it's not uncommon that say someone would call into our consumer services and say I need to change the address or something on my policy. I tried to call the company. I can’t get it done. Well, you call the exchange. The exchange is the one who does that and changes those kind of records. So whether it's simple questions like that or something more fundamental I can access this and that will be a situation where our consumer services division would say, here’s where you can access these resources. It's something frankly that I think our consumer services division has done throughout the period leading up to January 1, 2015. So setting aside policy, politics and all those other things that’s information that’s been given to consumers and will continue to be given to consumers assuming there are not laws or anything else that come into play that would have an impact on our ability to do that.

Q: Have the people in your office actually be trained to know how to answer the questions and who to send them to? How can consumers be sure, or we as journalists looking out for the consumers, be sure that people are getting to the right person?

Trey Sivley: One of the things that we had to figure out was a way to triage. I need to change some demographic information. Well, you’d need to go to the exchange for that. Now a consumer may think, well, why can’t I go to the insured. They’re the ones that I have the contract with. Well, you would have to go to the exchange. So interfacing with insurance companies, to a certain extent the exchanges, but that gets done based on some of the guidance that’s given out. But the information that our consumer services gives is I think accurate as it can be. I mean guidance comes out all the time that does change things. And it's tough to keep on top of all of that. But I think generally speaking that people get routed to the right place. And whether that is to a navigator or to the exchange or elsewhere that happens. We still regulate rates. We regulate what’s in the plans. We still regulate market conduct, still regulate solvency. We still regulate the insurance industry. And so while you don’t have maybe a specific enforcement of ACA that’s not—that’s really I don’t think all that relevant to a lot of the consumer issues we deal with.

And so I would say that people get the right information. I follow this pretty closely. I’ve been dealing with people, preparing for a long time as a regulator and also a practicing attorney. I’ve seen all sorts of exchanges and all sorts of states. So I feel like between myself and several others in the department we have a good battery of people who have a good understanding but also we have a lot of resources. The National Association of Insurance Commissioners, if you’re familiar, is a national body that all the insurance commissioners belong to. They keep the departments up to speed on a lot of the stuff that’s going on, consumer impact issues, this guidance that came to me today in an email. So I would say that we have resources and we utilize them to make sure we’re staying abreast of everything, and pass the information onto consumers.

Q: We’ve heard that there’s been kind of a backup or a delay in getting some of these navigator licenses processed through the insurance department. Some navigators have put their applications in and have waited for months to get them processed and finally approved. Is that true? And if so, what’s being done about that?

Trey Sivley:  I actually tonight heard the issue for the first time. I don’t really have my hand on that pulse but I’m going to go back and talk with folks. But certainly it's not anything anyone has come up with a policy or anything like that. I think that’s not something, which I am aware and I certainly don’t think that’s the case. But I think it's just an issue of just kind of a bureaucratic issue to deal with. And so we’ll deal with it. Hopefully, it will not have a negative impact on people’s ability to access the navigators.

Q: Do navigators actually teach people how to use insurance because a lot of these people are getting insurance for the first time?

Lisa Stein:  I think navigators are equipped to do some post enrollment assistance and there certainly are folks who’ve had a good experience with their navigator. We had a lot of consumer calls in February and March when people started to get their insurance and use their plans. There were some issues around sort of what we touched on earlier. They thought this specific doctor or hospital took the plan they purchased on the marketplace but when they actually called the doctor’s office or the hospital they weren’t part of the network, and so sort of figuring some of that stuff out. But what we’re also finding again, and I come back to what our study found and what other national organizations have found, is that folks have low health literacy. So what do I do? When you think about even when you have insurance through your employer there’s an HR director. And I know every time I have something. I hit my first stumbling block. I just go to the HR director and I’m like what do I do. And I think folks who have never had insurance need someone like that. And so there’s some role to play. I think there’s a lot of groups out there who are trying to do that work in conjunction and coordination with navigators. I mean I think the demand is difficult. I mean a priority for navigators and folks doing enrollment, and right now it was enrollment. And that’s a lot of technical expertise to get someone through the process. And enrollment isn’t just during open enrollment. You can have a qualifying life event year around. Obviously demand is different. And so we have some more capacity when it's not open enrollment.

Q: Is there a shortage of navigators?

Lisa Stein: In Georgia there are approximately 30 to 40 federally funded navigators for the entire state. That’s not enough people to help the hundreds and thousands of people who need insurance, and who are using it for the first time. And that’s not including the federally qualified health centers. And even if you put all of us together that have some federally funded I think we become just shy of one person per country. So I do think that that there is a need for more personnel to do that because in New York in one of our New York programs we do have a post enrollment counselor not funded with navigator funding. And the number one issue he’s dealing with, the number one reason people are calling him is how do I find a doctor? How am I supposed to—what’s my—like what do I do, physically do, with this card?

Dorian Martindale:  As a navigator when I sit with an individual the first thing that I ask them is how I can help them. During the course of that assessment, if you will, I am gauging what their knowledge of health insurance is. Once we get the application submitted and we actually start to shop the policies it's a part of our responsibility as a navigator to make sure they understand the terms deductible and premium and to understand the difference between bronze and silver and gold and platinum plans on the marketplace. So my role in assisting them beyond just submitting the application and getting the eligibility determination and selecting a plan it starts in that initial encounter and any subsequent encounters that occur in order to get this person covered. One of the last things—well, one of the things that I do to avoid all of that because last year we did run into the problem of there being a different network of providers and consumers weren’t finding it out until they were actually at their preferred provider’s office. And their provider said, ‘oh, we don’t accept that one because it was purchased on the exchange.’ One of the things I started doing as soon as I got wind of that is, beyond going to the carrier’s provider directory, I actually took the time to call the provider’s office while the person was there, while they were still considering making the purchase so they wouldn’t get surprised after they had made the purchase and enrolled in the plan.

So before we enrolled them in anything we got as much information for them as possible. When they left our application submission appointment they left there with what we call a form that I created called the applicant information sheet which had everything that they did in that appointment. If we had to set up a new email address for them, the new email address was there. The new email addresses password was there. The marketplace user name and password were there. In the notes section, if we had to call the marketplace the person that we spoke with and the time we contacted them was notated on that sheet that they left that office with on that day. So with regard to helping them become more health insurance literate and to know exactly how to use the information I think as a navigator it starts as soon as you sit down with that person. Now some organizations were funded and utilize their funding in a way that navigators were on staff year around. I work for an organization where we are on staff year around. I know some navigators in the state work a full load or some staffs were reduced. But we were on staff year around. And again, I work in a federally qualified health center so there are people coming in there to see doctors who can see us at any time if they have any questions.

But one of the last questions that I would ask is if there’s anything else I can help you with please let me know. If there was nothing at that point because sometimes we’re an hour, two hours, three hours, depending upon the size of the family and how many individuals were applying for coverage into this appointment. But when they left there they also had my contact information so that they could contact me. And I made sure that the consumers understood no matter what it is you need if you need help with any aspect of using or renewing your coverage please call me. And every form that I gave them had my personal contact information, my business card was in the folder that I sent with them when all of the things, eligibility determination letter, and applicant information sheet, and the Q&A sheet that we gave out. So we do have a role to make sure they understand beyond submitting the application and enrolling how to go about using it. And I think that we developed some things last year and we’ll continue to use some things this year that will make sure that we’re serving the consumer beyond just getting them enrolled in coverage.

Q: Is there a formal tracking mechanism for what you do?

Dorian Martindale:  The quick answer, no, not one that we utilize internally. What we did do was we kept track of the individuals that went from uninsured to insured and we tracked their movement through our facility. So if they came in at the front desk uninsured, they saw the provider. We know that they saw the provider. If they saw the navigator then in that system we see that they saw a navigator. And then at some point during the next year or the course of the year if they then became insured then we kind of pat ourselves on the back because we would get that email to say hurrah, hurrah, we have this many new insured. So yes and no, I guess. We track it ourselves internally as much as we possibly can just because somebody who is seen at our clinic goes from being uninsured to being insured, and saw a navigator. We report our enrollment numbers to the [Health Resources and Services Administration at the Department of Health And Human Services.] We report monthly to HRSA and internally we report to our superiors.