Philly health experts offer five key tips on navigating ACA enrollment

     Researchers (from left) Mike Kaiser, Charlene Wong and Cjloe Vinoya (Emma Lee/WHYY)

    Researchers (from left) Mike Kaiser, Charlene Wong and Cjloe Vinoya (Emma Lee/WHYY)

    Nov. 15 marks the start of year two of open enrollment under the Affordable Care Act. Last year’s launch was a bit of a disaster, so what’s in store for this year?

    Prologue: ‘It crashed. I crashed.’

    You wouldn’t know it from her humor and smiles, but Andrea Pearl Pinkett is in a lot of pain. Her fingers sometimes lock up; her wrists pop. Pinkett, who’s 63 years old, has been uninsured for as long as she can remember. She’s a a jazz vocalist, and she works at a fabric store in Mount Laurel, New Jersey. Without a doctor or a means to pay for care, Pinkett instead wraps her hands in fabric from the store and tries to find comfort in singing:

    Listen below to two of her favorites and why:

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    Pinkett got excited about the prospect of having access to insurance and a doctor when the online marketplaces launched last year. That is until logging on to the website during those rather disastrous first few weeks.

    “It crashed. I crashed. It kicked me off. I got depressed,” says Pinkett. “And I gave up. So no, I have no health insurance.”

    Pinkett wasn’t alone, but with round two of open enrollment just around the corner, running from Nov. 15 to Feb. 15, she and millions of others will have another chance to sign up.

    The Pulse checked in with experts who’ve been closely following the rollout of the marketplaces. Below are five key lessons from the first enrollment period that might help consumers, like Pinkett, better navigate round two (plus two bonus points for everyone).

    1. Something’s working. Tons of people have signed up for coverage.

    Despite major problems with the initial marketplace launch last year, some eight million people managed to sign up for private insurance and several million more enrolled in Medicaid through the health law’s optional state expansion.

    “We saw a significant drop in the number of uninsured,” says Karent Pollitz, senior fellow at the Kaiser Family Foundation. “I haven’t seen that in my whole career. The number of uninsured has been ramping up for decades.”

    Pollitz says the numbers point to the fact that people want health insurance and are willing to be patient and persistent. More than 100,000 people around Philadelphia signed up for coverage.

    As for the quality of that coverage and the range of provider options?

    “In Philadelphia, the plans last year generally did not focus on limiting provider choice but used tiers where you had to pay more to see certain providers,” explains Dr. David Grande, a director at the University of Pennsylvania’s Leonard Davis Institute of Health Economics. “However, the information about networks was difficult to navigate last year. It’s too soon to know how that information will be presented this year.”

    The federal marketplaces have yet to release plan details for this year, but stay tuned. That should be out any day now.

    One major change in Pennsylvania, individuals who may have earned too little to qualify for subsidies to purchase coverage last go around, but earned to much to qualify for medicaid, will now be eligible for coverage under the federally approved Healthy PA plan.

    2. The application process should be a lot easier this year.

    Since last year, the marketplaces brought in new IT contractors, and they’ve corrected a lot of the initial technical problems for consumers, according to Pollitz.

    “A lot of things didn’t go well and there have been efforts across the nation to improve the health care websites,” says Pollitz.

    The online application in Pennsylvania, New Jersey and other states with federally run marketplaces will be easier, with just 16 screens to go through instead of nearly 80, making it “more intuitive and user friendly.”

    3. Whatever you do, know the difference between a deductible and out of pocket maximum.

    …and the difference between a copay, a premium and coinsurance.

    That’s according to Charlene Wong, a pediatrician and researcher at the Children’s Hospital of Philadelphia. She closely followed a group of young adults try and sign up for coverage and found that beyond the technology, the big underlying challenge in signing up for coverage is understanding how insurance works.

    “It’s hard to explain,” says Wong. “It’s just a difficult concept.”

    She found that even savvy, college educated people, got stumped by the basics.

    “These words appear all over, all over the website, and it was clear to all of them that they must be really important,” says Wong. “But they found it really difficult to understand what these different numbers would mean for them, for example what it would mean when they went to the doctor, how much it would cost them out of pocket.”

    A deductible, for example, is typically the amount of money that people pay for any health care services before insurance kicks in and begins to pay.

    Coinsurance is the percentage of what an insurance plan pays for certain services once a person meets that deductible.

    Out of pocket maximum is the most a person would have to pay in an insurance year for all covered services. That maximum includes the money put toward a deductible and coinsurance, but not the premiums.

    Wong worries that the marketplace designers have yet to really clearly lay this out for people, even though she thinks pop up boxes and the use of narratives would really help.

    That’s concerning, she says, as the trend moves toward more high deductible health plans. Those plans tend to have cheaper monthly premiums.

    “If they don’t understand their $6,000 deductible, that means that they’re going to be paying out of their own pocket $6,000 before health insurance kicks in, that can be a really rude awakening when you seek care and realize insurance isn’t paying for anything yet.”

    4. Comparing plans was challenging last year. And it still will be.

    Wong’s colleague, Tom Baker, over at the University of Pennsylvania Law School, says beyond understanding insurance, it’s really, really hard to compare plans on the new marketplaces. As it stands, he says people have a lot to choose from – more than two dozen in Philadelphia last year – but few tools or filters to help them make critical comparisons.

    “The biggest thing I wish they’d do is I really wish they’d have more decision support,” says Baker. “I wish they could tell people what their costs would be under the different plans. I wish we had ratings that would help people know what a good choice is. Right now you’ve got to do a lot of guessing about what the right plan is for you.”

    Baker’s own research is starting to hint that as a result, a lot of people are not choosing their ‘best,’ most economical option – based on their predicted health care usage and overall costs – with the current comparison tools.

    Even when he had business students at Columbia University try and compare plans after telling them in a simulation how much health care they would use during that insurance year, the students needed spreadsheets to figure it out.

    He thinks with time, that will get better, but not by next week.

    5. Get help signing up (it’s available, for free).

    Baker, Wong, Pollitz and others all agree that the seeking help is key for making good decisions. Certified insurance navigators and application counselors can provide in person assistance for free. The federal marketplaces are also beefing up their call centers.

    “Talk to a navigator, talk to a couple different people, see what they say and then make a judgment,” says Baker. “There aren’t perfect decision support tools but .. I think you’re going to make a better choice than if you waited until the last minute to go through the website.”

    The outreach and advocacy group Enroll America found in their local and national surveys that people were twice as likely to get through the sign up process if they had help from a certified assister.

    Marieke Beck-Coon, a certified counselor with Resources for Human Development, a lead navigator agency in Southwest Pennsylvania last year, says counselors can walk people through the process and make sure they understand the implications of the different plans.

    That may take hours, she says, but they’re there to help.

    Her main concern looking ahead? Volume.

    “A ton of people could benefit from enrollment assistance, and there’s not nearly enough enrollment assistance to go around,” she says, recalling being swamped as people rushed to get help right before the enrollment deadline this past year.

    She says people will have more success if they plan ahead, and don’t wait until the last minute to get help.

    As for Andrea Pinkett, the jazz vocalist who’s still uninsured, she’s planning to do just that, seek help signing up, thanks to the urging of a friend, Suzanne Cloud. Pinkett says after hearing that Cloud, who herself got coverage last year, has since gained access to needed medications and specialists, she’s more determined this time around to get through that enrollment process.

    “To feel like someone’s going to care that you can’t move your thumbs or simply can’t get out of the bed, and that I’m going to be able to get help to keep that from happening, I could cry right now,” says Pinkett.

    Epilogue: Already have a plan? You’ll want to review it and may need to re-enroll

    Even people who already have coverage through the marketplace will need to take some steps this enrollment period to update their information.

    “We’re encouraging people, it’s five steps: review, update, compare, choose and enroll,” said Health and Human Services Secretary Sylvia Burwell on a recent visit to Philadelphia. “We’re trying to make it easy, we’re trying to make it simple.”

    A person’s age (as in, becoming a year older) and updated annual income could affect the price of a plan and what option might be most appealing.

    “If you are signed up for coverage and getting help paying the premiums, which is what about 80 percent of people with marketplace coverage are doing, you need to renew your subsidies as well,” says Pollitz, with the Kaiser Family Foundation. “If you don’t, the marketplace will continue with the amount of premium tax credit you’re getting this year. In most cases, that will be wrong.”

    Moreover, plan options and prices may also change.

    Dec. 15 marks the deadline to change a plan and have it take effect Jan. 1. If a person doesn’t do anything, the current plan will be automatically renewed. If a plan is renewed, a person still has until Feb. 15 to change coverage.

    P.S. Almost forgot, there’s something for everyone! Get ready to report health insurance on your taxes this year.

    Overall, the the health insurance marketplaces affect a small percentage of the population – those who don’t have insurance through their work. But for the first time, everyone will have to indicate whether or not they had insurance this past year on their 2014 tax returns. It’s the first year for the individual mandate, which is enforced through the tax system.

    “We’re all going to see a line item that asks if we have health insurance this year,” says Pollitz.

    People who have health insurance will receive a 1095B tax form either from their health plan or their employer, says Pollitz.

    If a person was uninsured for all or part of 2014, he or she can still apply for an exemption from the penalty.

    The other new tax form, 1095A, applies to people who received subsidies to help pay for coverage.

    “You’ll go through a worksheet on your tax form, and it will figure out the amount you’re supposed to get,” says Pollitz. “If you didn’t get enough, you can get a tax refund. Or if you underestimated you might have to pay all or some of it back.”

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