ACA open enrollment for 2015 causing anxiety for plans, providers

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.

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.”

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.

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.

Follow Paul Demko on Twitter: @MHPDemko