Enrolling in Health Insurance is Complicated. That’s Where Navigators Can Help.

With the close of Open Enrollment for federally run marketplaces last week, preliminary reports suggest this year’s total sign-ups will be fewer than prior years. Regardless of where the final tally ends up, it’s likely in-person assistance played a smaller role in open enrollment, given the Administration’s deep cuts to funding for Navigators. A survey of assisters found most Navigator programs planned to lay off staff and limit services as a result of the cuts. The Administration also recently released data that calls into question the value of Navigators, noting that they accounted for less than 1 percent of customers who were signed up by federally funded navigator organizations in 2016. That number relies on a narrow definition of enrollment, including only those plan selections completed in the presence of a Navigator. And it leaves out other Navigator services that drive overall enrollment, such as outreach, help estimating income, help with data matching issues, and post-enrollment help.  But in my experience, the major flaw in the Administration’s estimate is its failure to recognize the time and effort assisters put into each and every encounter with an enrollee.

My own experience working to enroll Virginians in marketplace coverage confirms the complexities documented by my colleagues at CHIR and others. The marketplaces have made coverage available to people with pre-existing conditions and provide substantial financial help to those who qualify. But the enrollment process is far from simple. To enroll in coverage and apply for financial assistance, consumers need to have with them employment information, income information, tax information like deductions, and citizenship or residency documents. Not only do assisters help prepare the application, we educate consumers on what insurance is and how to use it. As we guide them through their plan selection process, we ask them important questions about their medical needs and priorities.

For me, appointments with consumers seeking to enroll in a marketplace plan typically last about 90 minutes. After 90 minutes, the hope is that we have gotten through the application, received an eligibility determination for financial assistance, looked through the available plans, and successfully enrolled into the best plan for the consumer. In reality, this outcome is often not the case. It is likely that I or another assister must conduct follow-up calls or meetings with a consumer to complete the process. They may need to upload income or immigration documents, or determine if they have access to affordable coverage through a job or a spouse’s job. Sometimes they just need more help enrolling into a plan after they have gone home to think it over. This process – from initial appointment to enrolling in a plan — can last weeks.

A Case Study of Complexity: Why Consumer Assisters are Vital

In one case this year, I was assisting a man who I will call John. John got a raise this year and, for the first time, qualified for his job’s insurance. Unfortunately, his wife and daughter were not eligible for the coverage, and the plan did not include any of his doctors. Worse, the premiums for his employer-based coverage were more expensive than available marketplace plans that could enroll John and his family, based on estimates of the premium tax credits they could qualify for.

But when we did the math, using his estimated income of $50,000 in 2018, premiums for his employer-sponsored insurance amounted to 9.52% of his household income – just under the 9.56% affordability cut off set by the ACA. That would make the family ineligible for premium tax credits. Between his employer plan and a marketplace plan for his wife and child, premiums alone would eat up more than one of his two paychecks each month.

As you can expect, this was very confusing and stressful for him. He could not afford those premiums, but he also could not afford to lose his insurance. I passed along my phone number and promised to research his case. We emailed, called, and texted throughout the following week as I consulted with another assister. What additional options could we give John and his family? After some research and another review of his situation, we found a small error: John does not get paid for federal holidays, but our initial income estimate had assumed he would. Subtracting those days from his income projection lowered his income just enough so that his employer insurance would no longer be considered affordable under the ACA definition. With the more accurate income estimate, John’s household income is below 250% of the federal poverty level, making him eligible for significant subsidies to pay premiums as well as cost sharing reductions to lower his copayments and deductible. With that one change, John and his family avoided potentially losing a major source of their financial stability – health insurance – and gained significant peace of mind that they could continue to see their doctors and their care would be covered.

John and his family’s situation is not unusual. Many moderate and lower income families do not work salaried jobs, making it difficult to accurately predict income. Assisters have the training and experience to identify errors, understand how they can be fixed, and work together to ensure that consumers are receiving the best service and the best plan for their needs.

Throughout this year’s and prior enrollment seasons, I have assisted many people like John.  The process is long and confusing, and small errors can mean the difference between having access to affordable coverage and no coverage at all. While brokers play an important role in helping consumers enroll in marketplace plans, the ACA created a Navigator program in recognition of the need for free, in-person, unbiased assistance for the millions of consumers who are eligible for marketplace coverage. Based on my experience, that need continues.

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