By Cyril Tuohy
A fascinating behind-the-scenes look at some of the challenges facing health insurance marketplace assisters points to the frustrations and rewards of workers on the front lines of implementing federal and state health insurance exchanges over the past 12 months.
The experiences of employees in so-called marketplace assister programs were collected from a June roundtable and compiled in a 17-page issue brief titled “Taking Stock and Taking Steps: A Report from the Field: After the First Year of Marketplace Consumer Assistance.”
Many of those employees are gearing up for the second enrollment period of the Affordable Care Act (ACA). Government officials are working to smooth out the kinks as the Nov. 15 individual enrollment period approaches.
The brief — prepared by Rachel Grob of the University of Wisconsin at Madison, Mark Schlesinger of Yale University, Karen Pollitz of the Kaiser Family Foundation and Lori Grubstein of the Robert Wood Johnson Foundation — was published Oct. 1.
In the brief, assisters describe the barriers to insurance literacy as “huge,” with consumers unfamiliar with even the most basic workings of insurance, from how deductibles work, to why premiums must be paid every month, to understanding ACA cost-sharing subsidies.
Community outreach was also critical, according to the report. Assisters had to interact with consumers multiple times. Assisters also had to accompany clients in person or on the phone through the entire enrollment process.
Linguistic barriers were high as well, the assisters reported. Application materials were not translated, interpreters were in short supply and call centers often were unable to communicate with non-English speaking consumers.
“Participants suggested translation into multiple languages in time for open enrollment 2014-15, consistent availability of interpreters at call centers, and appropriate services at all levels of the system for people with disabilities,” the report's authors wrote.
Assisters said it was important — if not always easy — to stay ahead of rapidly changing regulations, guidance and practices. Assisters also reported that if they suspected a mistake, it was difficult to follow up or appeal to the Centers for Medicare and Medicaid Services.
Service provided by call centers was uneven, the assisters also said. They reported some call centers keeping up with huge call volumes while other centers were hobbled by long wait times, inconsistent guidance, a shortage of translators and confusion about state Medicaid policies at federally-run call centers.
Assisters recommended dedicated lines and a triage system to improve the handling of complex calls, particularly with so many consumers needing answers to complicated questions.
The report also said consumers had many questions about tax implications such as deductions for self-employed workers, and that even the questions were sometimes beyond the scope of an assister’s ability to help.
Immigrants, senior citizens and the disabled who faced complicated eligibility requirements were a challenge to enroll, the assisters said at the roundtable.
In all, about 4,400 marketplace assister programs employed more than 28,000 full-time-equivalent staff and volunteers around the country. Assisters included consultants, financial advisors, brokers, auditors and tax experts.
Assisters said the marketplace needs more tools to help consumers choose among the health insurance plans available in four tiers: platinum, gold, silver and bronze. The tiers help consumers distinguish the level of coverage.
“Cost sharing information proved particularly tricky to parse when many different plan variations were offered,” the authors of the report wrote. “Differences in plan provider networks could also be challenging to evaluate.”
There were many promising initiatives, however, such as the one used by the Illinois marketplace. It allowed consumers to search for plans based on whether a medical provider is in the network, the report said.
In Connecticut and Texas, partnerships with insurance brokers helped assisters understand how the plans worked.
Assisters said that consumers, once enrolled, often returned with questions and concerns about communicating with insurance companies, how to use the new coverage, logistics around premium payment, and appealing denied claims.
"Assister programs should remain as part of the permanent infrastructure of the ACA as consumers will need help picking their way through coverage mandates," roundtable participants said. "Enrolling consumers successfully and making sure they stay enrolled will create lasting demand for substantial marketplace assistance.”
A steady, permanent, wage-earning workforce would cut turnover, which was as high as 80 percent in one call center, they said.
Cyril Tuohy is a writer based in Pennsylvania. He has covered the financial services industry for more than 15 years. Cyril may be reached at [email protected].
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