Implementing the Affordable Care Act: An Update to Prepare for 2015 Open Enrollment

Care Share Health Alliance Pam Silberman, JD, DrPHClinical Professor, Department of Health Policy and ManagementUNC Gillings School of Global Public HealthOctober 21, 2014

Initial Enrollment• Initial enrollment period ran from October 1,

2013 through March 31, 2014 (Note: it was extended to April 15 for those who tried to enroll during open enrollment but had problems accessing the system).▫If a person failed to enroll during open

enrollment period, he or she generally will not be eligible until the next open enrollment period (November 2014), with certain limited exceptions.

• Next open enrollment period: November 15, 2014 – February 15, 2015.

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Special Enrollment Periods• Some of the criteria to enroll in the Marketplace

outside of open enrollment include:▫ Loss of minimum essential coverage (eg, Medicaid,

CHIP, employer sponsored insurance)▫ Gain a dependent ▫ Loss of dependent status (eg, aging off parents plan

when they turn 26)▫ A permanent move to a new marketplace state▫ Release from jail or prison▫ Change in status to citizen or lawful permanent resident▫ Exceptional circumstances, including people who were

in the Medicaid gap who now have incomes above 138% FPL

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North Carolina Enrolling More than Most States into Marketplace• North Carolina had the fifth highest enrollment*

into the marketplace as of April 19, 2014: 357,584 (October 1, 2013-April 19, 2014)

• North Carolina had the 9th largest enrollment as percentage of the uninsured and those previously covered by nongroup insurance who were income eligible for coverage in the Marketplace.▫ Third highest for “non-embracing” states

• North Carolinians qualified for $606 million in health insurance subsidies. (Levitt L, et al. How Much Financial Assistance Are People Receiving Under the Affordable Care Act. Kaiser Family Foundation. March 2014. Issue Brief).

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*Enrollment defined as selecting a health plan. The federal government does not collect data on the number of people who paid the premiums.

One-Third of Enrollees Under Age 35

Age Marketplace Total

State Based Marketplace

Federally Facilitated Marketplace

North Carolina

Under 18 6% 6% 7% 7%

18-25 11% 10% 11% 11%

26-34 17% 17% 17% 17%

35-44 17% 17% 17% 19%

45-54 23% 23% 22% 22%

55-64 25% 26% 25% 24%

65+ 0% 1% 0% 0%

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Source: Addendum to the Health Insurance Marketplace Summary Enrollment Report for the Initial Annual Open Enrollment Period. (Oct. 1, 2013-April 19, 2014). http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollAddendum.pdf.

Most North Carolinians Had Subsidies and Chose Silver Plans

Metal Level Marketplace Total

State Based Marketplace

Federally Facilitated Marketplace

North Carolina

Bronze 20% 25% 17% 16%

Silver 65% 58% 69% 74%Gold 9% 9% 9% 5%

Platinum 5% 7% 4% 3%

Catastrophic 2% 1% 2% 2%

Subsidies

With subsidies

85% 82% 86% 91%

W/o subsidies

15% 18% 14% 9%

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Source: Addendum to the Health Insurance Marketplace Summary Enrollment Report for the Initial Annual Open Enrollment Period. (Oct. 1, 2013-April 19, 2014). http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollAddendum.pdf.

Racial/Ethnic CompositionRace/Ethnicity

North Carolina (Where Race/Ethnicity Known)

NC from Census (2012) (includes all incomes and undocumented)

% of Uninsured (5-year ACS)

White 66.7% 64.7% 60%

African American 23.4% 22.0% 24%

Latino 3.0% 8.7% 23%

American Indian/Alaska Native

0.6% 1.5% 2%

Asian 4.9% 2.5% 3%

Native Hawaiian/Pacific Islander

0.1% 0.1% <1%

Multiracial 1.3% 2.0% 2%

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Source: Addendum to the Health Insurance Marketplace Summary Enrollment Report for the Initial Annual Open Enrollment Period. (Oct. 1, 2013-April 19, 2014). http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollAddendum.pdf. US Census. North Carolina Quick Facts.

NC Enrollment Rates

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Small Increase in Low-Income People Covered by Medicaid/NCHC

July 2013 June 2014 Change (June 2014-July 2013)

Medicaid 1,627,452 1,730,860 103,408

NC Health Choice

156,061 79,182 (76,879)

Total 1,783,513 1,810,042 26,529

9Data from the NC Division of Medical Assistance, September 2014.

Urban Institute Showed Decline in Uninsured (Uninsured Adults 18-64 through second quarter 2014)

10Urban Institute. Health Reform Monitoring Survey. http://hrms.urban.org/quicktakes/Number-of-Uninsured-Adults-Continues-to-Fall.html

Survey of In-Person Assister Organizations in NC• The survey was sent to a total of 172

respondents, representing 138 organizations.

• Response rate was: ▫Overall: 66% for organizational respondents,

63% for individuals.▫Funded in-person assister organizations had

higher response rates

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Collaboration with Other Organizations on Education, Outreach, and Enrollment Strategies • Note: While 93% of

respondents reported collaborations—most of the respondents reported examples of joint outreach or enrollment events (and/or use of space in another agency or cross-referrals), not regular meetings to share information, plan, develop joint messaging, etc.

• Only 55% reported being part of a collaborative that met regularly (at least once/quarter)▫ Most commonly met once/month

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Ongoing Collaborations: Lessons Learned

• Collaborative partners met to:▫ Share information, best practices and work-

arounds▫ Develop materials and joint messaging▫ Identify other potential community partners to

involve in ACA enrollment activities▫ Plan joint media, education, outreach, and

enrollment events▫ Coordinate volunteers.

• In different communities, different groups helped organize the meetings, including Legal Services, FQHCs, AHEC, CCNC, hospitals, or other community collaborative leaders such as United Way. 13

Organizations Involved in Coalition (Respondents were asked to describe up to 2 collaborations)

Note: many of these organizations may be partnering on outreach or enrollment events rather than ongoing collaborations. 14

Most Important Factors to the Success of the Collaboration• The most important factors to the success of

community collaborations included (in priority order):▫ Planning together or co-sponsoring events▫ Leadership organization (or group of organizations)

that convened the group▫ Regular meetings in person or by conference call▫ Coordinating available resources (around

education, outreach, or in-person assister events)▫ Including traditional partners in the collaboration▫ Including non-traditional partners in the

collaboration15

Reported Barriers to Collaboration Other reasons given:

▫ Few other organizations in the community working on education, outreach, and enrollment assistance

▫ Not enough time to work on collaboration because time needed to conduct education, outreach, or enrollment assistance or other job responsibilities

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Most Organizations Do Not Work with Agents/Brokers

Common reasons given for not working with agents/brokers:•Concern about the quality of services or potential conflict of interest (46%)•Unsure of whether the organization can work with agents/brokers (43%)•Don’t know local agents/brokers (20%)

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Most Common Collaborations for the Respondents who Reported Working with Agents/Brokers

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Common Locations of Education, Outreach and Enrollment Assistance Location Providing

information (written or verbal)

Scheduling apptmts

One-on-one counseling or assisting people w/ enrollment

Faith organizations 76 38 46Community events or health fairs 69 43 35

Libraries 65 38 40DSS 63 36 37Community colleges/ universities 57 32 31

Public health departments 60 29 31Other community nonprofits 59 31 28Other health related organizations (doctors offices, free clinics, etc.)

56 30 30

Immigrant/ Hispanic organizations 41 27 30Hospitals 42 21 23

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Common Locations of Education, Outreach and Enrollment Assistance (cont’d)

Location Providing information (written or verbal)

Scheduling apptmts

One-on-one counseling or assisting people w/ enrollment

Senior Centers or other aging organizations

40 20 20

Worksites or businesses 41 14 13Schools or smart start programs 36 11 8Beauty parlors or barber shops 26 11 11Recreation centers/YMCAs 25 14 11Food and beverage establishments 28 6 5Door-to-door canvassing 14 7 6Parks and recreation 18 6 5

Pharmacies 21 5 4Tribal centers 13 5 6Laundry mats 18 2 2

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Successful Education and Outreach Sessions•Strategies for successful education and

outreach sessions included:▫ Advanced planning▫ Educating staff in other community agencies about the ACA,

so that they would educate their clients and make appropriate referrals. “By providing information to individuals who are in regular contact with thousands of local consumers, we were able to create a strong referral network for navigation services. Consumers were more likely to contact the [toll-free] appointment line when it was recommended to them by someone they already trust.”

▫ Having trusted community leaders involved in the event, including national or state legislators, leaders in the faith community, or other known community leaders.“[Church events] have been most successful when a deacon, pastor or other faith leader introduces us and opens the event.”

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Successful Education and Outreach Sessions• Working with the media. One respondent noted:

“Local TV news was one of the most effective ways to reach consumers. We were able to get interviewed twice on the local news station…We saw an increase in appointments that were scheduled immediately following the airing of the interview.”

• Another respondent noted:“Another avenue of success has been my relationships with the local newspapers. Whenever I do an interview or something is written that includes my contact information, many people call for appointments…I sometimes contact the reporters to let them know of new initiatives we’re working on, like special enrollment periods. It’s a good practice to develop these relationships with the newspapers.”

• Similar results were reported for radio stories.22

Successful Education and Outreach Sessions• Other interesting ideas included:

▫ ACA video played in DSS offices (Cumberland DSS). ▫ Sending information about the ACA in school

mailings (Guilford County). ▫ Close working relations with community colleges.▫ Conducting enrollment in a mall in Gaston County.

“We opened an enrollment site at our mall in Gaston County. CaroMont Regional Medical Center and Gaston Family Health Services paid for radio, print, and internet marketing. Several television news reports were done because of the novelty of the approach. Over 500 people were enrolled at that site in 3 weeks due to all the publicity and the high-profile location.”

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Outreach and Education to Hard to Reach Populations• The most commonly targeted hard-to-reach

populations included Latinos, immigrants and refugees, homeless, American Indians, people with HIV/AIDS, and young adults.

• Strategies to target hard-to-reach populations included:▫ Partnering with organizations with ties to

community.▫ Offering services in Spanish and/or providing

interpreter services.▫ Meeting with clients on site of other organizations.▫ Offering services throughout community (to help

people with limited transportation or rural).▫ Working with the media (especially Spanish media) 24

Outreach and Education to Hard to Reach Populations• Immigrant/Latino/Refugee community

“The most successful partnerships we’ve had are with Catholic Churches…, small businesses (laundromats, tiendas, etc.), and Hispanic non-profits (El Centro Hispano, etc.). Our most successful outreach approaches have been faith outreach (speaking to the congregation after mass), tabling and clipboarding at Latino ‘hot spots’ (tiendas, flea markets, etc.), and participation in Latino events (festivals, celebrations, etc.). We have also targeted citizenship classes (for SEP consumers), interpretation classes (for consumers and volunteers), and have a strong presence in the local Spanish language media.”

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Outreach and Education to Hard to Reach Populations• Homeless and people with disabilities

“We partnered with Family Services of the Piedmont. We met with FSP staff, organized information session, and then had a navigator on-site one day a week at two different FSP offices…Meeting clients on-site who already had appointments with counselors and therapists helped increase comfort/rapport and limit no-shows. Important to get buy-in from staff, then have staff refer clients to our services.”

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Challenges with Education and Outreach Efforts

•Some of the common problems included:▫ Distrust of “Obamacare” which was exacerbated by

the initial roll-out problems, and local political opposition

▫ Lack of sufficient staff and resources (and in some places, internet access) to meet all the needs.

▫ Inability to create partnerships with other community organizations, and/or problems using or coordinating resources that different agencies offered.

▫ Need for better training materials and informational resources.

▫ Lack of funding for advertising or paid media.▫ Not being able to help low-income people because the

state did not expand Medicaid.▫ Difficulties reaching hard-to-reach populations (eg,

rural, migrants, people with disabilities, etc.) 27

Suggestions to Overcome Challenges• Several respondents offered suggestions for how

to overcome the reported challenges:▫ Better planning and coordinating with other agencies▫ Try to get invited to existing meetings of churches,

clubs, employers“Speaking to a captive audience is more effective than setting up events”“We were more successful in organizing events in collaboration with other community organizations who could help get buy-in from clients with whom they already had a relationship.”

▫ Set up the timing and location of the events to better meet the needs of the targeted populations (eg, when people are getting off work, weekends)

▫ Expanding the volunteer base 28

Conducting In Person Assistance Sessions Off-site

• Most common places reported for holding in-person assistance sessions included:▫ DSS▫ Hospitals▫ Faith-based organizations▫ Libraries▫ Other health care organizations▫ Public health▫ Other nonprofits▫ Other community events or

health fairs▫ Senior centers▫ Community colleges or

universities29

Most Effective Locations to Conduct in-Person Assistance

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Use of Shared Scheduling System

Most of those who use the shared scheduling system found it helpful

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Use of the Toll-free Number to Schedule Appointments

Toll-free Number to Schedule Appointments:1-855-733-3711

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Participation in the Big Tent

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Best Practices• A set of best practices are available on the Care

Share Health Alliance website: www.caresharehealth.org

• You need to register first, and then the Best Practices are in the collaborative network tab.

• Best practices available for:▫ Community development (eg, coalition building)▫ Outreach and education▫ Enrollment▫ Training and information▫ Working with agents/brokers

• For more information contact: Megan Bolejack at CSHA

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Enrollment Data• The Assistant Secretary for Planning and Evaluation

(ASPE) released enrollment data at the zipcode level (Oct. 1, 2013-April 19, 2014): ▫ Data suppresses information for any zipcode where fewer

than 50 people selected a plan.▫ Data is for plan selection, not actual enrollment. (ASPE

doesn’t have data on who paid their premiums)▫ http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollm

ent/EnrollmentByZip/rpt_EnrollmentByZip.cfm

• Holmes, et. al. did an analysis of geographic variation in plan uptake in the federally facilitated marketplace:▫ Same methodology used to produce North Carolina map.▫ National data available at:

http://www.shepscenter.unc.edu/wp-content/uploads/2014/09/EnrollmentFFMSeptember_rvOct2014.pdf 36

Important Contact Information• Federal website to apply:

▫ www.healthcare.gov cuidadodesalud.gov (for Spanish)

• North Carolina website to apply▫ Epass.nc.gov

• Paper applications can be accessed at:http://marketplace.cms.gov/getofficialresources/publications-and-articles/publications-and-articles.html

• To make appointment with NC navigator or Community Health Center for assistance▫ 1-855-733-3711 ▫ Federal website: localhelp.healthcare.gov

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For More Information

• Pam Silberman, JD, DrPHClinical ProfessorDepartment of Health Policy and ManagementGillings School of Global Public HealthUniversity of North Carolina at Chapel Hillpam_silberman@unc.edu919-966-4525

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Questions

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Sliding Scale SubsidiesIndividual or family income

Maximum premiums (Percent of family income)

Out-of-pocket cost sharing:*

Out-of-pocket cost sharing limits (2014)**

100-133% FPL 2% of income

6% $2,250 (ind)/$4,500 (more than one person)

133-150% FPL 3-4% 6% $2,250 / $4,500

150-200% FPL 4-6.3% 13% $2,250 / $4,500

200-250% FPL 6.3-8.05% 27% $5,200 / $10,400

250-300% FPL 8.05-9.5% 30% $6,350/ $12,700

300-400% FPL 9.5% 30% $6,350/ $12,700

400% + FPL No limit 30% $6,350 / $12,700

*Out-of-pocket cost sharing includes deductibles, coinsurance, and copays, but does not include premiums, noncovered services, or services obtained out of network. Subsidies tied to the second lowest cost silver plan in the market. 40

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2014 Federal Poverty Level (Year)Family Size

100% Federal Poverty Level (FPL)

138% FPL

200% FPL

250% FPL

400% FPL

1 $11,670 $16,105 $23,340 $29,175 $46,680

2 $15,730 $21,707 $31,460 $39,325 $62,920

3 $19,790 $27,310 $39,580 $49,475 $79,160

4 $23,850 $32,913 $47,700 $59,625 $95,400

Each add’l

$4,060 $5,603 $8,120 $10,150 $16,240

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Office of the Assistant Secretary for Planning and Evaluation. 2014 Poverty Guidelines. http://aspe.hhs.gov/poverty/14poverty.cfm