Obamacare navigators will face tougher second enrollment period

After last year’s ugly rollout of the healthcare marketplace, the Obama administration is no doubt counting on a smoother course for its second enrollment period.

The technical glitches that bedeviled HealthCare.gov a year ago may be largely gone. But those tasked with signing up consumers in health plans are sure to face plenty of challenges for the second open enrollment go-around. Throughout the Marketplace’s first year, healthcare navigators served a vital function. These workers, trained with federal grant funds to help consumers analyze insurance options, helped shepherd people through a new and cumbersome process.

“In-person assisters have an impact on the lives of so many Americans, helping individuals and families across the country access quality, affordable health coverage,” Health and Human Services Secretary Sylvia Burwell said in a statement.

According to a July Kaiser Family Foundation survey of the health insurance marketplace assistor programs, more than 4,400 of them, employing over 28,000 full-time-equivalent staff and volunteers, helped an estimated 10.6 million people during the first open enrollment period.  The navigators typically work in local libraries, churches and food bank offices.

Over 80% of those programs reported that most consumers who sought help didn’t understand the ACA or the coverage choices offered them, or simply lacked confidence to apply on their own. Almost 90% of programs reported the majority of consumers they helped were uninsured. (There are different types of assistor programs that provide outreach; they include navigators, in-person assistors and certified application counselors. Each receives training to provide enrollment assistance to consumers, but they differ in the extent of their duties.)

HHS announced this month it’s giving $60 million in grants to 90 nonprofit groups that hire navigators and assistors nationwide. That’s down from $67 million for the first enrollment cycle.

New challenges

In some regards, navigators and assistors, considered the backbone of Obamacare’s ongoing outreach effort, are likely to have a tougher job this year for a few reasons.

“I think the biggest challenge for assisters will be to help more people with more tasks in half the time,” says Karen Pollitz, senior fellow at the Kaiser Family Foundation. The coming enrollment lasts three months (Nov. 15, 2014 -- Feb. 15, 2015), compared with six months for the launch.

Many of the consumers who haven’t yet signed up for a plan are the hardest to get to. The 8 million newly insured people were the easier targets – out of more than 47 million nonelderly Americans who were uninsured in 2012 – and the 5 million people who the Congressional Budget Office forecasts will enroll for 2015 coverage may be less informed and resourced than the initial enrollees. And if that’s the case, consumers may require even more help from assisters than they did last year, Pollitz says.

Another unknown is continuity among assistor-navigator programs. People who worked as assistors and navigators last time can work more efficiently because they’re experienced and have established systems and procedures. But almost 40% of 2015 navigator programs that received federal grants are new, which means these groups and the navigators they hire “will have to master the learning curve,” Pollitz says. And again this year, HHS awarded the navigator grants late in the season, so time to prepare for the second enrollment period is limited.

“All these factors suggest a net increase in the workload, and intensity of workload, for this next class of marketplace assisters,” Pollitz says.

The ABCs of health insurance

The chief hurdle for navigators last year was a lack of consumer awareness and understanding of the law. A recent survey by Transamerica Center for Health Studies shows this ignorance hasn’t dramatically abated. It found that 46% of those who remain uninsured have still not heard of the individual mandate, and 43% haven’t heard of the health exchanges.

Answering questions about what the ACA was and its impact on consumers was the most important part of many navigators’ jobs in the first go-round, and it’s likely to be so again this year.  Fully comprehending the details of an insurance plan can be a struggle for someone who’s had it their whole working lives, but for those who’ve never carried an insurance card, it’s a whole other language.

Julie Leon, a navigator with the Ohio Association of Food Banks, last year helped enroll many people who had been uninsured before the ACA kicked in. Explaining the basics of having health insurance  was a prodigious effort, says Leon, who plans to work as a navigator again this year.

The slogging nature of navigators’ work has been universal. “Getting into the basics of insurance with an individual who’s never had insurance is complicated,” says Jodi Ray, principal investigator for the University of South Florida Navigator grant. (USF got a $5.38 million grant, the largest in the country.) “You’re talking about deductibles, co-insurance, how do you pick a network, a plan. It’s very time-consuming.”

Shopping for a health plan involves evaluating multiple price points – for instance, some plans have lower premiums but smaller doctor networks, while others have higher premiums but lower co-pays – adding another layer of complication to navigators’ work.

“That conversation really takes a long time – longer than we ever anticipated. Oftentimes it took several visits,” says Zach Reat, who oversees the navigator program at the Ohio Association of Foodbanks, which received a $2.18 million grant this year and $2.05 million last year.

Tax complications

For the second enrollment period navigators expect inquiries similar  to those they received the first time around, along with an increased focus on questions around tax subsidies.

Insurers are sending customers auto-renewal notices now, and many, if not most, of those already enrolled should go back to Healthcare.gov to review their plan choices and subsidy eligibility, says Pollitz. Plans and premiums have changed. Consumers who don’t review their options may get the incorrect credit amount for 2015 and risk over-collecting on the subsidy (which they’d have to ultimately pay back) or not collect all the subsidies they’re entitled to.

For example, if a consumer received subsidies for a silver plan last year that became cheaper for the following year, they may end up owing the IRS money when they file their 2015 taxes, even if their own income remained steady, Pollitz says.  Also, consumers’ subsidy eligibility may change if their income for 2014 looks like it will be significantly higher or lower than they estimated originally.

Though navigators aren’t tax experts and are not tasked with helping consumers file their tax returns, they have to be ready to answer these kinds of questions, Ray says.

“Navigators need to take time to be sure that consumers walk away with an understanding of how to pick a plan and what they do with the plan once they get it,” she says. “It’s not just filling out a form.”

Read more in our Obamacare series:

The Obamacare marketplace one year later: How you’re faring

How to see through opaque health care costs

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