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Questions and Answers about Patient Enrollment in Health Insurance Marketplaces
- Why should physicians help patients enroll? I'm a doctor, not a social worker.
- Where can I direct patients who have detailed questions about health insurance enrollment?
- My patients are very low-income. Will they be able to find coverage?
- I have a lot of patients who speak a language other than English. Are there resources to help them to enroll in coverage?
- What are some other resources I can use to help answer my patient's enrollment questions?
1. Why should physicians help patients enroll? I'm a doctor, not a social worker.
Prior to implementation of the Affordable Care Act, about 50 million Americans were uninsured, and millions more had insufficient insurance. Adults without health insurance are less likely to receive clinical preventive services that can reduce the likelihood of developing serious illness. Those with chronic disease are more likely than the insured to forego necessary therapies. Uninsured adults are also more likely to die from serious acute conditions than those with insurance. Lack of health insurance also takes a financial toll, as 60% of all bankruptcies are connected to the cost of medical care.
You want the best for your patients. Learn the basics about how the health reform law can help patients get coverage and let your patients know what is coming. Once it's time for them to enroll, consumer assistance resources will be able to help them.
2. Where can I direct patients who have detailed questions about health insurance enrollment?
Choosing a health insurance plan is an important decision and patients may need assistance to pick a plan that fits their needs and budget. Consumer assistance organizations, called Navigators or in-person assisters, are on hand to raise awareness about coverage options; help your patients fill out application forms; determine if your patients are qualified for financial assistance; provide impartial advice on choosing a plan; and refer your patients to the state Medicaid agency, ombudsmen or other assistance organizations as needed. Other entities called certified application counselors may include staff from community health centers, hospitals, and other health care providers, trained to educate consumers about their coverage options and help them complete applications. Provider organizations can apply and train to become certified application counselors. Health insurance brokers may also provide insurance information and assistance. The Marketplace call center can answer patient inquiries and ultimately help patients with their insurance applications and health plan selection. The center is staffed with personnel to answer questions in 150 different languages. The call center number for federally-operated marketplaces is 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325) If your patient has a question about health insurance enrollment, refer them to the appropriate consumer assistance organization.
More information can be found here:
Contact information for health insurance Navigator programs can be found at https://localhelp.healthcare.gov/ or your state's marketplace website.
Also check the State information page for patient enrollment guides.
What information should patients have to help them make an informed decision on selecting the health plans that's right for them?
To apply for coverage, patients will need their Social Security number, information that proves legal residency, and their household, employer, and income information. A Marketplace Application Checklist can be found here. They should also collect information about providers they want in their network, medications requirements, and other relevant benefits. Patients should also review plan benefit packages and educate themselves about insurance terms, such as deductibles and copayments. Marketplace-based plans are required to provide a provider directory, so patients will be able to know if their preferred physician is in the plan's network. Navigators and other consumer assistance organizations can assist with necessary information.
3. My patients are very low-income. Will they be able to find coverage?
The ACA mandated that all states expand Medicaid coverage to all individuals with incomes up to 138% of the federal poverty level or about $16,394 of 1 person or $33,534 for a family of 4 in 2016 dollars. However, the Supreme Court's struck down this provision but gave states the option to expand. As of October 2016, 31 states and the District of Columbia are expanding their Medicaid programs and 19 states are not expanding at this time. This means that in states that have not expanded Medicaid, the poorest residents (those with incomes up to about $11,880) will have no other way to get coverage, resulting in poorer health outcomes for them, more uncompensated care for the hospitals and physicians who take care of them, more cost-shifting for us, and ultimately, higher cost to the state. Medicaid-eligible individuals in non-expansion states will not be subject to the individual mandate penalty.
ACP strongly supports the Medicaid expansion. If your state has decided against expansion or remains undecided, contact your ACP state chapter and become involved in ACP's Medicaid expansion advocacy campaign. If your state has decided to expand, your patients can sign up for coverage through their state's marketplace or traditional channels such as your state's department of social services.
4. I have a lot of patients who speak a language other than English. Are there resources to help them to enroll in coverage?
The ACA requires that marketplaces provide services and resources for people with limited English proficiency. The federal government has created numerous resources for non-English speaking patients. Among them, a Spanish language version of healthcare.gov (www.cuidadodesalud.gov/es/) and resources in other languages (https://www.healthcare.gov/language-resource).
The CMS Marketplace has fact sheets, posters, brochures and other materials in many languages, from Arabic to Creole.
A call center (1-800-318-2596) will be staffed to answer questions in 150 languages.
5. What are some other resources I can use to help answer my patient's enrollment questions?
The Kaiser Family Foundation has created an exhaustive list of frequently asked questions regarding ACA enrollment.