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ACE TA Center Enrollment Tools Webinar Series Q&A

September 2014

ACE TA Center

ACE TA Center

In July 2014, the ACE TA Center hosted a webinar series to introduce new tools and resources for health insurance enrollment. During the four webinars, many questions were submitted via the chat function and the post-webinar evaluations. These questions and answers are compiled here by category. You may also view the archived webinars or download the enrollment tools.

If you have further questions, please contact the ACE TA Center.

View questions and answers by category:

  1. Enrollment
  2. Coverage
  3. Tools

Enrollment

  1. Are Ryan White HIV/AIDS Program (RWHAP) clients required to enroll in health coverage if they qualify?
  2. How do we respond to a client who states: "I'd rather pay the fine than pay for insurance”?
  3. One of the ACE tools indicates that family members enroll together.It is my understanding that the Ryan White HIV/AIDS Program (RWHAP) health insurance assistance is for the HIV+ client only. If a RWHAP client enrolls in an Affordable Care Act family plan and needs assistance with out-of-pocket costs, do the plans list the costs separately for each family member? If RWHAP only covers the HIV+ clients costs and the family can't afford the rest of the out-of-pocket costs of the plan, what happens when the plan coverage gets canceled?
  4. How can clients enroll if they do not have computer access?
  5. Can enrollment assisters and/or case managers recommend a particular health insurance plan to their clients?
  6. Will the Ryan White HIV/AIDS Program (RWHAP) issue recommended plans for each region?
  7. Is there a health insurance plan among the many in the Marketplace that fits the needs of the HIV+ individual?
  8. When does the next open enrollment period begin?
  9. Will all the clients have to go through the re-enrollment process for their Marketplace health plan?

1. Are Ryan White HIV/AIDS Program (RWHAP) clients required to enroll in health coverage if they qualify?

The Affordable Care Act requires all U.S. citizens and legal residents to have minimum essential coverage, pay a fee or get an exemption from paying the fee. Healthcare.gov provides additional information on the requirement to have minimum essential coverage here: https://www.healthcare.gov/what-if-i-dont-have-health-coverage/

As a RWHAP grantee/subgrantee, you are required to inform clients of their eligibility for other health care coverage and encourage enrollment by pointing out the benefits (for example, clients can receive care for other co-existing illnesses or unexpected injuries). According to the Health Resources and Services Administration (HRSA), grantees/subgrantees must “vigorously pursue” enrollment of people living with HIV in health coverage if they qualify. Check the HRSA website and this website, as well as your state and local RWHAP programs for expectations regarding ‘vigorously pursue’.

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2. How do we respond to a client who states "I'd rather pay the fine than pay for insurance”?

It is important to review insurance options and any associated costs with case managers/enrollment assisters who can discuss the available options with clients. In addition to HIV related care and medications, health insurance will cover other illnesses, conditions and medication as well as preventative care. For most people living with HIV (PLWH), financial assistance is available to help with the cost of health insurance. Some clients may need additional information about the fee if they do not enroll in health coverage. This information is provided at https://www.healthcare.gov/what-if-i-dont-have-health-coverage/. It is the RWHAP grantee/subgrantees responsibility to vigorously pursue and thoroughly document the process of working with the client on obtaining health care coverage. If the process is unable to identify health care coverage for the client, RWHAP funds may be used to provide HIV care and treatment.

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3.One of the ACE tools indicates that family members enroll together. It is my understanding that the Ryan White HIV/AIDS Program (RWHAP) health insurance assistance is for the HIV+ client only. If a RWHAP client enrolls in an Affordable Care Act family plan and needs assistance with out-of-pocket costs, do the plans list the costs separately for each family member?If RWHAP only covers the HIV+ clients costs and the family can't afford the rest of the out-of-pocket costs of the plan, what happens when the plan coverage gets canceled?

There is a way to enroll for a separate plan as an individual even when completing enrollment for a family plan.That mechanism would allow the RWHAP to pay for the individual and avoid the issue of cancellation. In these situations, we encourage the client to work with a case manager/assister to navigate the process on healthcare.gov. Once a family applies for coverage through the Marketplace and is determined eligible for a qualified health plan (QHP), they can select different plans for different family members. Also, if a family has more than one plan, any advance payment of premium tax credit (APTC) is allocated to each plan by the Marketplace according to a business rule described in 45 C.F.R. 155.340(f).

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4. How can clients enroll if they do not have computer access?

The Affordable Care Act requires states to provide multiple ways for individuals to apply for coverage. This includes over the phone, through mail, online or in-person. A phone or paper (mail) application may be a helpful option for clients without internet access.

Clients should contact their case manager or an enrollment assister in their region to request assistance in enrolling if they do not have access to, or cannot get to a computer. To find local help through the Marketplace, please visit https://localhelp.healthcare.gov/.

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5. Can enrollment assisters and/or case managers recommend a particular health insurance plan to their clients?

In general, case managers and enrollment assisters are supposed to provide guidance for people living with HIV (PLWH) who are trying to choose a plan, but are not allowed to pick a plan for them. It is important to know which plans the AIDS Drug Assistance Program (ADAP) or Ryan White HIV/AIDS Program have selected to provide premium and cost-sharing assistance for eligible clients. Case managers and enrollments assisters should familiarize themselves with the plans that the client’s current RWHAP providers are participating in as well as ensuring that the client’s HIV related medications are on the plan. Ultimately, it is the client’s decision to choose a health insurance plan, not the enrollment assister.

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6. Will the Ryan White HIV/AIDS Program (RWHAP) issue recommended plans for each region?

Case managers/enrollment assisters should check with the Ryan White HIV/AIDS Program (RWHAP)in their region/state, including the AIDS Drug Assistance Program (ADAP), to determine which plans are more compatible with the needs of people living with HIV and which plans the ADAP or RWHAP have selected to provide premium and cost-sharing assistance for eligible clients.

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7. Is there a health insurance plan among the many in the Marketplace that fits the needs of the HIV+ individual?

Each individual has different needs (providers, coverage levels, prescription drugs, cost-sharing, etc.) so we cannot say that any specific plan fits the needs for all or most people living with HIV. The ACE Health Care Plan Selection Worksheet was created to assist with this challenging part of enrollment. For help navigating through these questions, download the worksheet: https://taragethiv.org/library/health-care-plan-selection-worksheet

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8. When does the next open enrollment period begin?

The next open enrollment period is November 15, 2014 to February 15, 2015. However, individuals and families can enroll in Medicaid and CHIP at any time throughout the year.

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9. Will all the clients have to go through the re-enrollment process for their Marketplace health plan?

If the client is enrolled in a federal Marketplace plan, in most cases, the client will be automatically re-enrolled.If the client is enrolled in a state-based Marketplace plan, the he re-enrollment process will vary by state in many cases and the client should check with the state-based Marketplace.

Insurance companies will send clients information this fall about updated premiums and benefits. Clients should carefully review their plan’s 2015 changes to see if it still meets their needs. Most clients will be automatically re-enrolled, but they can still pick another plan during open enrollment. Clients should also return to the Marketplace to update information about their income and household size to ensure they are receiving the appropriate amount of premium tax credits and cost-sharing reductions, if eligible. There may be changes in the amount of premium tax credit and the amount the client must pay, so make sure the client is aware of these changes and any tax implications.

If the client is receiving assistance from an AIDS Drug Assistance Program (ADAP) or other RWHAP grantee, the client needs to ensure that they are still eligible for such assistance and should check with that RWHAP grantee to determine if changing to another plan is allowed.

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Coverage

  1. If a patient has a $10 co-pay and a $300 deductible, what happens when s/he goes to the doctor? Does s/he pay both the co-pay and the amount of the visit? Or just the amount of the visit?
  2. It is my understanding that undocumented workers cannot apply for assistance through the Marketplace. Is this correct?
  3. Will clients be able to keep their current doctors?
  4. Is vision care included in Affordable Care Act coverage?
  5. Some individuals have chosen plans that have high co-pays and co-insurance that they can't afford. Most ask about premium payments, high deductibles and co-pays for medication-what assistance is available? Is there help paying for premiums?
  6. Will health plans accept payment for my insurance if it is paid for by RWHAP?
  7. Clients in our area are used to using safety net options for the uninsured. It is a new experience and challenge for them to have insurance copays. Clients are asking us if they have to pay co-payments when they go to their medical providers and become upset when they receive bills from their doctor’s office.
  8. Clients have concerns with using services before their deductible or maximum out-of-pocket limit is met.
  9. What should people living with HIV (PLWH) be looking for as they review drug formularies?

1. If a patient has a $10 co-pay and a $300 deductible, what happens when s/he goes to the doctor? Does s/he pay both the co-pay and the amount of the visit? Or just the amount of the visit?

Insured clients may have to pay for a portion of their health care services through co-pays and/or deductibles.

A co-pay is a fixed amount a client may pay for some health care services. A co-pay is typically paid when the client receives the service. The amount may be different depending on the type of care. For example, a client might pay $15 when s/he goes in for a doctor’s visit and $30 for a visit to the emergency room.

A deductible is the amount that a client may have to pay for some or all health care services,before the health insurance plan begins to pay the services on his/her behalf. For example, if the deductible is $300, the client’s plan won’t pay anything until s/he has paid $300 for health care services covered by his/her health plan. Important: some services are “before deductible,” “no deductible,” or “after deductible”. A client should look closely at his/her plan benefits and contact the insurance company with questions.

Once the deductible is met, the client’s health insurance plan will pay for services and s/he may need to pay a co-pay for each visit. Case managers and enrollment assisters can talk with clients to help them anticipate out-of-pocket costs, and can also identify opportunities for additional financial support, where available. Start by checking with your state RWHAP Part B program. RWHAPs may provide support for premiums, co-pays and/or deductibles. The ACE Plain Language Guide is a resource that might help clients understand terms like co-pay, out-of-pocket, deductible and premium.

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2. It is my understanding that undocumented workers cannot apply for assistance through the Marketplace. Is this correct?

Yes, the Marketplace requires individuals be U.S. citizens or lawfully present. However, undocumented immigrants may continue to buy coverage on their own outside the Marketplace. They may seek non-emergency health services at community health centers or safety-net hospitals, and if they are living with HIV, RWHAP for HIV related care. They remain eligible for emergency care under federal law.

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3. Will clients be able to keep their current doctors?

Clients should work with case managers and enrollment assisters to identify the plan that best suits them, which includes keeping their current provider. In some circumstances, a client’s provider might not participate in a particular plan. If that is the case, a client might need to change providers.

State and local HIV programs, along with other groups can help encourage HIV providers to become part of qualified health plans (QHP), thus allowing clients to remain with their existing doctor. There are now additional Health Resources and Services Administration (HRSA) TA resources to help providers of HIV medical care become part of QHPs. Ask your HRSA project officer for more information.

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4. Is vision care included in Affordable Care Act coverage?

All qualified health plans (QHPs) sold on the Marketplaces include pediatric vision coverage. However, QHPs do not have to include adult vision coverage. If adult vision coverage is needed, check the details of any plan the client is considering to see if it’s included. If the client’s QHP doesn’t include adult vision coverage, the client can buy a “stand-alone” vision plan. Stand-alone vision plans are not offered through the Marketplace and premium tax credits cannot be applied to them. Learn more about available stand-alone vision plans by contacting your state’s Department of Insurance, or a local agent or broker. Clients in need of adult vision coverage should work with case managers and enrollment assisters to identify plans that include vision care.

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5. Some individuals have chosen plans that have high co-pays and co-insurance that they can't afford. Most ask about premium payments, high deductibles and co-pays for medication-what assistance is available? Is there help paying for premiums?

Clients should be advised to work closely with case managers and enrollment assisters. Case managers/enrollment assisters should remind the client that s/he may be eligible to enroll in plans with lower cost-sharing through the Marketplace. Individuals with incomes below 250% of the Federal Poverty Level who receive premium tax credits and enroll in a silver level plan may be eligible for lower co-payments, deductibles, and co-insurance. Clients should return to the Marketplace to determine if they are eligible for financial assistance to help lower their out-of-pocket costs.

Case managers/enrollment assisters should also check with the RWHAP in their region/state, including the ADAP, to determine which plans are more compatible with the needs of people living with HIV (PLWH) and which plans the ADAP or RWHAP have selected to provide premium and cost-sharing assistance for eligible clients. This will ensure better coordination with ADAP/RWHAP grantee to identify the best and most affordable plan for PLWH.

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6. Will health plans accept payment for my insurance if it is paid for by RWHAP?

Yes, the Center for Medicare and Medicaid Services (CMS), issued a rule requiring qualified health plans (QHPs) to accept third party payments such as RWHAP funds.

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7. Clients in our area are used to using safety net options for the uninsured. It is a new experience and challenge for them to have insurance copays. Clients are asking us if they have to pay co-payments when they go to their medical providers and become upset when they receive bills from their doctor’s office.

Part of the role for case managers/enrollment assisters is to teach clients to understand how health insurance works and the options available to help with medication copays including the Ryan White HIV/AIDS Program (RWHAP) and especially the AIDS Drug Assistance Program (ADAP).

Check out the ACE TA Tools that address ways to assist clients with understanding health insurance concepts and terms, and guidance on talking to clients about their questions: https://targethiv.org/ace/tools-and-resources

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8. Clients have concerns with using services before their deductible or maximum out-of-pocket limit is met.

For RWHAP eligible clients, some RWHAP grantees/subgrantees can assist with deductibles for HIV specific services. The client and/or case manager should check with their state and community RWHAP grantees/subgrantees to determine if this assistance is available.

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9. What should people living with HIV (PLWH) be looking for as they review drug formularies?

In general, questions related to formularies should be coordinated with the state/region’s RWHAP Part B and the ADAP program and discussed with case managers and enrollment assisters. They will provide guidance regarding which plans include HIV medications. In general, you are looking to see whether there are a wide array of HIV medications on the formulary, including the client’s current medications. It is also important to see what “tier” the drugs are on. Drugs on the 4thor 5thtier may have high co-pays or coinsurance that could be difficult for clients to pay, unless assistance is available from the State’s ADAP or another source. The ACE TA Center’s Health Care Plan Selection Worksheet may help you keep track of this information and do a side-by-side plan comparison.

Tools

  1. How do we view past webinars?
  2. Are there additional programs to help with premium coverage and/or cost sharing in addition to ADAP?
  3. If a RWHAP client is receiving insurance through their job, do you have tools to compare Affordable Care Act insurance plans that are best for the client?
  4. Is there a summary of what each of the tools is and how they should be used?
  5. Are resources and tools only for clients without insurance? Or perhaps for people that want to change their plan?
  6. Will the enrollment tracking worksheet be available online or is it hardcopy? And is it only for HIV/AIDS patients?

1. How do we view past webinars?

View the past webinars here.

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2. Are there additional programs to help with premium coverage and/or cost sharing in addition to ADAP?

ADAP is the primary program that will help with premium assistance and/or cost-sharing for Marketplace health coverage for eligible persons living with HIV. However, other RWHAP programs might also provide assistance. Check with your region’s RWHAP to identify what programs are helping with premium assistance and/or cost-sharing for Marketplace health coverage. For example, case managers and enrollment assisters can check with pharmacy assistance programs and other programs that might help cover medication costs, and can help clients explore eligibility for premium tax credits and lower costs through the Marketplace.

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3. If a RWHAP client is receiving insurance through their job, do you have tools to compare Affordable Care Act insurance plans that are best for the client?

Yes, the Health Care Plan Selection Worksheet is designed for any client, and it allows for a comparison of plans that includes different insurance options well as different Medicaid options.

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4. Is there a summary of what each of the tools is and how they should be used?

Each tool has its own page on this website with a summary and intended audience. You can also browse the Online Resource Guide, a list of resources specifically designed for enrollment assisters and case managers.

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5. Are resources and tools only for clients without insurance? Or perhaps for people that want to change their plan?

We have tools to assist through all the steps of enrollment, including making sure your client is retained in insurance, helping your client use their insurance, and many other things that come up throughout the process. In many ways, enrollment is not the end of the process, it is just the beginning.

The Online Resource Guide provides information on a step by step level about where during each step of the process you can use our different tools.

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6. Will the Enrollment Tracking Worksheet be available online or is it hard copy? And is it only for HIV/AIDS patients?

The ACE TA Center anticipates that the Enrollment Tracking Worksheet will be available in the Fall 2014. At that point it will be available as a downloadable PDF, for use in hard copy. The worksheet is currently being pilot-tested by a group of grantees and providers. Information about the worksheet’s release and how to find it online will be provided later in the fall.

The Enrollment Tracking Worksheet was developed for staff working with RWHAP clients. It includes activities and information specific to this population, such as coordination with ADAP and confidentiality concerns.

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