Perplexed by new insurance plans? He can help

Last year Curtis, a 47-year-old mason, tried to get insurance for himself and his family through Arizona’s health insurance marketplace, which is operated by the federal government.

“I tried to do it over the phone and thought it was too expensive,” he said.

So this year he sought out in-person help from a health insurance “navigator” — a person who is federally certified to provide nonbiased enrollment assistance. He recently spent several hours at a health fair on Tucson’s south side with Don Valdez, one of 21 health insurance navigators who work through the local Pima Community Access Program.

Valdez’s job includes not only enrollment help but outreach, too. While 120,000 Arizonans enrolled in health insurance through the marketplace last year, navigators are doing their best to raise the state total this year.

One in five Arizonans was without health insurance before Jan. 1, 2014, and while there’s been improvement, there’s still plenty of work to do, Valdez says.

Health insurance educators are particularly attempting to reach out to people like Curtis, who have not had insurance in a long time. The deadline for this enrollment period is Feb. 15, making for a shorter window than last year.

Consumer fear about the process during the last enrollment season and confusion about health insurance in general have prompted navigators like Valdez to reassure people with basic “health insurance literacy” information. They are also trying to clarify the “unaffordable care act” moniker they so often hear.

Many people still find the monthly premiums too much for their budgets.

“It’s the people living paycheck to paycheck,” Cochise County Health Department employee Francisco Segovia said after a recent education session with Valdez in Benson. “They don’t have the money to pay a monthly premium, but they’re going to get into even more financial trouble if they get sick and don’t have insurance.”

Segovia wasn’t sure what to tell those people, because he understands their dilemma. Valdez urged him to help those families calculate their federal subsidy and cost-sharing eligibility. That’s what he did with Curtis, who thinks that with better information, maybe he could have afforded insurance for his family last year.

Reaching out

Valdez gives informational talks where he plays health insurance games with those in attendance. Audience members can show off what they’ve learned about concepts like Medicaid, out-of-pocket maximums and co-payments.

“Last year we got the low-hanging fruit, you know,” Valdez said. “This year we need to reach more young people, Latinos. A lot of people don’t even know the marketplace exists.”

At a recent education session for health professionals at Cochise Community College’s Benson campus, Valdez explained that consumers can no longer be turned down for having pre-existing conditions, or charged more money, unless they are smokers.

“Getting people into the appointment is the challenge,” Valdez said. “A lot of people don’t know they are eligible for subsidies. A lot of people don’t know that they can’t be turned down for pre-existing conditions. A lot of people have been turned down for insurance multiple times. They don’t want to try again.”

Tucson Realtor Colette Barajas already had a $26,000 outstanding hospital bill from having inadequate insurance and was tired of avoiding medical treatment because of costs when she attempted to enroll through the marketplace last year.

But frustrated by the choices and terminology on healthcare.gov and by the site’s technical snafus, Barajas gave up and stuck with the limited coverage plan she already had but didn’t like.

So for 2015 she decided to do better. In the middle of a recent workday, Barajas sat down with Valdez, who went over her options.

Valdez spent 14 years working as an insurance broker, but tries not to use technical insurance jargon. People just want to know what they are purchasing and how to use it, he said. They also want to know that Valdez and other navigators aren’t being paid a commission for enrolling people. They are not.

NAVIGATORS TRAINED

Unlike his former role as a broker, as a navigator Valdez must be unbiased and have no conflicts of interest. Since he was a schoolteacher before becoming an insurance broker, he says he’s found the right job.

Navigators are funded through federal grant funds and must complete comprehensive federal training, criminal background checks, and state training and registration before helping consumers. The help they give the public is free of charge.

The navigators receive more training than certified application counselors, who are also federally certified to help people enroll. A key difference between the two is that navigators are required to do outreach.

Since many of the people the Affordable Care Act aims to assist have either never had health insurance or not had it in a long time, Valdez often starts with the premise of why health insurance is important.

“How can you not afford to have it? If you have a health catastrophe, you are facing hundreds if not thousands of dollars in bills,” said Valdez, who helps people enroll out of both his organization’s office on Tucson’s south side and out in the field.

Earlier in the month, Valdez helped a 52-year-old mechanic who earns $21,000 per year get insurance for $94 per month and no deductible. The man hadn’t wanted coverage, but felt he had no choice because fines for not having insurance go up this year.

The penalty in 2015 is 2 percent of one’s taxable income or $325, whatever is larger. For an individual who earns $35,000 in 2015, the penalty for not having health insurance would be $700, for example.

The theory behind the penalties is that when people can’t pay their health-care bills, all of us pay. That’s why the Affordable Care Act also offered incentives for people to get Medicaid. In Arizona, the number of people enrolled in AHCCCS is at an all-time high of 1.6 million, having jumped by 26 percent in the past year.

Valdez this month helped a married couple, ages 38 and 41, who had just moved to Southern Arizona from Bangladesh, to get a plan for $200 per month. The 38-year-old wife has Stage 4 cancer. Neither she nor her husband has a job and are going to have to borrow from family members for the premium and other out-of-pocket costs.

They didn’t qualify for federal subsidies because without jobs, they are not paying taxes. And they don’t qualify for AHCCCS because they haven’t had U.S. residency for five years or more. The Affordable Care Act does not have any minimum length of residency requirements for legal immigrants.

Overcoming frustration

When she visited Valdez’s office in early December, 61-year-old Susan Thompson brought a file folder of material to share with Valdez. Her Health Net insurance plan, which she bought through the marketplace with Valdez’s help last year, was discontinued. She needed to find a new plan by Dec. 15 in order for her insurance to start by Jan. 1.

Thompson hasn’t worked in two years, but her annual income of $20,000 from investments is too high for her to qualify AHCCCS.

Her healthcare.gov account had been disabled because she couldn’t remember her password. Valdez helped her to reset it.

“I personally could not have done this on my own,” Thompson said. “I have a low threshold for frustration, and I found it intimidating. Don is so patient.”

During the appointment, Valdez put his phone on speaker and called healthcare.gov. After a 15-minute wait, they were able to find a silver plan through the Arizona-based insurance company Meritus for $53 per month and a $400 deductible when cost sharing was factored in.

Thompson liked that price. Valdez said she should call her primary care provider to make sure the office takes Meritus.

“You really have to ask questions to make sure your provider will take the insurance before you buy it,” he said.

Thompson called her nurse practitioner’s office and spoke to the office billing person, who hadn’t heard of Meritus. Thompson asked about the University of Arizona Health Plan, which also offered good prices. And Thompson liked that the plan is local. But the billing person said no to that, too.

In the end she decided on another Health Net plan. Like most adult plans on the marketplace, the plan she bought did not include dental care. She hasn’t been to a dentist in a long time and doesn’t want the extra monthly expense of dental insurance, she said.

Health experts do not advise purchasing a plan based solely on the premium. There are other factors to consider — the deductible, co-payments for doctor visits, the out-of-pocket maximum and what the plan covers.

ELIGIBLE for SUBSIDIES

Valdez says many consumers are eligible for subsidies but don’t realize it — nearly three quarters of Arizonans who got insurance through the marketplace in the last enrollment season qualified for subsidies.

Some of the most confusing terminology is co-insurance versus co-payment, and out-of-pocket maximum versus deductible. A co-payment is a fixed amount a patient pays for a covered health care service at the time of service.

Co-insurance is the consumer’s share of the costs of a covered health-care service. If the health insurance allows $100 for an office visit and the deductible has been met, a 20 percent co-insurance payment would be $20. The health insurance or plan pays the rest of the allowed amount.

“I’ve learned to be patient; you have to be,” said Christopher Stead, another Pima Community Access Program navigator, as he helped a pregnant 39-year-old woman who unexpectedly lost her federal insurance subsidy in December.

After several back-and-forth calls to healthcare.gov and the insurance company, Stead figured out that her subsidies ended and her premium went up because she hadn’t paid federal taxes in several years.

The woman, a small-business owner, had a bad year in 2014, and Stead said she might qualify for AHCCCS in 2015 — a route she decided to try. Their appointment lasted more than an hour and was punctuated by periods on hold that lasted 10 minutes and longer.

With Valdez’s help, Tucson filmmaker Dan Buckley bought marketplace insurance through the University of Arizona Health Plan for $74 per month and no deductible.

Buckley was an arts writer for the Tucson Citizen until it closed in 2009. He had health insurance after the closure through a federal program that offers temporary coverage after job loss or job change. He eventually found himself without insurance, but not for lack of trying.

Buckley has a herniated disc in his back that qualifies as a pre-existing condition, and prior to the Affordable Care Act’s taking effect, he couldn’t get any health insurers to cover him.

“It is unpleasant and expensive to be uninsured,” said Buckley, who is 61. “Having pneumonia without insurance cost me a small fortune.”

Since Curtis, the father of three, works in construction, his income varies month to month.

With Valdez’s help, Curtis figured out that his family might be eligible for Arizona’s Medicaid program, which is a government insurance program for low-income people.

The program is called AHCCCS — Arizona Health Care Cost Containment System, and Curtis is waiting to find out whether he and his family will qualify. A family of five must bring in less than $37,120 per year to qualify.

Curtis’ income was too high for AHCCCS last year, but in retrospect he says he might have been able to enroll his family in insurance anyway through the marketplace. Until Valdez spent an afternoon explaining it all, Curtis said he didn’t fully understand how the new insurance system under the Affordable Care Act worked.

“Even if we don’t qualify for AHCCCS, I am buying health insurance,” Curtis said. “My family needs to have it.”

People who have a special life event such as a job change or a new baby may enroll after the Feb. 15 deadline, and people may apply for and enroll in AHCCCS year-round. To help those consumers, Valdez will continue his job after the deadline and throughout the year.