Health Reform: Role of County Human Services Agencies in Enrollment

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Aimee Wall

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Beginning October 1, 2013, individuals in North Carolina will be able to sign up to purchase private health insurance through the federal “marketplace” or “exchange” established under the Patient Protection and Affordable Care Act (PPACA or ACA). Some individuals will be eligible for subsidies to help with the cost of this insurance coverage. Under the federal law, most individuals will be required to have health insurance by January 1, 2014 or face a tax penalty (see this helpful infographic by the Kaiser Family Foundation for exceptions). Coverage will begin on January 1, 2014 for those who sign up through the exchange before December 15, 2013.

Many county agencies are getting calls for information about the enrollment process – What plans will be available? Will the county be able to help me enroll? Below are short answers to these two threshold questions and links to a few other relevant resources.

What plans will be available?

In North Carolina, two companies will be offering plans through the exchange. Blue Cross and Blue Shield of North Carolina will offer several plans statewide and Coventry Health Care of the Carolinas will offer plans in 39 counties. Plan details and rates will be available tomorrow.

While the plans will vary, ACA established baseline requirements that apply to all plans offered on the exchange. They must provide coverage for “essential benefits” including physician services, emergency services, hospitalization, maternity and newborn care, pediatric services, mental health and substance use disorder services, prescription drugs, pediatric services, preventive and wellness services, chronic disease services, and laboratory services. Some preventive services must be free to the patient (no deductible, coinsurance, or copayment). Patient costs for other care and services will vary depending on the type of plan that is selected.

Will the county be able to help me enroll?

Because ACA is a federal law and the exchange is a government-run operation, some people in the community think health reform established a government-funded public assistance program similar to Medicaid or Health Choice. As a result, they may think that the county human services agencies involved with those two programs – particularly the departments of social services – will be the central point of contact for enrollment for the exchange. This may create some confusion for the public and for local governments.

Another possible area of confusion is the connection between the eligibility and enrollment processes for Medicaid and Health Choice and the plans available through the exchange. As mentioned above, some individuals will be eligible to receive subsidies to offset the cost of insurance available through the exchange. Before eligibility for subsidies can be established, however, eligibility for Medicaid and Health Choice must be evaluated. It is likely that some who seek out insurance through the exchange will actually be eligible for one of those two programs; the North Carolina Institute of Medicine estimates that as many as 70,000 – 87,000 newly eligible individuals could be identified in the coming months. If the person or family is eligible for one of those two programs, they should be enrolled in those rather than continue the process of applying for private insurance through the exchange.

If the individual or family is not eligible for one of those two programs, they can proceed with determining eligibility for subsidies and enrollment in a plan available through the exchange. This connection between the public programs and the exchange means that the two systems must be able to share information and coordinate. It is my understanding that the state and federal systems are not coordinated as yet so there may be some confusion or delays. For example, if a person applies online through the federal website to enroll in a plan through the exchange but the federal government determines that he would be eligible for Medicaid, the federal system may not be able to push that application to the state right away. It will likely take some time for this new interconnected state-federal system to work seamlessly.

Because there is still a good bit of confusion about health reform in general, it is likely that county departments of social services will be the first stop for many in the journey to finding coverage. There are several different ways county departments can play a role in sharing information with the public about the insurance options available:

  • Direct individuals to the enrollment portal and hotline: Individuals may apply for the exchange online or by phone: (English), (Spanish), or 1.800.318.2596 (multiple languages). They can also apply online for Medicaid and Health Choice at
  • Host an official Navigator: The federal government provided funding to four organizations in North Carolina that will train and coordinate official “Navigators.” Navigators are expected to help individuals understand the options available and the process for enrolling. They are required to receive specific training and may not receive financial compensation or gifts from insurers. The North Carolina Department of Health and Human Services recently sent a letter to all counties encouraging social services agencies to allow Navigators to work onsite if possible. The organizations receiving funding for Navigator programs are Community Care Networks (statewide); North Carolina Mountain Projects, Inc. (Haywood, Jackson, Macon, Swain, Graham, Clay, and Cherokee); Randolph Hospital, Inc. (Randolph, Moore and Montgomery), and Alcohol/Drug Council of North Carolina (specialized services for people in recovery from mental illness and/or substance abuse).
  • Host or apply to become a Certified Application Counselor: Local government agencies and others may apply to the federal government to serve as Certified Application Counselors. (See 45 C.F.R. 155.225). Either the agency or individual staff members may apply. Like Navigators, the Counselors are expected to provide information and assist with enrollment. More details are available here.
  • Direct individuals to assistance available in the community: There may be Navigators, Certified Application Counselors, staff or volunteers at local health care providers, such as hospitals and community health centers, nonprofit organizations, or health insurance brokers in the community who are available to talk with individuals and explain the insurance options available through the exchange. Federally-funded community health centers specifically received some funding to provide enrollment assistance (here is a list of NC centers receiving funding). The U.S. Department of Health and Human Services is maintaining a database of such resources online. Locations identified as providing “Application Assistance” are available to help guide individuals through the process. As of September 30, only one county DSS is identified as providing application assistance (Carteret). It is my understanding that many applications are still pending.

There is obviously a lot of activity around this issue right now. The News and Observer had a helpful summary over the weekend for those new to the conversation. The NC Association of County Commissioners has also organized a very timely seminar on this topic for October 15.  Details are available here.  It is possible that county social services agencies will be flooded tomorrow with new people seeking information about health reform. If so, hopefully everyone can “take a deep breath” – as one wise social services director suggested – because there really is plenty of time for people to read information online, study their options, and get their questions answered.


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