Robert Calandra, Philadelphia Inquirer, Author at ��ϳԹ�� News

Beware: Your Insurer May Define A Health Emergency Differently Than You Do

Robert Calandra, Philadelphia Inquirer — Mon, 22 Jun 2015 16:34:57 +0000

On a frosty late February morning, Dennis Doman awoke with the metallic taste of blood in his mouth.

Throwing off the blankets, he padded the few steps to the bathroom sink. He coughed and then coughed again.

The third time, he spewed blood. He bled so profusely, “I turned my bathroom into a crime scene,” he says.

Doman called 911 and was rushed to a hospital. The initial diagnosis was a gastrointestinal problem.

“I told them no because I can taste blood,” remembers Doman, 64.

Further tests revealed Doman was right – it wasn’t his stomach. The next day, he was sent to Thomas Jefferson University Hospital, where doctors discovered he had a cancerous mass in his neck.

The mass was successfully removed, but over the next six weeks, Doman endured a series of emergency-room and operating-room visits. Throughout his experience, the former warehouse manager’s biggest worry was whether his UnitedHealthcare Silver Compass 100 plan would cover the cost of his care.

“The doctors assured me that I was covered,” he says.

The bills he has received since, he says, and those mounting on his UnitedHealthcare account, say otherwise.

All he knows for sure is that at a time when he felt in no shape to figure out the intricacies of health coverage, that’s exactly what he needed to be doing.

In an emergency, whether a doctor or hospital is in a plan’s network doesn’t matter. Every health insurance plan – whether purchased on the Affordable Care Act marketplace, employer-based, or privately purchased – allows you to go to the nearest hospital.

But what people might not realize is that once you are stabilized, you must transfer to an in-network doctor or hospital. If you don’t, you are responsible for the cost of your care. And you won’t be saved by the ACA’s yearly maximum out-of-pocket costs of $6,600 for an individual and $13,200 for a family.

“The out-of-pocket maximum only applies to in-network services,” says Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. “So they would lose that protection once the emergency is over if they’re still getting services out of network.”

Doman’s experience is in part a cautionary tale about choosing a health plan wisely. Don’t look at just the monthly premium amount. Dig into every aspect, from deductible to co-pays to coinsurance. Make sure that the pharmacy formulary covers your prescriptions and that the network includes your doctor and preferred hospital.

Some plans do allow customers to use out-of-network providers, but they still must pay extra.

“It is part of the plan design,” says Mary McElrath-Jones, director of public relations for UnitedHealthcare. “The plan will tell you this is what we pay if you are in network and this is what we pay if you are out of network. So you will know up front whether you have an out-of-network benefit.”

Doman’s Silver Compass 100 does not include an out-of-network benefit. He sees the result every time he examines his bills, which he says are near $200,000 – though that might be hospital charges, not the amounts he would really be expected to pay.

McElrath-Jones says Doman does have “some out-of-network bills associated with Jefferson,” because of follow-up visits with an out-of-network doctor. “We have taken steps to double-check and fully review each of Mr. Doman’s charges to ensure they are absolutely correct. We will continue to scrutinize the medical bills for him.”

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Cancer Survivor Worries About Supreme Court Ruling On Obamacare Subsidies

Robert Calandra, Philadelphia Inquirer — Fri, 03 Apr 2015 13:07:18 +0000

Until she noticed the tiny blood spots on her sheets, Peg Fagan thought the itchy, raised area on her shoulder was a spider bite.

So when her doctor asked during a routine checkup in April whether Fagan had any health concerns, she mentioned the bite. The doctor took a sample to biopsy. A few days later, Fagan got a call saying she had to come in to the office.

“I said, ‘No, I don’t,’ ” remembered Fagan, 56, a breast cancer survivor. “If you are going to tell me that I have cancer, just tell me.”

Fagan had melanoma, the most serious kind of skin cancer.

The diagnosis was emotionally crushing. But if she had received it a month earlier, before the Independence Blue Cross silver tier Proactive plan she bought through healthcare.gov kicked in, it also would have been financially devastating.

“I don’t know what I would have done if I couldn’t afford to pay for the operation I had last year,” she said. “I would have lost my home.”

Now that she finally has health insurance, Fagan, a personal chef and owner of the Flying Avocado Wholefoods catering business in Ottsville, Philadelphia worries that a Supreme Court ruling could take it away.

“It gets me mad,” she said. “I’m not a slacker. I’m not sitting at home doing nothing all day. I’m paying my taxes and doing the best that I possibly can, but I can’t afford $600 or $700 a month for health insurance.”

If the court rules for the plaintiffs in King vs. Burwell, it will narrow who can receive a subsidy to buy insurance through state-run exchanges. The Rand Corp. and the Urban Institute estimate that will mean up to 8 million low- and middle-class people in 34 states – including Pennsylvania and New Jersey – will lose their federal subsidies.

Since the ACA became law five years ago, more than 16.4 million previously uninsured people are now covered, according to the government. But if almost half lose their government subsidy, the marketplace, and the law, will likely collapse.

While the court debates the case, the U.S. Department of Health and Human Services announced last week that new insurance coverage through marketplace plans or Medicaid expansions had reduced uncompensated hospital care costs by an estimated $7.4 billion.

Most of that saving – $5 billion – is from states that expanded Medicaid.

The marketplace open-enrollment period this year is generally closed, but people filing income taxes and paying a fine because they did not have health insurance last year have until April 30 to get covered for the remainder of 2015. For the 2015 tax year, the penalty for being uninsured is $325 per adult or 2 percent of household income, whichever is greater.

The only other way consumers can buy insurance through the marketplace is due to an event such as marriage, having a baby, or losing job-provided coverage.

“I don’t know what would keep people from signing up,” Fagan said. “It’s not worth not being covered and it’s not hard to sign up.”

Before the ACA, Fagan had been uninsured for five years. Money was tight after she lost her job as a chef. And when preexisting conditions still were a bar to insurance, being a breast cancer survivor put coverage financially out of her reach.

“I was paying out of pocket for everything,” said Fagan, who also has other medical issues. “My medications were costing me almost as much as my unemployment was bringing in.”

Like an overwhelming majority of consumers (81 percent in Pennsylvania and 83 percent in New Jersey), she qualified for a tax credit subsidy ($400) that reduced her monthly premium to $39 last year and $112 this year.

“It was so inexpensive that I couldn’t believe it,” she said.

After getting her melanoma diagnosis last year, Fagan saw a dermatologic oncologist and was quickly scheduled for surgery. While in surgery, she went into anaphylactic shock and was intubated, put on a respirator for several hours, and whisked off to surgical intensive care.

“The thing I think about is what would have happened if I didn’t have insurance,” she said. “This was like $100,000. How could I have ever afforded that?”

With her business growing, Fagan is looking forward to not needing a subsidy. But for now, she needs the help.

“I’m doing the best I can,” she said. “I don’t understand the mean-spiritedness of the people who resent those of us that need some help.”

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Pa. Medicaid Expansion Switch To Be Done By September

Robert Calandra, Philadelphia Inquirer — Wed, 11 Mar 2015 09:00:04 +0000

The switch from former Gov. Tom Corbett’s “Healthy Pennsylvania” program to the traditional Medicaid expansion endorsed by Gov. Tom Wolf is expected to be completed by the end of September, said Ted Dallas, acting secretary of the state Department of Human Services.

But the transition is a “couple-of-phase process” that will blend the three parts of the former governor’s program into the single Medicaid expansion plan adopted in more than 20 other states, Dallas said. The first phase is expected to be finished by April 30.

“There are IT changes needed to do that and all the other changes we need to get done,” he said in an interview.

The state will continue to provide individuals with health-care coverage and no coverage would be interrupted by the decision, he said.

Wolf, a Democrat, had announced last month that he planned to dismantle his Republican predecessor’s alternative Medicaid expansion and instead implement a traditional plan to extend health insurance to hundreds of thousands of low-income Pennsylvanians.

Wolf said the “Healthy PA” alternative plan was flawed, confusing some patients and leading others to lose treatment. He called his action a step “toward simplifying a complicated process and ensuring hundreds of thousands of Pennsylvanians have greater access to the health insurance they need.”

Unlike in other states, the governor does not need legislative approval to move forward with Medicaid changes.

Corbett’s plan, which had been implemented less than three weeks before he left office, used federal Medicaid dollars to buy private health insurance for low-income residents (below $32,913 for a household of four). Households above that level are eligible for premium subsidies in the form of tax credits for insurance purchased on the Obamacare insurance exchange.

Corbett had argued that traditional Medicaid expansion would be unsustainable and his plan contained numerous measures to cut costs and require small payments from participants. But most were not included in the version that the Obama administration approved in August.

Corbett aides spent more than a year negotiating with the Obama administration to let them use federal money to pay private insurers to cover the uninsured.

But the program was beset by problems when enrollment opened last fall, including a backlog, confusion among new enrollees and glitches in moving Medicaid recipients into new plans. Among those affected were patients who lost treatment for drug and alcohol problems because most private plans do not cover addiction and mental health treatment.

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Enrollees In Pa.’s Medicaid Expansion Locked Out Of Substance Abuse Services

Robert Calandra, Philadelphia Inquirer — Mon, 26 Jan 2015 20:10:20 +0000

A year before Healthy Pennsylvania’s rollout, Michael Harle, president and CEO of Gaudenzia, the drug and alcohol treatment center, was assured by top state Medicaid officials his clients would not see their health insurance change.

Harle has been around. So he asked for that guarantee in writing. He didn’t get it.

A high-placed executive “promised me that they would get it right,” he said.

But “they” didn’t.

After Medicaid recipients began shifting to the new program on Dec. 1, “all hell broke loose,” Harle said. A glitch in the system covered his clients and thousands of people across Pennsylvania in need of substance-abuse and mental-health services with private insurance instead of Healthy Plus, the new program for the medically frail.

The problem is most of those private plans don’t offer addiction and mental-health treatment, and those that do have less robust benefits than Healthy Plus.

The result is thousands of people have been locked out of treatment centers, risking their lives, said Deb Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania, a statewide coalition of treatment programs.

“The problem with addiction is you can’t wait,” she said. “Alcohol and other addictions are progressive and are always fatal illnesses if they go untreated. You can’t wait.”

In a letter sent two weeks ago to behavioral health providers, the Department of Human Services said it was working with drug and alcohol and mental-health groups to prevent interruption of service.

People shut out of care often end up in emergency rooms, jail, or on the street, Harle said. Some die. In 2011, Pennsylvania recorded more than 2,000 drug overdose deaths, ranking it seventh nationally, according to the federal government.

The lockout is also a financial burden on providers, especially smaller ones. How much of a burden is still unknown since many providers bill Medicaid a month or two after services are given.

“I suspect that, particularly for small outpatient programs that haven’t sent their bills in yet, it could be a shock,” Beck said.

Last year, Pennsylvania treated 162,000 people for substance-abuse disorders in a variety of settings. The larger programs appear to be continuing to treat patients without payments, Beck said. But the residential rehabilitation programs that serve the poor have been affected the most. They serve 25,000 people a year, and December admissions were down 10 percent to 25 percent, Beck said.

At Gaudenzia, which has 900 beds in Southeastern Pennsylvania, December admissions fell by 247.

“They really botched this up,” Harle said.

The program was a signature health effort of former Gov. Tom Corbett, who had long resisted Medicaid expansion because he deemed it unsustainable. After losing his re-election bid in November, Corbett pushed a narrower version of expansion, called Healthy Pennsylvania, which cut benefits for all Medicaid recipients beginning Jan 1.

Problems began surfacing in the second week of December. That’s when Beck started getting calls from programs about their Medicaid clients. She spoke to state officials who told her there was a glitch in the system they were trying to figure out.

“I’m guessing that whoever did the data entry didn’t understand the addiction-treatment system and how it related to Medicaid,” Beck said. “And the misunderstanding became practice.”

When treatment programs realized what was happening, they had a choice. They could stop treating patients who didn’t have Medicaid coverage or continuing helping their clients. Harle and Gaudenzia decided to keep treating people.

“We get them treated and fight about it another day,” Harle said. “What is most important to us is the client.”

Gov. Wolf, who was sworn in last week, has pledged to scrap Healthy Pennsylvania for a more traditional Medicaid expansion program.

Estelle Richman, head of Wolf’s special transition team focused on human services, said the first thing on Secretary of Human Services Theodore Dallas’ to-do list was to “fix the drug and alcohol problem.”

“At the same time, we have to make sure that the providers are going to be paid,” she said. “Forcing providers to eat large sums of money only weakens them and their ability to provide comprehensive services to their clients.”

Richman said she would be in Harrisburg this week to continue working on the transition of Medicaid expansion. And though she didn’t want to speak for Dallas, she expected he would announce a plan that would unknot the problem.

“I will tell you that within the next couple of days we will have a plan and we will be communicating back out to the counties and people like Mike [Harle] how we plan to remedy this very quickly,” Richman said.

From Harle’s vantage point, the fix is really pretty simple. “There is a system in Pennsylvania that works,” he says. “It’s called HealthChoices and has been in place since the ’90s. It has rules and a system and a common language that people understand.”

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Pa. Man Hates The Law That Will Pay For His Health Insurance

Robert Calandra, Philadelphia Inquirer — Wed, 10 Dec 2014 19:03:12 +0000

Terry Sullivan doesn’t like the Affordable Care Act. Never will.

Sullivan believes that the federal government has no business being involved in his choice of health insurance.

For 28 years, that insurance was Independence Blue Cross’ Special Care plan. But the plan was discontinued in 2013 because it didn’t meet the ACA’s qualified health plan standards. So Sullivan, of King of Prussia, Pennsylvania, went on the marketplace and bought the company’s silver-tier special reserve plan.

“I had no beef with the plan,” says Sullivan, 60. It “was basically better than what I had before.”

Terry Sullivan, 60, doesn’t like what the ACA stands for. Photo from Terry Sullivan

Then Independence axed the plan for 2015. So back online he went, shopping for new coverage on healthcare.gov.

With only a week left to sign up for coverage that starts Jan. 1, the federal government reports that, as of Nov. 28, 765,135 people had filed applications and chosen a plan on federally run marketplaces, like those in Pennsylvania and New Jersey. An additional 1.5 million had submitted applications but had yet to select a plan.

Sullivan thought he would be among that number. But when he plugged in his $12,000 annual income, a message popped up that read, “This household may be eligible for free or low-cost care” through Medicaid.

The self-employed accountant now will join an estimated 600,000 low-income Pennsylvanians – many of whom have never had health insurance – covered through Healthy Pennsylvania, the state’s Medicaid expansion program, which starts Jan. 1.

Pennsylvanians with incomes of less than 138 percent of the federal poverty level – $16,105 for an individual, about $27,000 for a family of three – can now apply for health insurance through Healthy PA. (New Jersey has had Medicaid expansion since Jan. 1, 2014.) The program offers subsidized plans through private insurers.

In the first two days, 41,500 Pennsylvania residents have applied with 30,000 coming through healthcare.gov. Along with the federal site, people can enroll by visiting any county assistance office, by making an appointment with an in-person assistor, or by calling the Department of Human Service’s hotline (1-866-550-4355) from 8 a.m. to 5 p.m.

To enroll you’ll need your tax return and other financial data, information on the size of your family and household and pertinent health records.

“We strongly encourage folks to go through the in-person assistor process” due to the complexity of the process, says Neil Deegan, Pennsylvania director of Enroll America. “Depending on the plan and depending on your income, there may be a co-pay and there may be a premium under the current way the program is structured.”

But that may change come Jan. 20, when Tom Wolf becomes governor. Wolf has said he will switch the program to a traditional Medicaid expansion.

But for now, people who are eligible should apply, advocates said. “If changes are made by the governor, that’s down the line,” Deegan said. “Getting enrolled now is what is important.”

Healthy PA has two levels; the Private Choice Option and Healthy Plus.

The private options cover current Medicaid recipients and new enrollees who aren’t “medically frail.” Five companies – UnitedHealthcare, Aetna Better Health, Health Partners, Gateway Health, and Vista (AmeriHealth Caritas) – are participating.

Every company must offer the same basic set of benefits, according to Laval Miller-Wilson, executive director of the Pennsylvania Health Law Project. To be competitive, some companies may be more generous with benefits than others. For instance, one plan may include more home or chiropractic visits.

But no one is sure who will offer what, since that information isn’t yet available. When Miller-Wilson asked the administration about its plans, he says he didn’t get any answers.

“I don’t even know if [Private Choice] plans are offering more” because that “is not available yet,” he says.

Newly eligible or current Medicaid recipients with serious medical needs will be placed in Healthy Plus, the program’s high-risk plan for people who are pregnant, 65 or older, in a nursing home, or part of several Social Security programs. Four companies are writing policies for Healthy Plus.

Miller-Wilson recommends that consumers covered by a marketplace plan wait until their Medicaid application is approved before canceling because “you don’t want to not have coverage.”

Sullivan applied for Healthy PA online at the state’s Compass website at . The application asked for “a lot of information” about income, checking account, and life insurance coverage. He filled out a detailed health questionnaire. An hour later, Sullivan pushed the button – and nothing happened.

“It was almost like they said, ‘OK, your application was accepted and you do fit our criteria to be on the plan,'” he says. “That’s about all they tell you.”

Miller-Wilson says that once Sullivan is deemed eligible, he will get an enrollment package and a list of option plans.

“I liked it much better when I could just buy Special Care from Blue Cross and I didn’t cost the taxpayers any money,” Sullivan says. “I just think it [ACA] is a government fiasco.”

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Obamacare Still Has “Back-End Issues”

Robert Calandra, Philadelphia Inquirer — Tue, 04 Nov 2014 17:24:56 +0000

When the Affordable Care Act marketplace opens on Nov. 15, consumers can expect healthcare.gov to have robust technology, amped-up functions, and a shorter application form for individual plans.

What they won’t see – and likely won’t know about – are the ongoing communication problems that many on the insurance industry say continue to plague the “back-end” transfer of consumer files between the website and insurance companies.

“Everyone reports that there are still back-end issues,” says Joel Ario, a managing director at Manatt Health Care Solutions and a former Pennsylvania insurance commissioner. “That means there will be some cleaning up to do in terms of reconciling accounts and making sure payments are correct and the coverage dates are correct.”

Judimarie Thomas, senior director of external affairs for Independence Blue Cross, agreed that “issues remain” with the back end of the marketplace. She said that the insurer worked through the technology problems of last year and that “we’ll continue to make sure that consumers can enroll successfully in the plans they want.”

Aetna spokesman Walt Cherniak wrote that while his company was encouraged by improvements, “much work remains to be done, including testing and implementing a permanent, fully automatic back-end financial system to reconcile payment, subsidy, and eligibility data.”

It may be the law’s second enrollment but it marks the first time healthcare.gov will manage 7 million people renewing their policies – some of whom will change plans, carriers, or both – while enrolling about the same number of new consumers.

“This year is a different approach than what we had last year given the fact that there is re-enrollment and a new reconciliation process,” says Clare Krusing, spokeswoman for America’s Health Insurance Plans, a trade group.

Consumers will have from Nov. 15 to Dec. 15 to buy or renew their individual coverage beginning Jan. 1, 2015. Returning consumers will have three options: auto-renew in the same plan; pick another plan with the same insurer; or buy a new plan with another company.

Those choosing to auto-renew in a plan that has been discontinued will be placed in a policy with similar benefits and monthly premiums.

Whatever choice is made, it is important for consumers to revisit their application and update their income information. Slight changes in the federal poverty level may affect their subsidies. People who are renewing will have to continue using the old, longer application.

But with an estimated 25 percent increase in the number of insurers joining this year’s marketplace, renewing consumers should take the time to shop for a plan with similar benefits and lower premiums. The government’s Centers for Medicare & Medicaid Services will contact renewing consumers seven times by e-mail and telephone before Dec. 15 to remind them about buying insurance.

“If people would shop, they could find a better deal, particularly if pricing moves around as much as it is with the different carriers this year,” Ario says. “The big question is how many people will actually read the material that comes to them.”

While people are being urged to shop, switching plans is exactly what has insurers worried. Because of back-end communication issues, insurers won’t be able to tell the difference between a customer who has auto-renewed and one who has left for another company.

A termination file will not be sent from the marketplace to an insurer when someone switches companies until after the exchange closes on Dec. 15. So an insurer will not know that it has lost a customer until the reconciliation process takes place.

For consumers who switch, that can mean getting billed for two plans, or worse, getting lost in the system.

If a lot of people switch, it will be a “big workload for the exchange to process,” Ario says.

But it will be an even bigger headache for insurers who will have the tedious task of cross-checking names on each other’s lists.

To minimize the potential for losing data lost in transition, consumers should read all the information that comes in the mail, update their exchange application, and call their insurer or the exchange with any questions.

“There is still work that needs to be done on the back-end system,” Krusing says. “It’s an issue we have on the radar and working toward finding the right solution that works for consumers.”

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Benefits ‘Essential’ In N.J. But Not In Pa.

Robert Calandra, Philadelphia Inquirer — Thu, 30 Oct 2014 16:36:14 +0000

Every “qualified” health insurance plan sold on the Affordable Care Act individual or small business marketplaces must include 10 essential health benefits.

They are mandated by the law, and cover everything from emergency services and hospitalizations to maternity care and prescription drugs.

But there’s one little rub: Each state has a surprising amount of leeway to define what is essential. And benefits in Pennsylvania are a lot stingier than in New Jersey.

“Pennsylvania is one of the states that doesn’t do well,” says Janet Weiner, associate director of health policy at the Leonard Davis Institute at the University of Pennsylvania.

In a study published last week with the Robert Wood Johnson Foundation, Weiner and colleague Christopher Colameco laid out how “essential” benefits can vary.

Bariatric surgery is essential in 23 states (45 percent) but only five (10 percent) cover weight-loss programs.

Chiropractic visits are essential in 45 states (88 percent); only five states (10 percent) pay for acupuncture.

In Pennsylvania, chiropractic care is the only practice identified from a list of 11 condition-specific services. Hop over to New Jersey, and chiropractic care along with six other condition-specific services are covered.

A similar pattern holds for infertility care, Weiner said. It’s essential in New Jersey, not in Pennsylvania.

Getting a standard every state would accept was the Department of Health and Human Services’ job. But as the days ticked down to last year’s marketplace launch, the agency decided to punt.

Weiner says that was probably wise. Trying to establish a new standard in the run-up to the ACA “would have been quite bloody.” That’s because state-mandated benefits often follow long battles among various advocacy groups and politicians.

Instead, HHS opted to let each state define its own essentials for the first two years. Last year and again this year, states can choose from 10 benchmark plans: One of the three largest federal employee plans; the state’s largest non-Medicaid HMO; one of the three largest small-group plans; or one of the three largest state employee plans.

“This was a reasonable alternative because it allowed HHS to take advantage of plans that were already enforced in the states and already had existing pricing,” she says.

Pennsylvania defaulted to its largest small-group policy, Aetna’s Point of Service plan. New Jersey picked a Horizon HMO small-group plan.

HHS is set to announce an interim policy in 2016. But after gazing into her crystal ball, Weiner doesn’t see that happening. “The same battles and the same difficulties would appear to them in 2016, which is not that far away,” she says. “So I wouldn’t be surprised if this interim policy continues.”

So really, how much of a game changer are the 10 essential benefits if the same limits that existed pre-ACA remain? Weiner says they have added services such as maternity care and preventive care that weren’t routinely available before.

She also understands why someone in Pennsylvania needing hearing aids, which are not covered, would be upset that across the river those same hearing aids are deemed essential benefits.

“These are real issues for people needing these services,” she says. “You don’t have to have a lot of inside-baseball knowledge to understand the issue.”

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Tech-Savvy Subjects Test Exchange Website, Advise Changes

Robert Calandra, Philadelphia Inquirer — Tue, 15 Jul 2014 05:01:00 +0000

This copyrighted story comes from , produced in partnership with KHN. ��ϳԹ��.

His plugged-in friends said he was a fool not to buy health insurance on the federal marketplace.

Mark Gaines knew they were right. He was, after all, a 26-year-old law school graduate. But if a judge had asked him for a summation of the Affordable Care Act last fall, it would have been a one-sentence brief.

“I didn’t know anything about it,” said Gaines, who lives in South Philadelphia and was working part-time. “I knew that it was going to make [insurance] open to everyone and make it cheaper.”

Then, one frigid day in early January, a friend forwarded an e-mail. The University of Pennsylvania was recruiting educated people ages 19 to 30 who wanted to purchase insurance through the Healthcare.gov website. Gaines volunteered.

The three-month study was the idea of Charlene Wong, 31, a pediatrician at Children’s Hospital of Philadelphia. Wong knew just how confusing and challenging buying insurance for her own family was, and she is a health policy researcher. What, she wondered, was it like for young adults doing it for the first time? Even more intriguing, what changes might the digital natives suggest to make the website more user-friendly?

The results, published in the Annals of Internal Medicine, recommended six changes: Rename “catastrophic” coverage; identify dental coverage as a separate purchase early on; create an easily accessible glossary of terms with concrete examples; clearly explain that tax credits in the form of premium subsidies and cost reductions in deductibles, copays, and coinsurance are linked – in very different ways – to silver-level plans; prominently mention that preventive care is free and part of every plan on the site; and reposition tools that are already there.

“They are relatively small changes that would improve the understandability and usability of the website,” said Wong, who is a Robert Wood Johnson Foundation Clinical Scholar, a competitive program that trains physicians in health policy and community research.

The project, which involved six researchers from various Penn schools, began in January, after most of the website’s bugs had been fixed. It ended when open enrollment closed on March 31.

The team watched the 33 subjects make their way through the website. They were told to navigate as they would if they were at home – including talking to themselves out loud, Wong said, “so we could capture their reactions in real time.”

Then they were asked a series of open-ended questions about their impressions. It turns out that when it comes to health insurance, young, tech-savvy adults are not all that different from old Luddites.

“I didn’t expect [the site] to be easy, but I didn’t expect it to be a labyrinth,” said Gaines, who had imagined that Healthcare.gov would be like shopping online – as the Obama administration had pitched it.

Wong said “a lot” of the participants were surprised that the site didn’t use their income information to recommend options. The panoply of plans left them overwhelmed.

“I could buy health insurance, yes, but if I don’t understand something I’m not going to buy anything,” Gaines said.

Wong said the group recommended that the website tailor offerings based on consumer preferences. For example, filters could suggest plans based on how much a consumer wants to pay in premiums, or whether she wants dental coverage or a health savings account.

“They pointed to all these other online shopping websites where you are able to do that and they said, ‘Why can’t they do that here?’ ” Wong said.

Participants also wanted the insurance industry to clean up its language. Terms such as deductible��Ի��coinsurance should have “instantly accessible glossary definitions paired with concrete examples for complex cost concepts,” the authors wrote.

And then there’s catastrophic coverage. Participants found the term confusing or frightening – prompting them to ignore a category that was created largely for their demographic.

“I thought it was the most extreme health insurance, but it is actually one of the simplest,” Gaines said.

The research team is using its contacts to make sure the findings get to the right people in Washington while the website is being redesigned in advance of the start of the next open-enrollment period Nov. 1.

So, how many of the young adults actually bought coverage? That’s a secret, the subject of Wong’s next paper.

Gaines, for one, did not. But he does understand the process a lot better now.

“I want health insurance, but I’m not going to choose a plan impulsively,” he said.

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For Asian Immigrants, ACA Coverage Contains Mysteries

Robert Calandra, Philadelphia Inquirer — Tue, 06 May 2014 12:39:00 +0000

This story was produced in partnership with

When Biak Sung escaped from Myanmar in 2011, there was no health insurance for people like her.

So it’s not surprising that months after buying a plan on the Affordable Care Act marketplace, Sung, 27, a mother of two and a political refugee – whose English consists of “hello” and “thank you” – doesn’t know how to use her family’s policy.

Last week, Sung, whose husband works full time, went to the Southeast Asian Mutual Assistance Association Coalition (SEAMAAC) in South Philadelphia to learn about her new policy, an Independence Blue Cross silver-tier Keystone HMO Proactive plan.

“She doesn’t know what steps to do next and she is concerned,” said Zing Thluai, a SEAMAAC worker who speaks one of three Burmese dialects.

For 30 years, SEAMAAC has been addressing the concerns of Asian immigrants in this region. In the fall, it realized the ACA enabled many of the city’s 23,000 uninsured Asian Americans to buy coverage.

Amy Jones, SEAMAAC’s health director, developed a program that ultimately got 451 families covered. For that, Jones was among 11 people recently awarded the White House Champions of Change for ACA outreach to Asian Americans and Pacific Islanders.

The task was tougher than expected, said Michael Donnelly, SEAMAAC’s health coordinator, because most clients don’t speak English and need help with basics like paying bills. Add to that an innate fear and distrust of authority.

Backed by 11 bi- and multilingual staffers and seven volunteers trained as certified application counselors, Donnelly and Jones fanned out to discuss premium payments, deductibles, co-pays, coinsurance, and preexisting conditions.

They even tried explaining the tiers and networks embedded in the silver-tier Keystone HMO Proactive plan. Members can pay no deductible at certain hospitals and as much as $3,000 at others.

“Just try explaining the tier concept,” Donnelly said. “If you speak perfect English and lived in this country 20 years, you are going to have trouble” grasping it.

The group also confronted political concerns. People opposing the ACA were telling others that signing up meant they would forfeit next year’s income-tax refund.

When Sung learned that her Proactive plan would cost 27 cents a month, she was worried because others she knew were paying a $35 monthly premium. She asked her navigator to make her premium $30 a month to preserve their tax refund.

“This was [an] organized and coordinated effort to throw false information out there to scare people,” said Thoai Nguyen, SEAMAAC’s chuief executive officer.

When the marketplace closed last month, the SEAMAAC staff sighed with relief. And then they realized their real work had begun. Many clients finally had a plan, but most didn’t know the basics of how or when to use it.

So the staff started calling clients, asking whether they had paid their premiums or needed assistance. It wasn’t unusual to hear people say they had received a bill but didn’t know what to do with it because they weren’t sick. Staffers had to explain that the bill must be paid every month, sick or not.

Clients also said they were still using free clinics rather than a private doctor. The group has now begun teaching people how to find a physician and make appointments. And, no, members tell clients, you don’t have to be near death to see a doctor.

“Preventative medicine is a tough concept for most people in developing nations,” said Nguyen. “The idea of going for an annual checkup when you’re not sick is strange to them. You only go [to a doctor] when it is possibly a matter of life and death.”

Seeking care for issues like depression and alcoholism is also foreign to many Asian immigrants and refugees.

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Choral Director May Be First Healthcare.gov Enrollee In Philadelphia Area

Robert Calandra, Philadelphia Inquirer — Mon, 28 Oct 2013 14:13:02 +0000

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Holly Phares was a mouse click away from becoming the first Philadelphia-area consumer to successfully enroll in coverage on healthcare.gov, and she was psyched.

“I want to ‘confirm,’ ” she proclaimed to the three people gathered at the Resources for Human Development (RHD) office in Roxborough, Pa. Everyone stared at the screen bearing the words, “Confirm and Save Your Health Care Plan” as Phares positioned the cursor and clicked.

Since the health-insurance marketplace opened Oct. 1, RHD has not enrolled one client using the federal Healthcare.gov website.

It wasn’t for a lack of trying. In three weeks, the group, recipient of the state’s largest federal grant to train navigators, has fielded 450 calls and helped 40 to 50 people in southeastern Pennsylvania buy plans using old-school paper applications.

But buying coverage via the now famously flawed website has been mission impossible.

Phares was there to end that shutout streak.

Both Pennsylvania and New Jersey are among the 36 states that chose to use the Healthcare.gov website, rather than develop their own. And from the start, Phares thought she had an unusual rapport with it. Not only did she get on relatively quickly, but she got all the way through the process without being kicked out or having her computer freeze.

Maybe it was divine intervention, since she is choral director for the Tabernacle United Church in West Philadelphia.

But Phares thinks that her secret is more Ethernet than ethereal; she used her smartphone.

“We couldn’t get through to the website very well on a laptop,” said Phares, 50, who is also a freelance vocal teacher. “We did it all on my smartphone.”

Her quest began after church last Sunday. She and Laura Line, a fellow congregant and RHD’s corporate assistant director for Health Care and a certified navigator, spent 90 minutes trying to access the website with a laptop.

Later that day, Phares tried again, this time using her smartphone. Her experience was oddly Amazon-like.

“I got to the point where I called Laura and told her that I got through,” Phares said. “She was ready to cry she was so happy.”

Phares filled out the basic enrollment information and set up her account. She created a checklist of her needs in the “Health Plan Notes” section. To view sample plans, she entered her name, age, zip code, county, and yearly income. Within seconds, the screen filled with a list of plans matching her requirements. She was even able to see that she was eligible for a subsidy.

“It was very user-friendly,” Phares said. “You basically keep clicking on the hyperlinks.”

Phares also called the website’s 800 number three times and found customer service to be polite and patient. She placed the last call around 1 a.m. Tuesday. Ten hours later, she was sitting at the desk, her trusty smartphone connected to a monitor, ready to commit.

“I’m going with Independence Blue Cross’ Personal Choice PPO Platinum plan because I can go anywhere I want,” said Phares, who has a complex health history.

She clicked through several screens until reaching the “Confirm And Save Your Health Care Plan” page. The moment had come. She put the cursor on Confirm and clicked. The screen faded, and in the foreground appeared the familiar spinning icon and “Please Wait.” Phares did a drum roll with her fingers.

Seconds became minutes. The icon and “Please Wait” disappeared, replaced by the Confirm page. Phares was confused. Was she enrolled? Not sure, she clicked confirm again. The sequence repeated. By the seventh time, the spinning wheel had become trance inducing.

It was time for a fourth help-line call.

Phares explained what she had done and how she had no idea whether her choice had been registered. Over the next hour, the rep asked questions and put her on hold to confer with “internal support.”

She finally advised Phares to contact the health insurer and gave her a phone number and web address.

But Phares wanted reassurance that her information was part of the government website.

“You are definitely enrolled,” the rep said.

Hearing that, Phares said that she might just wait to get final confirmation from the site.

“At this point I wouldn’t do that,” the rep said. “There is no telling what is going on as far as what glitches you might encounter.”

Three days later — and after a morning spent on hold with Independence Blue Cross (IBC) — Phares still didn’t know whether she was successful. An IBC spokesman said it had no record of her enrolling, but noted that signups can take a few days to post.

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