The trusted source for
healthcare information and
Many overwhelmed, confused patients turn to patient access employees to help them make decisions about healthcare coverage and even to obtain coverage. A recent Health Affairs policy brief discusses some difficult questions that often come up.1
For example, “What is your household size?” might seem like a simple question, but it can be complex if members of extended families share a home. Similarly, a person’s immigration status might be unclear in mixed-status families.
Many hospitals have trained patient access employees to be certified application counselors (CACs), who help people fill out applications for coverage, regardless of whether that coverage is Medicaid or a Health Insurance Marketplace plan.
“Although this is an expanded role for hospital personnel, it is not new,” says Sarah Goodell, an Arlington, VA-based health policy consultant who authored the policy brief. Goodell is a former policy analyst in the Office of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services.
For years, many hospitals helped qualified uninsured patients get Medicaid coverage, even before the Affordable Care Act.
However, says Goodell, “the stakes are higher now with the decline in uncompensated care funds. Hospitals are likely providing additional training to help uninsured patients get coverage.”
Renee Shores, MAFM, CAC, manager of transplant financial services at Ann & Robert H. Lurie Children’s Hospital of Chicago, sees many patients and families with chronic healthcare needs facing high insurance premiums and high out-of-pocket expenses.
“Whether a patient is an accident victim, has received a new diagnosis, or has ongoing healthcare needs, they all have the same question,” says Shores. “They want to know, ‘Where can I get help navigating this insurance nightmare?’”
Patient access has a responsibility to help families understand their insurance plan and out-of-pocket costs, Shores emphasizes. “With employers and individuals experiencing ever-increasing insurance premiums and out-of-pocket expenses, our goal is to help ease the finance burden by providing individual family counseling,” she says.
The maximum out-of-pocket costs for plans purchased on the Health Insurance Marketplace are $2,850 for individuals and$13,700 for families, according to Healthcare.gov.
Families whose income changes make them no longer eligible for Medicaid require specialized financial counseling. “Unfortunately, with more frequency, parents are calling in sheer panic, stating they received a letter informing them they no longer qualify for state-funded Medicaid,” says Shores.
They were not financially responsible for medical insurance while covered by Medicaid. However, says Shores, “they are now bearing the financial burden of insurance premiums being deducted from their paychecks and paying for co-pays, deductibles, and out-of-pocket, as well as having to select an insurance plan.”
Recently, a parent received a 3% raise that put them slightly over the income criteria for Medicaid eligibility. “Termination of state insurance is a life-changing event that allows access to enroll onto an employer’s insurance plan outside of open enrollment,” notes Shores.
With their new commercial insurance, the family was able to retain all their healthcare providers, with a monthly insurance premium of $375 deducted from their paycheck. “We helped the family enroll in internal as well as external foundations to assist with their $5,000 deductible and $10,500 out-of-pocket expenses,” says Shores.
An “Affordable Care Act Patient Communication Team” at Lurie Children’s Hospital educates staff and families. More than 50 employees from admitting, social work, and transplant administration share information on patient and family insurance issues.
“Each staff member invests over 10 hours studying for both the Illinois and federal tests to become a CAC,” says Shores.
Each department designates one or two individuals to become a CAC. That employee attends workshops on healthcare reform, Health Insurance Marketplace plans, and Medicaid managed care. “Additionally, we instituted super-user ‘train the trainer,’ which has been incredibly powerful,” says Shores.
A group of employees attended several training sessions held by a panel of experts from central registration and managed care. The employees then were asked to share the information with their coworkers.
“Between the Marketplace Exchange plans and the state of Illinois transitioning to Medicaid managed care, providing updated information to the staff is challenging,” says Shores.
Like many chronic health conditions, transplantation requires lifelong healthcare services, including pharmacy. “To help combat high out-of-pocket family expense, we actively seek external resources to share with their patients and families,” says Shores.
The goal is for families to make a well-informed decision on their insurance plan. “Having the right information will reduce denials and improve access to care,” she says. [The Financial Corner from the department’s newsletter for patients and families is included with the online issue. For assistance accessing your online subscription, contact Customer Service at Customer.Service@AHCMedia.com or (800) 688-2421.]