What "outreach & enrollment" actually looks like...

"Outreach & enrollment" means much more than putting up posters and helping people fill out MassHealth applications. Recently, over the course of a two hour appointment, my supervisor and I counseled one household on eleven different public health insurance, subsidy and care programs. We helped them file four separate applications to five different insurance programs, putting together a patchwork of care options to cover the hole left by the loss of employer-sponsored insurance.

Last fiscal year, the state made it a priority to provide grants to community organizations that provide health insurance counseling and application assistance. We learned last week that, after some uncertainty, the line item for these grants was finally included in the legislative budget for the current fiscal year (2009). For anyone that believes that the work of "outreach and enrollment" workers is over, read on. Three hundred thousand newly insured residents is wonderful news, but it doesn’t mean the job is done. Things happen, people lose their insurance.

Recently, I met with a 54 year old woman, whose 55 year old husband is about to be laid off because the factory he’s worked at for twenty years will be closing its doors and moving to China. With the loss of his job, the couple will also lose their employer-sponsored health insurance. What follows is a factual account of my experience guiding them through the health insurance labyrinth that persists even as we move toward "universal coverage."

To begin with, when a member of a household is likely to qualify for unemployment income, we automatically help that person to fill out an application for the Medical Security Program (MSP). There are two types of assistance through MSP: assistance paying a COBRA premium, or direct coverage for those who can’t get or really can’t afford COBRA even with the subsidy. Because the employee isn’t eligible for COBRA in this case, we decided to file for direct coverage from MSP.

Here's where it gets crazy...

While the husband will soon be entirely uninsured, the wife has Medicare A coverage (which only covers hospital claims) through her Social Security Disability Insurance (SSDI) benefit. MSP direct coverage would fill the gap (primary/specialty care and prescription coverage) left by the wife’s Medicare, except that after placing a call to MSP customer service we learned that only the husband would likely be approved because the wife’s limited Medicare A ("other subsidized coverage") makes her totally ineligible.

We had to figure out how to close the gap in her insurance. Losing employer sponsored coverage is considered a qualifying event, so she can elect to enroll in Medicare B for $96.50/month. A quick call to the local Social Security office confirmed that her Medicare B coverage could begin July 1st provided she fax in the signed election form and pay two month’s premiums in advance.

On to the drug coverage...

The woman then needed to choose between stand-alone Medicare D drug coverage and more comprehensive coverage that would fill in some of the other gaps left by traditional Medicare. The woman definitely wanted drug coverage and was uneasy about paying the 20% coinsurance left by traditional Medicare, so my boss and I counseled her on the coverage and price differences between Medex and Medicare Advantage plans. She is used to paying copayments and one of the Medicare Advantage Plans seemed to affordably meet that need at around $50/month. I screened her eligibility for the different subsidy programs available to help pay for Medicare premiums and prescription drug costs (Medicare Savings Program, Low-Income Subsidy and Prescription Advantage), but found that due to her household income she wasn’t eligible for any assistance.

Then, a toothache...

Then she tells me that in a few days she’s scheduled to pay an oral surgeon a few hundred dollars to remove a decayed tooth that is causing her tremendous pain (her husband’s employer didn’t offer dental coverage). I had planned on filing a Virtual Gateway application for state-subsidized coverage anyways, so that her husband would have an insurance program (Commonwealth Care) to transition into once the MSP coverage ends or in case he doesn’t qualify.

The combined Virtual Gateway application will also enroll them in the Health Safety Net (HSN), which should cover this necessary dental procedure. In addition, HSN will provide a supplement to her Medicare/Fallon Senior for reimbursement of certain hospital expenses. The last thing we needed to do was to find her an appointment at a community health center dental office, which presented its own challenges.

Next, a colonoscopy...

After the dental issue had been mostly dealt with, she shared her concern that her husband is scheduled for a consultation that will likely lead to a colonoscopy. The consultation is scheduled on the last day he’ll be covered by his employer’s insurance plan. Because he’s anxious to have the colonoscopy performed, I called our contact at the Men's Health Partnership to see if he might also qualify to get a voucher to cover the procedure and what paperwork he'd need to fill out for that program.

Now, I didn’t forget the additional necessity of explaining the individual mandate, and whether or not they might face a tax penalty for the month gap in coverage due to the 2-3 week lag between the husband’s last date of employment and the opening of his unemployment claim (at which point we can actually mail in the MSP application we filled out in advance). I decided to leave out information on affordability and minimum creditable coverage – she'd been in my office two hours, her nerve pain was beginning to act up, and all the talk of dentists was causing her to notice the tooth pain was returning. She's planning on at least two follow-up appointments.

I share all this not to complain about the system, rather to offer a glimpse of what some people have to go through to maintain their coverage. As long as health care means health insurance (complicated), we need permanent funding for this sort of "outreach and enrollment" – and a more appropriate name for the ongoing work we do to get and keep people connected to the health care they need.