This is a continuation of the Special Enrollment Period verification conversation from earlier in the week. I am of the opinion that the new CMS requirement for eligibility verification for the four major qualifying events is a reasonable accomodation to insurer’s needs to promote a more stable market and for people with legitimate qualifying events, not a significant barrier. Someone I greatly respect disagrees.
Data show fewer than 15% of SEP eligible have used SEP; roadblocks shouldn’t be priority. https://t.co/DRUq5ZA6zM https://t.co/av9cR2hhiq
— Claire McAndrew (@claire_mcandrew) February 25, 2016
The five major QE’s that make up 75% of the SEP triggers that now need verification are:
- Loss of minimum essential coverage
- Permanent move
- Birth
- Adoption, placement for adoption, placement for foster care or child support or other court order
- Marriage.
From my perspective, the triggering event produces official paperwork in four of the five scenarios and that paperwork arrives very quickly. It is not a case of an individual needing to find an original birth certificate from halfway across the country. Is my middle class privilege overwhelming reality here? I don’t think so, but I need a reality check
The loss of minimum coverage triggers a COBRA eligibility letter if the loss of coverage is because of a job loss that had ESI. If an individual makes too much for Medicaid or otherwise loses Medicaid/CHIP, a termination letter with appeals rights is sent. If the loss is due to the non-payment of premium, termination letters are sent. This is recent paperwork.
Birth of a new baby produces lots of poop and a birth certificate.
Marriage produces a marriage license. Divorce produces a divorce decree. Both of those documents are freshly produced after 1/1/16.
Adoption, foster care, adoption placement, and child support produces reams of legal documentation and orders. And again, this is fresh documentation after 1/1/16.
The hardest one to prove for some people is permanent move. Middle class individuals can easily produce a signed lease or a mortgage or several bills at a distinct address. However, people who are far less connected to the system may be using informal housing arrangements without leases or documentation, and they may only have a few bills and no bank account. Those bills could be paid online and thus it would not matter if they all still went to a parent’s address 2 states away as they always were thrown away. This is a challenge in my mind, but that is the only QE that is not guaranteed to produce recent verification documentation.
Does this make sense?
Mayken
Part of the barrier may be that, in at least a few of those cases, the documentation does not come to you for free and/or must be obtained in person from a court house. Another thought is the population that is most often going to end up needing the SEP are among those for whom navigating these types of bureaucracies is very hard – working poor, mentally ill, addicted etc. – however simple it seems to us with middle-class, able privilege. The fact that only 15% of eligible persons have used the SEP certainly points to something big being wrong here.
KH
What professional gamblers used to do with online gambling to get an official address in a different state is start paying a relative’s utility bills (they pay you back, of course).
So the move should be easy to fake. That’s good, because it should continue to help kill this abortion of a health insurance system.
BubbaDave
My only question about that 15% number is whether it reflects eligible people and not people for whom a change would be rational. For instance, if I were getting coverage on-exchange and married another person who was getting coverage on-exchange, that’s an SEP event but it wouldn’t necessarily make sense for either of us to change our health insurance, right? So it wouldn’t be that we weren’t able to take advantage of the SEP, it’s that we rationally chose not to?
Richard Mayhew
@Mayken: I agree, getting a copy of my marriage license from almost half a lifetime ago is expensive. However, that license is not needed for a current SEP validation. If I got married in the past 2 months, I would have a fresh copy of the license either currently with me, or in the mail from my county to get the fancy-schmancy one.
Same with divorce decrees. An old one might be a pain in the ass to get, but a recent divorce that just finalized, the paperwork is there.
Court orders for child custody are commonly handed out as they are needed to get kids in and out of schools, get doctors to talk to non-related guardians etc.
Moves are a pain in the ass to prove.
@BubbaDave: Yep, eligible versus makes sense is a good question.
@KH: What would you replace this system with that is both better and can get enough votes in Congress to pass within the next 5 years?
nutella
I’ve always been unhappy with the common practice of determining residence by providing a printed utility bill with your name and address on it. IL drivers license does that (or used to do, I haven’t renewed lately).
This leaves out the many people who don’t get printed bills any more as well as the many, many people who don’t live alone. If two or three adults live in the same apartment, are they supposed to split up the bill-paying so one pays the electric bill and one the gas bill and one the phone bill … wait a minute, there’s no phone bill for the residence any more because how many people have land lines now? … just in case one of them has to prove their address to a government agency some time.
Raven Onthill
Just getting paperwork can be fairly difficult, and Congress invariably raises such bars higher and higher, to shut out the “undeserving” poor. For instance, it can be hard to prove a move. Getting a state to recognize residency has been made fairly difficult because “terrorism.”
There seems to be a conspiracy to prove all the bad things that conservatives have been saying about government-provided health care. This is like drug-testing welfare recipients; it’s going to cost a lot of money to bring in very few scofflaws.
Papers, citizen?
Ruckus
@Richard Mayhew:
Don’t you know that if you don’t like a government program you can wish for a unicorn and if you click your heels just right, twice, it will magically appear and having the power to make everyone you don’t like listen and obey your every wish, will change a multi billion dollar program that thousands of people argued about, designed around current practice – taking into account the costs and impossibility of complete change, to just that program that everybody will love. Because MAGIC.
The Other Bob
Shouldn’t pregnancy, not childbirth, be a QE?
Mayken
@Richard Mayhew: Does every state and jurisdiction automatically and for no cost issue a marriage/birth/divorce decree? I know for a fact that here in CA, a copy of the marriage license is neither automatic nor free. And I’m not talking the fancy schmancy one. The “license” fee pays for the county to record it. If you want more than a letter that says your license was recorded (if you’re lucky; lots of couples I know never get the letter) then you have to pay extra. I don’t know how it works for birth’s in CA, but I have exactly one piece of paper from a foreign country about the adoption of my son and I wouldn’t let an insurance company have it if my life depended on it.
I’m not arguing it’s an impossible barrier but unless one has a guarantee from every state and jurisdiction that all the QEs trigger an automatic and free document, I think it is sorta middle-class privilege-y to say it’s not much of a barrier.
ETA: I also never got a copy of my divorce decree here in CA. Just a letter. And I’m the one who filed for the divorce.
Richard Mayhew
@The Other Bob: From a risk insurance perspective, pregnancy should be an automatic Medicaid qualifying event and not a SEP —
https://balloon-juice.com/2015/07/01/pregnancy-and-open-enrollment/
New York has pregnancy as a qualifying event, and it can work as long as there is very good risk adjustment. But it is iffy.
Richard Mayhew
@Mayken: Would you scan a copy of that 1 piece of paper and e-mail it to the insurer?
That is all that is usually needed.
Kylroy
@Richard Mayhew: Stop being distracted by the suffering people, Richard, and remember the most important thing: destroying health insurance companies.
Richard Mayhew
@Mayken: But the letter saying your divorce was finalized is sufficient to validate a SEP.
PsiFighter37
OT: Christie just endorsed Trump. Must be counting on a Veep / AG nod?
Mayken
@Richard Mayhew: Ah, I did not know that. For some reason I was thinking certified copies like with so much else we do with the government. Heh. Yes, those things will decidedly lower the barrier. Though, like I said, best make sure the court really sends the letter. I’ve had to call more times than I can tell you. Heh.
M
Mayken
@Richard Mayhew: So, then, yes, likely we are looking at other issues – or perhaps making sure that said persons understand – as I did not – what the actual documentation requirement is.
I will also say that we know there is a large population who quite literally needs to be held by the hand when these kinds of things need to be done. Not because they are lacking in intelligence but because they have various daily challenges that make doing what seems to us easy very, very hard. My brother does mental health advocacy work and the vast majority of his clients he spends hours just helping them do paperwork, walking them to places to get documents they need etc. Admittedly he’s dealing with vastly more complicated systems most of the time, but I know many of his clients would find getting the piece of paper that says they just got married scanned and sent off more than they could handle on any given day without him.
Shrug.
Also, admittedly, many of these folks may be covered by other services and programs so maybe I am projecting.
I don’t argue that this is responsible for the entire 85% of people who don’t take advantage of the SEP but it does make me wonder.
M
Kylroy
@Mayken: I’d like to see that 85% not using drilled into. BubbaDave pointed out that being eligible for an SEP doesn’t necessarily mean you’d want to use one; I also wonder how much of this is simply widespread ignorance of what the rules are now. Until 2014, we’d had a century of insurer-dominated healthcare where none of the five listed events entitled you to purchase health insurance coverage – I can’t imagine people’s reaction to these events to change a huge amount in two years.
piratedan
well…. say for example with the change of address… you go from having an address to no address. Say for example that you’re living with friends until you get a new address, or can save up enough money to get a security deposit for a new place. That kind of transition essentially sucks and is fraught with fluidity as you try and get re-established. how can this happen? Kid gets kicked out of the house, you break up with a significant other, someone gets arrested and the arrangement isn’t quite as arranged as it used to be…. and naturally, you’d have to change it again once things resume a sense of normalcy, if you can achieve it.
Mayken
@Kylroy: Yes, I definitely don’t think external barriers account for the whole block. ETA: Ignorance of the new process is almost certainly at play here. There is probably also a pretty big helping of “not gonna do it!” or similar sentiments involved in that number. I was just throwing out some “for instances” because I suspect external barriers are significant here as well.
gvg
Foster care paperwork isn’t as efficient as you may imagine. We only fostered about 13, most for 3 weeks or less. 2 long term resulting in 1 adoption. Paperwork…well we got a placement letter on all of them but anything else varied alot. The efficiency from one case to another depended on how hostile bio family was about giving info (like actual name) how much was known (like who the child left at a nurses station really was) competance of case worker, which private agency handling the case as Florida “privatized” most of child welfare and its now fragmented and different everywhere. State is supposed to give them all insurance not us though we can add them to ours for supplemental if it makes sense.
Adopted nephew, we had trouble getting official new social security paperwork and getting his insurance because of it. Fun.
Both the long term foster we tried to adopt and the adoption have had stolen social security number issues related to healthcare bills and tax credits. Their info is in too many places and easy to steal and I don’t know how to fix that because the info is needed by a lot of agencies. Its been terribly inconvenient and yet I wonder if it doesn’t mean extra checking is a good idea with foster care? I suspect if the short term cases we took care of had their data stolen, it likely wouldn’t get caught.
Foster care is a small % of the population though so perhaps its not worth making special rules for.
My impression is that many states are less competent than Florida, which is scary.
Roger Moore
@The Other Bob:
No. Qualifying events are things that change your insurance category. That could be a move, which requires you to get different insurance at a new location or a change in the people being covered (marriage, divorce, birth, adoption, or death). That’s different from a pregnancy, which is a medical event that should already be covered under existing insurance.
Matt McIrvin
Hmmm… the last time I started a new job, I actually needed a birth certificate for myself (for I-9) and a marriage certificate (for something to do with health insurance), and both of those cost significant fees.
My parents were given a certificate of live birth when I was born; this had faded into illegibility, but they did get one. I think I have one for my daughter from when she was born.
But I don’t think I was ever given a free marriage certificate by anybody! There was the license, but that got handed in when we were legally married.
Mnemosyne
@Mayken:
I think middle-class people (like me) tend to forget how many people were just going without insurance entirely unless they got it from their employer. If you never had insurance at all, you’re not going to understand things like open enrollment times or qualifying events. It would be like throwing me into a hockey ring and expecting me to understand all of the rules.
NonyNony
@The Other Bob:
If it was, then people could choose to go with minimal coverage until they got pregnant, then switch to better coverage. It would be a way to game the system and drive up costs overall.
Personally I think it should work that way and that we should pay for the expense of doing it that way out of taxes (because pre-natal care is important and it isn’t like the baby is the one who made the boneheaded decision to lowball their coverage and then get pregnant), but there are a lot of things that don’t work the way I think they should work.
NonyNony
@Mnemosyne:
Oh Grod this.
I’ve had insurance coverage all of my adult life through either my employer or my spouse’s. And to be honest I still don’t understand everything about open enrollments and qualifying events.
Mayken
@Mnemosyne: Yes, this. And even here in Ca, where I think we are doing a pretty good job of advertising and making the system accessible, there is still just the standard, everyday bureaucracy to navigate.
Matt McIrvin
@Mnemosyne:
A lot of people who surely had had employer-based insurance since forever acted as if these were strange alien concepts when they came up in the context of the ACA. Of course, a lot of that could have been political play-acting.
currants
@Mayken: I think the moving might be the biggest hurdle: lower income = instability, which includes housing. And if you’re moving frequently, it is unlikely that all your mail catches up with you (if you even have a place to get mail). I moved something like 27 times once in a 2 1/2 yr period (because poor), and–well, in addition to mail having a hard time following, things get LOST when you move, and the more frequently, the more is lost. And the more likely you are to decide you don’t need X stupid pieces of paper, and then….
So the 85% is probably pretty important. And invisible at least in part because of this privilege you mention.
Ruckus
@Mnemosyne:
I went without health insurance for 6 1/2 yrs, pre-ACA. Now I had all the paperwork I needed but this came about from getting a passport nearly 2 decades ago, what I lacked was money. And then it got worse. I had no address, living with a friend. I also used to purchase healthcare (and workers comp) insurance for my business. Still, navigating the requirements, filling in the current health form, having the papers handy took effort to try and get insurance was a pain in the ass. So even if you are somewhat conversant with everything, it still takes effort. And time. We won’t even talk about the prohibitive cost of the insurance. The ACA, at least how it works in CA, is easier, but still not a 2 minute process. Now if you want to discuss bureaucracy come on over to my side of the street and we will discuss the VA. Works wonderful most of the time. Have any little issue outside of their normal channels/procedures and it gets logarithmically more difficult and frustrating. How many people here have had to discuss things with the SSA? From what I’ve seen the major issues are that people don’t have any clue how/what things work and either ask for something that can’t be done or is so far outside the norm. It’s an information/education thing. You can get what you need (if it’s legal) but you have to know how to go about it and work within the system. Many citizens either have no idea about systems or actively fight working within them. All that individuality stuff maybe.
Roger Moore
@gvg:
Realistically, though, kids in foster care really ought to be getting coverage from the state, not from their foster parents, especially if they’re short term. It will take longer to get the paperwork through than a lot of the short term stays, and there will likely be better continuity of care if it’s covered by the state.
Ruckus
@Matt McIrvin:
Employer based insurance is understandable but unless your job is in HR and working with insurance, you most likely are not going to know many details. And when faced with all of those details front and center it is far easier to fall back on what you know, and that is that someone else took care of all of them. Having seen a large company discus healthcare insurance changes a few yrs ago with all their employees, it was obvious that most people had no clue, not one, zip, nada, zero, the square root of jack, about it more than they had some.
Brinks Truck Driver
Re: paperwork for loss of Mec from employer-sponsored coverage.
Employer-sponsored health plans have 44 days to send out the cobra election notice, which can be a long time without coverage for some people.
Raven Onthill
Of course, if everyone was covered, this would not be a problem.
Nah. Makes too much sense.
Kylroy
@Raven Onthill: You must be a hoot to game with.
“What strategy should we pursue, Raven?”
“I think we should WIN!!!”
Currants
@currants: 27 times? Where did that come from? It was 14 times, 2.5 yrs.
Raven Onthill
@Kylroy: that’s a goal, not a strategy. I keep hearing how the ACA system will slowly be improved. And yet the biggest changes seem to be making it worse.It might help if we set a goal of covering the whole country, rather than trying to figure out how to dice and slice coverage to keep people out.