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The Affordable Care Act (ACA) was enacted in 2010 to make comprehensive health insurance coverage available to more Americans and support innovative clinical delivery methods created to lower the cost of care. Each year, the program hosts an open enrollment period between November 1 and January 15, when individuals can enroll in Marketplace insurance plans (certain life events reopen the enrollment window outside of these dates, and Medicaid and the Children’s Health Insurance Program accept applications throughout the year).
It’s a critical time of year for the more than 50,000 covered entities nationwide. Successfully navigating individuals through the enrollment process is no walk in the park, but doing so can have a monumental impact on the health of their patients and their clinics’ missions, including their 340B programs.
“It’s important to understand the impact this opportunity affords patients throughout the following year for all their healthcare needs, including any new challenges that may arise,” says Avita Chief Advocacy Officer Glen Pietrandoni. “Selecting the right health plan now creates a patient safety net for the entire year and helps covered entities sustain 340B income to ensure adherence and retention to patients’ healthcare journeys.”
A little help, please?
Avita Manager of Insurance Optimization Mary Jane Hardman has helped covered entity partners analyze and choose the best health insurance plans for more than a decade and says putting in the effort to increase patient enrollment strategically benefits everyone. “ACA insurance allows patients to see providers for underlying health conditions they may have never addressed before because they didn’t have a payor source,” she says. “The covered entities can bill for services instead of pulling money from grants. On top of that is their ability to participate in the 340B drug discount program, which allows them to expand their services.”
However, because the ACA has so many moving parts, covered entities must constantly monitor the data to keep up with patient enrollment and other analytics. “The organizational aspect of it can be overwhelming,” says Mary Jane. “If a covered entity is striving to get patients signed up, wants to pay the insurance premiums, and then needs to ensure patients are coming to appointments and filling their prescriptions using a 340B contracted pharmacy—someone has to keep track of all that.”
To lighten the load, Mary Jane helps potential and current Avita covered entity partners assess their options when selecting plans that best suit their patients’ needs. “I tailor my recommendations to each entity,” she explains. “My assistance might include offering them an ACA 101 seminar and keeping it high-level. Or I can go deep into the trenches and analyze prospective plans for drug formularies, including which medications are tiered and which require prior authorizations. We’ll discuss the importance of making sure a patient’s pharmacy of choice is considered. I’m also there to help them find foundation programs that might offset the cost of premiums and explain what services insurance brokers can offer.”
Seven tips for a successful open enrollment period
After years of consulting on open enrollment campaigns, Mary Jane has turned the process into a science. She offers the following tips to covered entities looking to enhance their SOPs:
1. Clear, concise, and personalized communication is key: Different patient demographics may react differently to various forms of open-enrollment outreach. This includes the channel—from traditional methods like letters and phone calls to digital campaigns via social media, email, and website campaigns—and the core message. Research how your clientele likes to receive information and gauge their level of health insurance savvy, then customize your engagement to assorted groups.
2. Simplify, simplify, simplify: The insurance enrollment process can confuse even the savviest consumer. Make the experience as simple as possible for patients and offer to guide them through the process if needed.
3. Start early and make deadlines clear: The open enrollment period is over before you know it, so inform patients of it well in advance. Emphasize upcoming enrollment deadlines to create a sense of urgency, including leveraging reminders and countdown clocks as the last day approaches. The early bird also catches the worm when it comes to getting your clinic’s providers signed up with new ACA plans. “This might take one year or longer depending on the insurer and how often they allow new providers to be in-network,” Mary Jane says.
4. Don’t be pushy: Act as a source of information for patients while ensuring they feel empowered to make their own decisions. Meeting people where they’re at includes respecting their healthcare choices.
5. Think strategically: Pick your low-hanging fruit first, says Mary Jane. “I advise covered entities to focus first on their re-enrollments from November 1 to December 15, so those patients have a smooth transition on January 1,” she says. “If you have the time, go after new enrollments during that period, too. If not, focus on the new enrollments after December 15th and allow their plan coverage to start February 1.”
6. Look at the big picture: Covered entities helping patients choose an ACA plan should triple-check which pharmacies, medical, and lab providers are in-network and ensure that the plan’s formulary covers a patient’s essential medications. Doing so directly impacts potential revenue generated for an organization’s 340B program.
7. Stay organized and use helpful resources: “You’ve got to have the proper technology in place to easily access your enrollment database, premium details, and other critical information,” says Mary Jane. “The Centers for Medicare & Medicaid Services (CMS) offers a lot of great ACA webinars for free.”
To learn more about how Avita Care Solutions is committed to promoting health equities by providing an integrated suite of comprehensive, compassionate, and inclusive health care and pharmacy services to underserved communities, reach out to us today.
Mary Jane Hardman is manager of insurance optimization at Avita Care Solutions. She can be reached at maryjane.hardman@avitacaresolutions.com
Glen Pietrandoni is chief advocacy officer of Avita Care Solutions. He can be reached at glen.pietrandoni@avitacaresolutions.com.
