Ezra Watland, Enroll America Helping Consumers Get Covered & Stay Covered: Lessons From OE2 to Build on in OE3 Ezra Watland, Enroll America

Who we are Enroll America is an independent, nonpartisan, nonprofit 501(c)(3) organization that provides coalition-building and technical assistance support in all 50 states and the District of Columbia. Enroll America is an independent, nonpartisan, nonprofit 501(c)(3) organization with the goal of making health coverage enrollment a way of life and an institutional reality in every community and America, and we view health insurance literacy as an integral piece of our effort to keep individuals covered. We are working to achieve this goal by: Continuing to educate and engage consumers about their options. Improving consumer-facing tools and application support infrastructure Conducting research & developing cutting-edge resources that aid enrollment organizations Empowering local organizations with knowledge and skills to lead the enrollment effort For more information about how to get in touch with state or regional staff, and for information about all of our training programs, you can visit EnrollAmerica.org.

Total 2015 enrollment As of March 2015, 22 million Americans had Marketplace coverage or gained Medicaid/CHIP coverage! That last graphic just showed what had been accomplished after the first open enrollment period. Now with the second open enrollment period over, nearly 12 million people are enrolled in marketplace coverage across the country, with millions more gaining coverage through Medicaid and CHIP as well. Sources: CMS, March 31, 2015 Effectuated Enrollment Snapshot, June 2015; CMS, Medicaid & CHIP: April 2015 Monthly Applications, Eligibility Determinations and Enrollment Report, June 2015

A Comparison of Uninsured Rates by County Looking at the 2013 model and the 2014 model we can see changes in the uninsured rate among different groups. The 26 to 35 age group had the largest reduction in uninsured rate Women had a higher reduction in uninsured rate than men. Among race Latinos had the biggest reduction in uninsured rate. Overall, consumers would were modeled to be more likely uninsured ended up having the biggest reductions in uninsured rates. Rate of uninsured Source: Civis Analytics’ and Enroll America’s data targeting model

Preliminary findings from Oe2

Help Consumers Get Covered and Stay Covered Our Ongoing Mission Help Consumers Get Covered and Stay Covered Research conducted by Enroll America following the first open enrollment period found that individuals who reported that they knew more about the ACA, including new coverage provisions, were more likely to report that they would keep their coverage.

Uninsured & marketplace enrollees wanted more information Note: when it comes to data-heavy slides, the important thing is to not get caught in detail but instead to direct your audience’s attention to one or two key points. The key points of this slide are bolded below. The Uninsured and Marketplace Enrollees Want More Information! Post OE2 Enroll America surveyed its Get Covered America email list of over 1.2 million consumers about health insurance. (Get Covered America is Enroll America’s consumer facing campaign). Over 1,6000 individuals responded to our web-based survey, and while it’s not nationally representative, the findings shed light on how consumers think and feel about health insurance education. [Based that survey], almost half (48 percent) of the uninsured expressed a lack of confidence in choosing a plan for themselves in the future. Marketplace enrollees — those new to the marketplace and those renewing coverage in 2015 —reported being very or somewhat confident about their ability to choose a plan that would meet their needs and budget at a rate 21 percentage points higher than the remaining uninsured. The experience of enrolling may instill a degree of confidence in the plan comparison process. However, similarly to the uninsured, a significant proportion of marketplace enrollees reported still wanting more information about health insurance and almost 9 in 10 marketplace enrollees wanted more information about how to use their coverage. This is consistent with survey research released by the National Health Council in April 2015, which found that only 42 percent of marketplace enrollees who purchased Gold plans, 37 percent of marketplace enrollees who purchased Silver plans, and 24 percent of marketplace enrollees who purchased Bronze plans reported having the information they needed when selecting coverage. Source: Enroll America, A Guiding Framework on Health Insurance Literacy for the Outreach and Enrollment Community, May 2015

Knowledge gaps Only 14 percent of consumers accurately understood these four concepts: deductible, copay, co-insurance and out-of-pocket maximum. Nearly half of assister programs had seen people who did not understand how to use insurance. This being said, there has been quite a bit of research conducted over the past few years on gaps in knowledge among marketplace enrollees about health insurance and how it works. While insured Americans report feeling confident about health insurance concepts, actual understanding is very low Only 14 percent of all respondents accurately understood these four concepts: deductible, copay, co-insurance and out-of-pocket maximum 44 percent of consumer assistance programs had seen people who did not understand how to use insurance Limited health insurance literacy can have very serious consequences, such as buyer’s remorse or loss of coverage completely. Sources: Adapted from Enroll America & Consumers Union Presentation; Loewenstein, “Consumers’ misunderstanding of health insurance,” Journal of Health Economics, September 2013; Kaiser Family Foundation, Survey of Health Insurance Marketplace Assister Programs, July 2014

What the consumers need to know to use their care Why health insurance matters When and how to get covered Financial help (or low or no cost coverage) is available How to find a plan that meets needs and budget How to use health insurance How to keep coverage Where to go for help! There’s lots of information that consumers need to know -- why health insurance matters, when and how to get covered, how to use health insurance, and so on – but here at Enroll America we believe that our role is to help take the burden off of the consumer so that the process of obtaining and maintaining coverage isn’t so overwhelming!

What the consumers need to know to use their care Why health insurance matters When and how to get covered Financial help (or low or no cost coverage) is available How to find a plan that meets needs and budget How to use health insurance How to keep coverage Where to go for help! The bottom line is that consumers need to know where to go for help – whether that’s in person assistance in their community, a consumer-friendly website, or access to a hotline when they have questions. We do not expect consumers to be experts on health insurance, but we do want to empower individuals with the information they need and want when they need it most. The goal is not to make consumers think about health insurance year round, but to help them feel confident and secure with their coverage and navigation of the health care system, so that they can go on living their lives.

Getting the info & timing right is key 1 2 3 Uninsured Shopping for Coverage Covered Above all – getting the info and timing right is absolutely critical if we want to move the needle on HIL. At Enroll America we are segmenting the population into three buckets – the uninsured, those shopping for coverage, and covered. Individuals at these different stages are going to potentially need very different information. Think back to the slide on all the things consumers need to know in order to be health insurance literate – it was quite a bit of info! This approach allows us to engage consumers with “bite size information” using a “right in time” approach.

Getting the info & timing right is key 1 Uninsured Why health insurance matters Financial help is here! In-person assistance is available 1 in 4 consumers who used the Get Covered Calculator immediately went on to start the enrollment process People who got in-person assistance were nearly 60% more likely to successfully get covered And people who got in-person assistance were nearly 60%more likely to successfully get covered so it’s absolutely critical that we connect individuals to in-person help. We have a small window of opportunity to engage consumers, and it’s important that we reach them with messages that work.

OE2: Messages that motivated “Get free, local help with your health insurance application.” “Jenny from Provo got covered for $49.43/mo. See what you qualify for.” “Sign up by the February 15th deadline or you might face a fine of $325 or 2% of your income, whichever is higher!” We tested a lot of different messages and these were the three most important. Emails with these messages performed at least 13% better than our average emails. Referring to assisters as “Free, local help” outperformed calling assisters “experts” Briefly mentioning an example of someone who got coverage for less than $10 a month was a big driver, although telling much more of the consumers story than just this simple fact actually reduced engagement. And, not that surprisingly, nothing was more important than the deadline and the mention of the fine. “Fine” was the keyword there – not fee or penalty.

Getting the info & timing right is key 2 Shopping for Coverage How to find a plan that meets needs and budget Deductible, coinsurance, networks, copays, MOOP, and more! Personalized info has most powerful effect on behavior. Sharing personalized information with consumers will likely have the greatest impact on consumer knowledge, confidence, and retention. When it came to Enroll America and Get Covered America’s programs, during OE1 and OE2, personalized information (e.g. using the Get Covered Calculator to give individuals an estimate of their premium cost with financial help) had the most powerful effect on consumer behavior. However, in order to share personalized information with consumers about health insurance and how it works, information about provider networks and formularies needs to be more readily accessible to consumers and stakeholders working to improve retention and consumer comprehension. The U.S. Department of Health and Human Services (HHS) is taking steps in this direction by requiring health insurance issuers operating in federally facilitated marketplace states to submit formulary information to HHS in a machine-readable format for the 2016 plan year, and has increased provider network transparency requirements that will require health insurance issuers to submit data to HHS in a standardized format. Here at Enroll America we are very excited for better, more complete data – it will allow Enroll America and others to develop the tools and resources consumers need to make informed decisions!

Getting the info & timing right is key 3 Covered Test to see what works! Onboarding sessions for new beneficiaries Informational brochures Community classes Follow-up (phone calls, text messages, emails, direct mail) How to pay monthly premium and why it matters. How to use coverage How to report changes How to file an appeal How to renew coverage Thanks for all the points folks raised! At step 3, when individuals are covered, they also need personalized information, but they need to know less about plan selection, and more about how and why to pay their premiums, how to use their coverage, how to report changes to the marketplaces, how to file an appeal, and how to renew their coverage. The trick is to get the timing and info right. Some options for doing that include: Text message program Onboarding sessions for new beneficiaries Informational brochures Community classes

Getting the info & timing right is key 1 2 3 Uninsured Shopping for Coverage Covered How to pay monthly premium and why it matters. How to use coverage How to report changes How to file an appeal How to renew coverage Why health insurance matters Financial help is here! In-person assistance is available How to find a plan that meets needs and budget

How Do We Get There? Build this 5-Point Framework Into Your Evaluation of Materials or Programs to Learn What Works! Identify the most persistent gaps in knowledge. Understand what information consumers value about coverage. Learn the best times to expose consumers to information in order to positively affect behavior. Identify how and under what circumstances consumers are interested in receiving new information. Know who consumers want to hear from (e.g. health plan or provider). The findings from Enroll America’s post-enrollment survey and HIL email test led to the development of a 5-point framework that Enroll America will be using as we continue to think about and develop programs on HIL. Any program or initiative will help us: Identify the most persistent gaps in knowledge Understand what information consumers value about coverage Learn the best times to expose consumers to information in order to positively affect behavior Identify how and under what circumstances consumers are interested in receiving new information Know who consumers want to hear from (e.g. health plan or provider)

Outreach Tactics that worked

Easy Access to In-Person Assistance Help is Key “Get free, local help with your health insurance application.”

The Fine + Deadline Motivate Consumers “Sign up by the January 31st deadline or you may face a fine of $325 or 2% of your income, whichever is higher” $325.00 Accompanying this key message with an example of someone who got covered also helps. But don’t belabor the story – keep it short and sweet, otherwise consumers lose interest. Something simple like, “Pam from Pennsylvania got covered for $9.43. See what you might qualify for.” These were the top messages that drove consumers from email to our website. Emails with these messages performed 13% better than our average emails.

Affordability is Key Not enough to say “financial help is available” 1 in 4 consumers who used the Get Covered Calculator immediately went on to start the enrollment process Not enough to say “financial help is available” Tell me how much What will it cost? What will it cover? Source: Enroll America, State of Enrollment: Helping America Get Covered and Stay Covered, 2014-2015, http://www.enrollamerica.org/soe_report_2015/?utm_source=EA_homepage&utm_medium=sidebar_1&utm_campaign=EA_homepage

Get Covered Calculator Simple to Use Minimal Variables NOT Trying to be Comprehensive Provides an accurate first estimate https://www.getcoveredamerica.org/calculator

Consistent Follow-Up Matters Enroll America’s Field Program, June 2013- April 2014

New Tool for Consumers and Partners We’re excited to officially announce the Get Covered Plan Explorer! Enroll America will launch a web-based plan comparison tool, the Get Covered Plan Explorer, on GetCoveredAmerica.org later this year for consumers to view and compare health insurance plans available to them through the health insurance marketplace. Empowering marketplace consumers to better understand key features of the health plan choices—what they will pay out-of-pocket for health care services in a given year, and what doctors and drugs are covered—is crucial to maximizing the number of Americans who get covered and stay covered. Maintaining our commitment to a “just the facts” approach to consumer education, the tool will not recommend which plan is best for a given consumer. It will provide clear, easy to understand information about available plans, so that consumers can made educated decisions about what is best for them and their family. Just like Enroll America’s other digital tools (the Get Covered Calculator and the Get Covered Connector), consumers can use the tool for free.

Who Can Use the Get Covered Plan Explorer? Available in FFM states only Consumers can use the tool for free by visiting www.GetCoveredAmerica.org Assisters can also use the tool for free Partners can embed on their websites

Additional Information The Get Covered Plan Explorer will NOT: “Rank” plans Recommend which plan a consumer should choose Use quality ratings at this time

Key takeaways Know the population you serve Learn what enrollees value Meet consumers where they are in the process Just sharing info is not enough Develop partnerships to engage consumers Here are the key takeaways on HIL as we approach OE3 -- Get to know the population you serve and the knowledge gaps that exist Learn what enrollees value about their health insurance through surveys and in-person conversations Design programs that meet consumers’ needs based on where they are in the health insurance coverage process Test different strategies to uncover the best modes of communication–providing written information in plain language is not enough to move the needle on HIL Identify trusted messengers and develop partnerships to engage consumers

Thank you! Ezra Watland EWatland@EnrollAmerica.org