How will health insurance open enrollment look different this time around? With the launch of the second Affordable Care Act (ACA) Open Enrollment Period this past Saturday, November 15, we have reflected on our work with states and charity care programs as they implemented the ACA’s key coverage provisions last year and offer the following lessons:

Lesson 1:  Messaging Matters

Individuals Already Enrolled in Coverage
Individuals who signed up for coverage during last year’s Open Enrollment Period value health insurance and are motivated to keep it. So while there’s little need to persuade these individuals to stay insured, there is a need to educate them about the renewal process. According to a recent Robert Wood Johnson Foundation-funded study by PerryUndem and GMMB, over 70 percent of marketplace-enrolled individuals surveyed did not know when the Open Enrollment Period was or that they needed to renew or choose a new plan by December 15, 2014.

Messaging Strategy:  Provide already-enrolled individuals with basic information about the renewal process.

Uninsured Individuals
Enrolling uninsured individuals during this Open Enrollment Period will be more difficult than last year, as the remaining uninsured will be harder to reach (including populations like jail-involved and homeless individuals) and more likely to believe health insurance is too expensive for them to afford.

Messaging Strategy:  According to PerryUndem and GMMB, three main messages tested well for reaching the remaining uninsured:

• “There are many low-cost health plans to choose from.”
• “Free, in-person help is available to help guide you through the enrollment process.”
• “Millions of Americans will qualify for financial help to pay for insurance.”

Lesson 2:  Enrollment Assisters Continue to Play an Important Role

Navigators, in-person assisters, and certified application counselors (CACs) will continue to be needed to help individuals understand their options and enroll in marketplace coverage, Medicaid, and safety net services. The Centers for Medicare & Medicaid Services has trained 1,400 new navigators and 11,000 new CACs since September to help consumers understand their options. Even charity care organizations, which provide low- or no-cost health services to the uninsured, are altering their business models to serve as enrollment assisters. Enrollment assistance is especially critical for individuals who are:

• Unfamiliar with health insurance “know-how;”
• Eligible for coverage during a Special Enrollment Period” due to changes in “life circumstances;”
• Churn off coverage due to income fluctuations or other life changes; and
• Realize they are significantly affected by the ACA’s tax implications.

Lesson 3:  Affordability Challenges + Narrow Networks = Need for Consumer Education

After individuals sign up for coverage on the marketplace, many are realizing they did not fully understand or appreciate the nuances of their plan choice. For example, many individuals purchased a policy based on its low monthly premium, without considering its high deductible—until, that is, the individual needed expensive medical care and had to pay the $6,000 deductible out-of-pocket. Some individuals with high deductible plans are alternatively choosing to defer care or seek services at federally-qualified health centers, where costs are based on a sliding-fee scale.

Additionally, individuals may have signed up for a plan without knowing that it excluded their preferred providers or hospitals. These narrow network plans are increasingly common (about 48 percent of marketplace networks were classified as narrow in 2014, meaning they covered fewer than 70 percent of providers in a geographic area), and can be a successful way to keep costs down. Yet if consumers do not know what they’re buying, they’re likely to be dissatisfied with their policies.

Better consumer education and more consumer-friendly shopping tools can help address these issues. One step in the right direction is the new ability to “window shop” on the marketplace prior to making a purchasing decision. This feature is available on the federal healthcare.gov website and some state-based marketplaces, like Maryland’s. Enrollment assisters can also provide assistance to help consumers choose the right option and understand how to best use their new coverage.

Lesson 4:  Churn will be an Ongoing Challenge

Churning between different types of coverage (and in some case, on and off coverage) will be a reality for many individuals in 2015 and beyond, given the current patchwork of coverage options available for individuals based on their income, location, and employment. States see benefit in mitigating churn to ensure that people have access to continuous care, yet have run into multiple roadblocks while trying to do so. Nevertheless, there are a number of churn mitigation strategies that states can put in place to help ensure individuals remain covered under the same plan, including:

• Adopt 12-month continuous eligibility or presumptive eligibility for Medicaid-eligible adults;
• Establish a premium assistance program to provide “wraparound” services for individuals transitioning from Medicaid to private insurance;
• Create a Basic Health Program to provide affordable coverage for low-income individuals who do not qualify for Medicaid; and
• Use automatic enrollment or renewal procedures, like SNAP verification or express lane eligibility, to efficiently enroll individuals in Medicaid.

The U.S. Department of Health and Human Services is lowering expectations about this Open Enrollment Period’s results, yet states shouldn’t assume the worst. In fact, states can learn valuable lessons from last year’s Open Enrollment experience and adopt new policies and strategies to promote a smooth and successful enrollment experience in 2014-2015.