Enrollment Counselors Clarify Coverage for Lower-Income Californians

Clive Smith had already been to The Children’s Clinic of Long Beach once before to speak with Nadya Afredi, a Certified Enrollment Counselor (CEC) for Covered California. He’d submitted his application and Afredi had shown him the insurance plans for which qualified.

“He wanted to go home and just review it,” Afredi said. “Then he called me back and said, ‘Can I come in to complete it and choose one?’”

But now Smith, who works part-time doing building maintenance for the City of Long Beach, couldn’t find the printout for the plan he thought he preferred. So Afredi went through some of the basic questions with him again, like, how often does he visit the doctor in a year?

“It all depends on how I take care of myself,” the 53-year-old Smith said, his accent still giving away his Jamaican origin despite the 30 years he’s spent in the United States. “Sometimes it’s twice a year. But since I’ve been doing bad, it’s like every three months.”

Prescription drugs were his main concern; he’s taking four medications right now. “I take high-blood pressure medication, so it’s not really that serious, but I have to take it,” he said. “That’s my main priority.”

Reviewing the information about his income that he’d previously submitted, Afredi was able to track down the plan he was looking for: the LA Care Bronze plan, under which a primary-care visit would be a $60 copay, and generic prescriptions would be $19.

She handed Smith the printout. “In Clive’s case, the plan would have cost $299.50 a month,” Afredi pointed out, “but with the federal subsidy, he only pays $1 per month.”

Afredi, a 20-year-old graduate of UCLA, is one of 12 CECs at the clinic and one of the almost 3,500 CECs statewide. As of Jan. 11, nearly 2,600 were still in the process of being certified — a process that entails both online and in-person training. Along with 10,725 county health workers and nearly 10,000 certified insurance agents, CECs are key person-to-person “assisters” who help individuals sign up for new insurance under the Affordable Care Act.

CECs fill a role under the Affordable Care Act similar to the one that’s often described as a “navigator” on a national level. But under Covered California, CECs and navigators are not the same thing. CECs are often individuals who have other jobs with the 538 certified enrollment entities in the state (including community-based nonprofit advocacy groups, clinics, faith-based organizations, labor unions, etc.), and they earn a payment of $58 for each individual they enroll. The navigator program has not yet started in California; when it does, most likely later this year, navigators will not only sign people up for coverage, they will also have education and outreach duties. Both aspects of the navigator job will be covered by their salary – i.e., they won’t be paid a per-enrollee bonus.

Despite a slow start when CoveredCA.com went live on Oct. 1, enrollments surged in December. October-December enrollment in exchange insurance plans came in at 500,108 individuals. Covered California hasn’t released statistics breaking down how many of these individuals signed up on their own and how many needed in-person help, but the these assisters have clearly been essential to the strong enrollment numbers so far.

In addition, some 584,000 people who applied for coverage were determined to be eligible for expanded Medi-Cal. Individuals use the same online system to apply for coverage; if their income falls below a certain threshold (up to 133% of the federal poverty level, which works out to about $15,800 a year for one person or $32,500 for a family of four), they are eligible for Medi-Cal.

“In my personal view, the Medi-Cal expansion has been much more helpful and much more important, at least working in a community clinic setting,” Afredi said. The generally lower-income patient population at free and low-cost clinics are more likely to fall into the Medi-Cal range rather than be eligible for the exchange programs.

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Cynthia Carmona, director of government and external affairs for the Community Clinic Association of Los Angeles County, estimates that, among the regular clients of her group’s member clinics, only about 15 percent make enough money to qualify for exchange plans, with most others falling under the Medi-Cal threshold. The undocumented immigrants the clinics serve don’t qualify for coverage at all. Afredi noted that the majority of the applicants she sees are permanent residents, rather than U.S. citizens.

Lilliana Martinez, interim director of health education and outreach at Children’s Clinic, pointed out that Los Angeles County clinics, unlike many others in the state, do have options for undocumented individuals. “We’re also servicing mixed-status families,” she said. “The beauty of it is, we are a safety-net clinic, so the people who don’t have the legal status to qualify for Medi-Cal or Covered California, we can give them information about how to access county clinics and safety-net services, including Healthy Way L.A., the county’s ability-to-pay program.”

Clive Smith didn’t have a computer at home, so he had to rely on a third party to sign up. Bridging the digital divide in California might be one of the most important aspects of the CECs’ role -- that and clarifying the whole process for applicants.

“There’s a lot of different jargon going around -- Obamacare, the Affordable Care Act, the exchange -- and it confuses a lot of people,” Martinez said. “They do have a hard time differentiating between Covered California, because Covered California chose to work up their own exchange, with the media’s discussion of the federal government. We explain that, ‘No, we’re good, our webpage is working!’”

Even after sorting all that out, CECs can face a certain amount of skepticism, as well as a lack of understanding of what exactly health insurance entails. Afredi says she allows two hours for each Covered California appointment; some have run as long as three hours, and return visits like Smith’s are quite common.

“I’ve had people come who, like, bicker with me for two hours,” she recalled. “At the end, when they get their health insurance, they’re thanking me, and it’s amazing to see that.”

Image by Medill DC via Flickr

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