How Patient Navigators Drive the Medicare Open Enrollment Season

On a Sunday afternoon during Florida’s Medicare open enrollment season, Janet Mills is deep into a twelve- or fourteen-hour day of volunteering as area director of the state's patient navigator program, Serving Health Insurance Needs of Elders (SHINE).

This will be her sixteenth Medicare open enrollment season working as a volunteer for SHINE, a Medicare program designed to help seniors navigate health insurance options.

Florida’s 500 SHINE volunteers are on the ground, seeing and hearing Medicare beneficiaries struggle through the application process. Through phone consultations, in-person appointments, fairs, and presentations, the organization helps seniors and caregivers access the information they need to make an informed decision about Medicare.

Mills’ observations show how high-level projections and statistics are playing out on the individual level.

For example, one of the major differences Mills has noted between this year and her past fifteen years of serving at SHINE is the volume of traffic this year.

“We have had an overwhelming response to people booking appointments, face-to-face appointments and calling. It's really increased this year,” she told HealthPayerIntelligence.com.

Each day, two or three navigators work in Mills’ office alone, conducting hundreds of calls with worried Medicare enrollees who could not manage to book an in-person appointment with a navigator. Face-to-face appointments fill up in the first two weeks of enrollment.

The calls and appointments that exhaust the SHINE team are merely the symptoms of a larger problem: when it comes to healthcare, Americans are illiterate.

In early October, a Policygenius survey used Google Consumer Surveys to collect data from 1,500 individuals. The results demonstrated that healthcare coverage confusion discouraged slightly over 27 percent of respondents from seeking medical care.

The trend is nothing new. However, for seniors on Medicare, changes to Medicare Part B coverage and the new Medicare Plan Finder may be compounding the seasonal open enrollment bewilderment.

Starting in 2020, Medigap F plans will no longer be available to new members, as CMS eliminated plans offering full coverage for Medicare Part B. While some payers have quickly adjusted, creating new plans to fill the hole left by Medigap F, Medicare members were left confused about whether or not they would need to switch plans. Some Medicare agents were disseminating mistaken information about this new development.

Furthermore, in an attempt to streamline a complex process, CMS updated its Medicare Plan Finder for the first time in a decade. While the tool aims to increase price transparency and informed decision-making for users, some industry leaders have been critical of the tool, specifically the emphasis placed on premiums over prescription drug prices and lack of personalization based on the enrollee’s prescriptions.

Mills knows how important those factors are in a senior’s Medicare plan search. The first two questions she asks when a senior approaches her for assistance are: who is your primary care physician and what prescription drugs do you take? This helps the client prioritize plans that fit their needs.

SHINE volunteers aim to give clients a broad scope from which to identify the best solution for their healthcare needs, working hard to place a lot of distance between themselves and any specific health plan.

To Mills, although maintaining that distance is one of the program’s greatest challenges, it is also SHINE’s greatest strength. By remaining neutral, she said, SHINE volunteers can offer enrollees a broader view of their options.

“If you are dealing with an agent from one company, then you might not have the whole picture. If you are dealing with an independent agent, you still might not have the whole picture because he might only deal with companies A-B-C-D-E, right?” Mills explained. "I would say the heavy lifting that SHINE does is the education and the advocacy and the time and kindness that is allotted to doing that, the non-biased portion. And then we're also problem solvers.”

While SHINE does not work with payer organizations directly, they frequently attend plan presentations to hear how the agent explains the plan, listen to the questions that the audience has, and prepare for open enrollment season.

Mills said that she and others work with SHINE out of concern.

With the increased number of plans available and technologies that exist to assist in the process, Mills always advises her clients to make sure to check with an insurance agent before moving forward with a plan.

“I speak for myself because I'm really concerned, I would not encourage anybody to enroll online,” she said.

Seniors need the second layer of thoroughness that comes with enrolling through the payer. In that conversation, enrollees can ensure that their provider would be covered and that the prescription drugs they need are in the plan’s formulary. Other resources still cannot provide the same security that addressing these specific needs directly with a payer will accomplish.

Despite her concerns, Mills found a more positive trend in Medicare Advantage plans’ mounting popularity.

Medicare Advantage 2020 enrollment is expected to surpass previous peaks, amounting to around 24.4 million beneficiaries or over 40 percent of the Medicare population.

From her conversations, Mills indicated that even seniors who are not looking to purchase a Medicare Advantage plan want at least to be informed about the plans. Her clients appreciate the variety of options, which are more extensive than in previous years. They are also attracted to the additional benefits and the Medicare Part B coverage which some plans offer.

The concerns that Mills perceived in her community are trends that payers can consider and address as they enter the second half of the 2020 Medicare open enrollment season.