It’s open enrollment season. Here’s what you need to know.

By Clarissa Donnelly-DeRoven

It’s the time of year when millions of North Carolinians will pore through health insurance offerings trying to determine what will be the best coverage for them this coming year. Just under half of the state’s residents receive insurance from their employers, the state’s 710,000 Medicare recipients need to update their enrollment, and about a million people in the state don’t have access to health insurance at all. 

Because North Carolina hasn’t expanded Medicaid, thousands of those uninsured in the state fall into the coverage gap: they make too much to qualify for Medicaid and too little to qualify for subsidies that would enable them to buy their own private insurance through the Healthcare.gov marketplace. 

But, a new database by UNC researchers at the Cecil G. Sheps Center shows that far more people across the state are actually eligible for those subsidies and subsequent coverage than are taking advantage of it. 

Along with that, a number of adjustments to the insurance landscape may have made it more possible for many of the state’s uninsured to finally find coverage.

More rural residents are eligible for marketplace coverage than enroll 

In far-western Jackson County, about 12 percent of the total county population is eligible to purchase affordable insurance through the marketplace according to the new database, but only about a quarter of those people are actually signed up. Far-eastern Bertie County sees a similar pattern: 13 percent of county residents are eligible, but just 29 percent of those people sign up. 

This repeats in rural counties throughout the state: significant chunks of the population are eligible to get affordable coverage through the marketplace, but they don’t receive it. 

“A big part of it is just awareness and the traditional structural barriers to enrolling in a program,” explained Mark Holmes, the director of the Sheps Center who worked on the database. Those barriers might include needing to find tax documents from last year, or being overwhelmed by the sign-up platform. 

There are also barriers particular to rural residents. The Federal Communications Commission estimates about 19 million people across the country lack access to the internet, 75 percent of whom live in rural areas. This makes signing up online for health care, obviously, more difficult. It also poses an outreach challenge, which is where the researchers envision this database could do the most good.

“I’m not sure hundreds of thousands of people are going to find this dashboard interesting,” Holmes said, “But those who are interested in helping [uninsured North Carolinians] connect [with health insurance] hopefully will.”

Confused if you qualify? Contact the NC Navigators 

Many people are familiar with insurance brokers as the people who usually help people find health insurance. 

“It is a real business for the folks that are out there,” said Mark Van Arnam, who works at Legal Aid of North Carolina. “That’s the way they make their living, but there is a possibility of going to an agent or broker, and you think they’re going to show you all the plans, but they’re only showing you the Blue Cross plans, because those are the ones that they work directly with.” 

Van Arnam directs a more impartial project helping consumers find the best online marketplace coverage for them, free of charge: the NC Navigator Consortium. It consists of eight different nonprofits, led by Legal Aid of North Carolina, that receive federal funding to help residents navigate the process and sign up for coverage on the federally funded marketplace. 

There are no income restrictions to receiving help from local navigators. They’re present in each of the state’s 100 counties and they work on a hybrid model, meaning you can visit an office for help, or reach somebody over the phone.

North Carolina’s navigator program has existed since 2013, though it has seen massive ebbs and flows in its budget. The Trump administration drastically cut funding to the program nationwide, shrinking its national budget from $63 million in 2016 to $10 million in 2018. The Biden administration has worked to build the program back up, increasing national funding to a record high of about $100 million this year, with at least $6.9 million headed to North Carolina. 

Van Arnam said for this enrollment season, there are about 250 navigators in the state. They are a mix of volunteers and paid staff. Both go through a federal certification process as well as a North Carolina-specific training. 

“Our navigators are really prepared to provide quality service to every consumer, no matter what their medical needs are, or what’s in their formulary, or anything like that,” he said. 

Changes to make coverage more affordable 

If you’ve tried to get coverage through the Marketplace in the past, but it’s been too expensive, there’s a reason to try again this year. A handful of federal policy changes intended to bring costs down are now in place.

For one, “the family glitch is a thing of the past, which we are excited about,” Van Arnam explained. “The family glitch” refers to the very common situation where an employer offers someone in the family insurance, and it’s affordable for them as a single person, but once they add their spouse and children to the plan the cost grows astronomically. 

Previously, because the coverage was affordable for that single recipient, the coverage for the whole family was deemed “affordable,” and those people were locked out of eligibility for tax credits. 

To begin Healthcare.gov coverage in January, you must sign up on the marketplace by Dec. 15 — but, if you miss that deadline, you have until Jan.15 to get coverage for the rest of 2023.

That’s no longer the case, Van Arnam said. 

“There’s over 100,000 North Carolinians who that directly affects,” he said.  

In addition, subsidies used to only be available for people who earned between 100 percent and 400 percent of the federal poverty line (between $13,590 and $54,360 for a single person). Now, subsidies are tied not to income, but to the affordability of the coverage for an individual. 

If, for example, your workplace offers an insurance plan that would require you to pay more than 9 percent of your income toward the premium, “you’re eligible to enter the marketplace and get tax credits,” Van Arnam explained. “Those credits are much smaller, but we’re still seeing them get assistance in paying for their coverage.”

Finally, additional subsidies created with the passage of the American Rescue Plan last March have been extended through 2025 by the Inflation Reduction Act. Those are expected to keep premium costs from rising significantly.

I know I’m going to lose my Medicaid coverage once the Public Health Emergency ends. Should I sign up through the Marketplace now?

Open enrollment is the period during which anyone can sign up for coverage and usually if a buyer misses that window, they’re out of luck until the following year. 

But if people have coverage — private or Medicaid — and then lose it outside of the open enrollment period they don’t have to wait for the next open enrollment session to get insurance. They qualify for a “Special Enrollment Period” and need to sign up within 60 days of losing coverage.

The NC Navigators have been connecting with statewide and local organizations who are connected with many Medicaid patients so that when those people are rolled off the program, the navigators will be able to help them find coverage.

“Many of them will be eligible, and they will get plans at $0 a month, $3 a month, $10 a month after those tax credits,” Van Arnam said, “We’re ready to help.”

If North Carolina still hasn’t expanded Medicaid by the time the federal emergency ends, Van Arnam said the navigators can still help people in the coverage gap. The organization has relationships with free and sliding scale clinics across the state to help people get the medical care they need. 

“There’s so much misinformation out there and so much politicization of the law,” he said. “It’s not a political thing to us. It is all about making sure folks can go to their doctor, and lead happy, healthy and productive lives.”