The United Way of the Greater Triangle is offering $1 million in financial assistance to help low-income residents obtain health insurance at no monthly cost.
The unusual approach, funded by an anonymous donor, will pay monthly insurance dues that are not covered by federal subsidies under the Affordable Care Act.
For many low-income households, that could be about $50 to $100 a month - amounts that have proved too expensive for some financially struggling families in the first year of the Affordable Care Act.
"We had people who walked away with premium payments of $50 a month," said outreach and enrollment coordinator Ricardo Correa of the Lincoln Community Health Center in Durham.
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"And when we called them back to see how they were doing," Correa said, "some just couldn't afford it, and they stopped paying it."
The United Way's PremiumHelp program demonstrates the intense grass-roots commitment the Affordable Care Act has generated in North Carolina. Aggressive outreach efforts here have resulted in the state achieving the fifth-highest enrollment nationwide this year.
Nevertheless, PremiumHelp also underscores the unwieldiness of the federal health care law. United Way's well-intentioned program is facing resistance from some navigators in the state as well as from health insurance companies here.
"All of this has been complicated," acknowledges Melanie Davis-Jones, United Way's senior vice-president for marketing.
Launched last week, United Way's PremiumHelp is believed to be one of only a handful of such programs in the country; it's modeled on a similar approach in Wisconsin, now in its second year.
As a one-year experiment, PremiumHelp is available only in Durham County, and only to residents in the lowest income bracket. United Way expects to be able to assist 700 to 800 households with the $1 million it received for 2015.
The program is open to households within 100 percent and 175 percent of the federal poverty level, whereas ACA subsidies are available up to 400 percent of the federal poverty level.
Thus a 25-year-old with a household income of $17,000 could get a Blue Cross and Blue Shield "Blue Select 3500" plan for only $100 a month (after receiving $275 a month in federal subsidies). PremiumHelp would pay the outstanding $100, bringing the monthly cost to zero.
"Our program is designed for them to have no out-of-pocket costs for their premium," Davis-Jones said. "Providing access to health care is a priority for our organization."
But PremiumHelp is available only for Blue Cross insurance policies. Two competitors - Coventry Health Care of the Carolinas and UnitedHealthcare - have not agreed to participate.
Walt Cherniak, spokesman for Aetna, Coventry's parent company, said the insurer doesn't participate in voluntary financial assistance programs because of the "administrative complexity" involved.
UnitedHealthcare issued a statement Tuesday saying it is open to participating. The insurer has less than two months to decide before open enrollment closes Feb. 15 for the ACA health insurance marketplace.
PremiumHelp's success depends on publicity from navigators and certified assistance counselors, the volunteers and social workers who are trained to explain the workings of the health insurance marketplace and subsidized coverage to first-time insurance users.
Some navigators in Durham are reluctant to promote United Way's program for fear of running afoul of federal rules that prohibit navigators from promoting one insurance carrier over another.
"I'm not going to do anything until I receive guidance, because it puts us in a precarious situation to mention it," said W. Scott Edmonds, a trained navigator and a program manager at the Benefit Bank in Durham.
Edmonds said he'll describe PremiumHelp only if he is asked about it, but he won't volunteer information about the program.
Correa, at Lincoln Community Health Center, provided similar guidance to Durham County navigators in an email Friday:
"United Way has decided that a Health Care Center can promote the program, but can't initiate the interaction between a health center employee and a patient/customer," Correa emailed. "We can have posters and literature, but the staff can't announce it to the public."
North Carolina navigators who elect to mention PremiumHelp to the public will also have to explain other nuances: The program doesn't cover all health care costs, such as deductibles and co-payments.
And navigators will have to explain that financial assistance from PremiumHelp could result in the household having to pay extra income tax and also return some federal subsidies at the end of the year.
United Way officials are erring on the side of caution and are advising Durham navigators that the PremiumHelp donation will boost a beneficiary's household income, even though the payment will be made directly to the insurer, not to the household.
So in the earlier example involving the 25-year-old Durham resident, if PremiumHelp paid $100 a month toward that person's insurance for 12 months, the program would increase his annual income by $1,200. Since federal subsides are based on household income, the United Way's financial assistance would reduce the person's monthly subsidy by $12.
That would require the PremiumHelp beneficiary to repay $144 in subsidies at the end of the year. The maximum amount a consumer has to pay back to the IRS is capped based on income.
Wisconsin officials, however, have reached the opposite conclusion. Their donation is also sent directly to the insurer and never touched by the low-income person who benefits from it, said Jay Young, the program's coordinator for community engagement.
Wisconsin's HealthConnect covers households between 100 percent to 150 percent of the federal poverty level. The program made payments to 792 households in the first year of the Affordable Care Act, Young said.