Viewpoints: September/October 2013

<!–– Assisting Patients with Health Insurance Exchanges ––>

With many Americans looking for healthcare coverage starting Jan. 1, 2014, the importance of understanding the new health insurance exchanges cannot be overstated. A recent Kaiser Family Foundation poll showed that over 40% of the U.S. population is still unaware of the current status of the healthcare law, and pharmacists can play an important role in patient education initiatives. By using the patient’s prescription profile and various website tools, pharmacists are ideally situated to assist patients in enrolling in a health plan.

Helpful Site
The subsidy calculator created by the Henry J. Kaiser Family Foundation can be a helpful resource for your patients. The calculator can be located at subsidy-calculator/

Before patients go online to begin the enrollment process, you can educate them about who is eligible to use the exchanges and what documents and information they will need to sign up. Only U.S. citizens or nationals living in the United States can use the exchanges. Eligible individuals should have the following items before they begin the process of enrolling:

  • Social Security numbers for each family member.
  • Employer and income information for everyone in the household who needs coverage.
  • Policy numbers of current health insurance plans covering household members.
  • Completed federal Employer Coverage Tool form if anyone in the household is eligible for employer-sponsored coverage, even if he or she does not enroll in it.

You can find links to each state’s individual exchange via, the federal government’s website. For patients living in states that have chosen to default to the federal exchange, this is the website where enrollment will take place.

Subsidy Calculator

Individuals and families with incomes between 100% and 400% of the federal poverty level will be eligible to receive premium subsidies to help offset the cost of insurance. For a family of four, subsidies will be available to those with an annual income roughly between $24,000 and $94,000.

One helpful tool is the subsidy calculator created by the Henry J. Kaiser Family Foundation. The calculator can be located at With this calculator, patients receive an estimate of how much they can expect to spend on health insurance, along with their eligibility for subsidies. The calculator is easy to use. It involves answering a series of six simple questions. The first two questions require patients to enter either their annual income or the percent of poverty level, if known. The calculator also asks if the person has available coverage options through his or her employer and poses questions about family size (number of adults and number of children enrolling in the exchange). Current tobacco status is also taken into account. After submitting the information, the calculator gives an estimated dollar amount of subsidies the person is eligible for and the cost of premiums based on a silver-level plan. Aside from the actual subsidy calculator, the site itself offers some valuable explanations on the different levels of coverage, catastrophic coverage, and out-of-pocket costs.

For independent pharmacists, this may pose a unique opportunity to turn your pharmacy’s website into an information center on the insurance exchanges.

You may choose to direct patients to this website; the Kaiser Family Foundation has also given permission for organizations to embed the calculator in their website. (Instructions on how to do this are available at the above website.) For independent pharmacists, this may pose a unique opportunity to turn your pharmacy’s website into an information center on the insurance exchanges. Creating this hub for information could help to drive website traffic.

Prescription Profiles

Healthcare navigators and certified application counselors (CACs) may directly assist patients in signing up for health insurance through the exchanges. Therefore, as patients are signing up for new insurance plans, you might experience an increase in requests for prescription profile printouts.

States such as California and Massachusetts already have their exchanges online for plan comparison. These exchanges, Covered California and Health Connector, respectively, were the first to launch, but all states should have their exchanges online by Oct.1, 2013. For pharmacists providing advice to patients signing up for insurance on the exchanges, the prescription co-pay information found on these websites can be invaluable. Based on a patient’s current medication list, you can help patients calculate their monthly medication costs using the co-pays listed for a particular plan. This information may also lead to other educational opportunities, such as discussing the nuances of co-pays and formularies. Bronze and silver plans have lower premium costs than gold- and platinum-level plans. However, these plans are more likely to subject brand medications to an annual drug deductible before patients pay a co-pay for the prescriptions. Although you can provide tools for comparing coverage and answer drug questions, the decision of which plan to choose is ultimately up to the patient.

Reaching Patients

Flu shot season provides an opportunity to assess how much your patients know about enrolling in health insurance exchanges, and it can create an opening for directing them toward your website, where they can find more information. Remember, word of mouth is a great advertiser, and having even a dozen patients each day spread the word may have a profound effect on your community. See the box at right for examples of ways to reach patients about exchanges.

You should also remember to inform patients that they should only enter sensitive information into the government website,, or a state-run exchange website. With emails promising cheap premiums, insurance “sales” calls, and fake navigators springing up everywhere, identity theft is a major concern surrounding the open enrollment process. That said, you should be careful in handling any patient identification information, including Social Security numbers and W-2 forms. These documents should be treated according to HIPAA privacy requirements and be returned to the patient.

Pharmacists will be called upon to help patients research health plans on insurance exchanges. Using prescription profiles, income levels, and employment information can help patients choose the health plan that best fits their needs at a price they can afford. Being knowledgeable about the exchanges will better prepare you to assist your patients. Making your pharmacy’s website an exchange information destination will help ensure that everyone has coverage on Jan. 1, 2014. CT

Ann Johnson, Pharm.D., is a pharmacist consultant, and Kelly Dye is an Ohio Northern University School of Pharmacy Pharm.D. candidate on rotation at Pharmacy Healthcare Solutions, Inc., in Pittsburgh, Pa. The authors can be reached at and