Norma and Rodolfo Santaolalla have always worked but have never had health insurance.  When the Arlington, Va., couple tried to apply online for coverage under the health care law, it was just too confusing.

“I didn’t understand about the deductibles and how to choose a plan. It’s difficult. It’s the first time we’ve done that,” said Norma, 46, who cleans houses for a living.  Rodolfo, 47, is a handyman. “That’s why we came here, to ask them to help us.”

“Here” was the Arlington Mill Community Center, where help was available on a recent Saturday as part of a national effort to increase Affordable Care Act enrollment, especially among Latinos.

Hispanics represent about a third of the nation’s uninsured, and for a number of reasons, signing them up has been harder. According to the latest government statistics, as of Jan. 16, two months into the current open enrollment period, just 10 percent of those who had enrolled in the 37 states served by healthcare.gov are Latino. Despite a concerted effort by officials and health law advocates to reach Latinos, that’s up only slightly from 7 percent during the first few months of last year’s enrollment.

Experts caution that those numbers are reported by applicants and there’s no requirement that anyone signing up for coverage on healthcare.gov state their race or ethnicity. Nonetheless, the Department of Health and Human Services and pro-health-law groups have stepped up their efforts through media campaigns and with a greater emphasis on the kind of in-person assistance the Santaolallas and many other Latinos are seeking.

In fact, nearly a third of the ACA’s media budget this year is focused on Hispanic media, tripling the 10 percent spent on reaching Latinos last year, according to HHS Secretary Sylvia M. Burwell.

Providing in-person assistance, however, takes time.  A session can easily run 90 minutes to two hours, and several meetings are often needed to explain how insurance works and what the various options are. Even though applicants may qualify for the law’s tax credits, many will have to still pay a premium each month. And people who have been doing without health insurance might not feel the need to pay for it.

Still, since October 2013, 2.6 million Latinos ages 18 to 64 gained insurance through the health law, according to HHS.  As of last June, the percentage of Latinos without health insurance dropped from 36 percent to 23 percent, with the highest gains in states that adopted the health law’s Medicaid expansion, according to a Commonwealth Fund analysis. That’s important to the success of the overall health law, because uninsured Latinos tend to be young and healthy. They are likely to use fewer medical services and thus will help offset the cost of sicker people in the insurance “risk pool.”

To enroll, though, some Latino applicants have to work through extra paperwork and overcome language barriers.

Joaquin Barahona, 41, is a construction worker. He’s never had health insurance, and when he did go to the doctor, he paid cash.

When he tried to enroll in the health law in late January, at the Legal Services of Northern Virginia in Arlington, he found that the health law’s website couldn’t verify his identify. Now the Centreville resident will have to mail in additional documents, including his employment authorization card.

That same evening, Lusmila Morales, 53, also hopes to obtain ACA coverage. She sent in a paper application last year but never heard back and wanted to try again this year. She brought along her 17-year-old nephew to translate.

The Falls Church resident is applying for health insurance “out of necessity,” said her nephew, Daniel Palacios. She has arthritis but can’t afford the medication. She needs a mammogram and a physical but can’t afford the tests. In addition, her mom has diabetes and she wants to find out how her parents — who are both in their 80s and here legally but without the work history that would qualify them for Medicare –can get coverage under the health law.

But Morales couldn’t complete her application because she forgot her green card, which proves she is a lawful permanent resident of the United States. She would have to come back.

One of the most stubborn obstacles is the widespread fear in the Latino community that those who are eligible for coverage might endanger others in their family who are undocumented. That concern persists even though President Barack Obama and other administration officials have said repeatedly that no information on a health law application will be used for deportation purposes.

“The federal government can proclaim every day, every hour on the hour how immigration information in the exchange is not going to be used for deportation proceedings, but it’s still really scary,” said Alicia Wilson, executive director of La Clinica del Pueblo, a Washington, D.C., health center that provides comprehensive services primarily to the Latino community.

“You don’t want to be the family member that because you signed up for coverage you’re getting your grandmother, your uncle or your parent deported,” said Anthony Wright, executive director of the group Health Access California, a health care consumer group.

Mixed immigration status families also face special challenges when it comes to enrolling in the health law, Wilson said.  Some may be here legally but are not eligible for coverage under federal programs. Some may have children who were born in the U.S. but other family members who are undocumented.  Some may qualify for health insurance through a job while family members qualify for Medicaid or the Children’s Health Insurance Program.

“Each one of those insurance vehicles has a different enrollment process and different eligibility criteria, a different set of documents that you have to demonstrate, a different level of proof of who you are and a different schedule for enrolling and reenrolling,” Wilson said. He added that the identification process can be even more difficult for those who do not have a credit history.

The patchwork of state-based and federally based exchanges can also cause confusion, with some state governments more welcoming than others when it comes to Latino outreach and enrollment efforts.

Just over half of states have expanded their Medicaid programs, with Indiana the latest to make the change. According to HHS, if all states participated in the health law’s Medicaid expansion, 95 percent of uninsured Latinos might qualify for Medicaid, CHIP  or tax credits to help lower the cost of health insurance on the federal and state marketplaces.

In states like Virginia, which has not expanded its Medicaid program, individuals must earn at least $11,670 a year to qualify for subsidies to buy coverage on the exchange. Those who earn less fall into the “coverage gap” because they don’t qualify for their state’s existing Medicaid program and don’t earn enough money to qualify for the health law’s financial assistance.

“It’s heartbreaking to tell them,” said Leni Gonzalez, outreach and education specialist with Enroll Virginia. .

The fact that this year’s enrollment period is  three months shorter than last year’s further complicates efforts to enroll the uninsured.  And those who work with the Latino community say because so many in it have been uninsured for so long, it’s not surprising that it will take longer to increase their enrollment.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Almost 6.5 million consumers qualify for an average tax credit of $268 per month through the Health Insurance Marketplaces

It’s been more than two years since most health plans have been required to cover all Food and Drug Administration-approved methods of contraception without requiring women to pay anything out-of-pocket. But even though an unplanned pregnancy would cost an insurer a lot more than the contraceptives to prevent it, some insurers still try to limit what they cover.

In a recent twist, a reader wrote to Kaiser Health News saying that her daughter’s insurer had moved her generic birth control pill out of the zero copayment tier of her plan’s formulary into a higher tier that requires cost sharing of $19 per month.

That’s not surprising, says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. Regulations that allow insurers to use “reasonable medical management techniques” to control costs open the door to excluding some generic pills from free coverage, Sonfield says.

The regulations allow a plan to charge for a brand-name contraceptive, for example, if an equivalent generic is available without charge.

But it doesn’t follow that a plan can charge for most generics as long as it offers some for free, Sonfield says.

“All generics aren’t the same,” he says. “All of the different formulations should be on the zero tier, but that isn’t clear in the current guidelines.”

The health law’s contraceptive coverage requirements are aimed at improving preventive care for women. Most health plans have to comply. Plans with grandfathered status under the law are exempt as are those covering employees of religious institutions and certain privately held companies whose owners have a religious objection to covering contraception for their employees.

This isn’t the only instance in which insurers have tried to sidestep the law’s contraceptive coverage requirements. Some insurers have refused to cover the contraceptive patch or vaginal ring, claiming that those methods use the same hormones as birth control pills. Administration officials said they were separate types of hormonal methods and grouping them together isn’t permitted.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Mental Health Parity and Addiction Equity Act of 2008 is viewed as a landmark step in improving patients’ access to mental health services. The effort was bolstered in 2010 by the Affordable Care Act. The bottom line: Individual and group insurance plans that choose to offer mental health coverage now must do so at a level equal to that of medical coverage.

But the rollout has been slow. Federal officials didn’t release final rules for employer-based plans and policies offered on the health law’s marketplaces until November 2013. And how the law will affect Medicaid managed care plans that include both medical and mental health benefits is still unclear. Proposed regulations for those plans are being finalized by federal officials and expected to be released sometime this year.

There’s a lot at stake. The regulations from the Centers for Medicare and Medicaid Services will also likely determine the extent to which the law applies to Medicaid managed care “carve-out” mental health plans that are frequently paired with separate medical insurance. In addition, experts suggest the proposed rule could, like the final regs issued for marketplace plans and employer-based coverage, do away with lifetime spending caps and other limitations that aren’t equal to those applied to medical services.

Medicaid is the largest payer of mental health services, covering 27 percent of all mental health spending in the United States, and 11 percent of people with Medicaid have a mental illness, according to the Department of Health and Human Services. Nationwide, 70 percent of Medicaid recipients are enrolled in managed care plans, which are generally designed to reduce costs through improved coordination of primary care that stops unnecessary or inappropriate services. However, these plans also often have lower provider reimbursement rates that can impact physician participation.

Emily Feinstein, the director of health law and policy at the National Center on Addiction and Substance Abuse at Columbia University, has been tracking the parity law’s implementation and works with states on improving mental health and substance abuse care. If mental health and addiction services are not covered at the same level as medical, she says, there is the potential for more emergency room visits and acute care services that might not happen if people with Medicaid managed care plans had access to a weekly counseling and other mental health services.

Kaiser Health News staff writer Lisa Gillespie spoke with her about some of the issues in play and her expectations.  An edited version of the conversation follows.

Q: Why is this rule going to be so important?

A: Parity offers the promise to dramatically improve patients’ access to the full range of evidence-based mental health and addiction treatments, especially for people with more complex health problems. As chronicled by 60 Minutes in the recent segment, “Denied,” claims for intensive behavioral health care services are routinely denied. … The hope is that insurance companies will start to cover mental health and addiction services for people as comprehensively as they cover care for other complex chronic diseases, like diabetes, heart disease or cancer.

Q: What’s an example of something that might change if parity was applied to Medicaid managed care?

A: A big problem right now is Medicaid excluding medications that treat opioid addiction –methadone, buprenorphine and naltrexone. Medicaid coverage for these medications is uneven and even in states that cover them, managed care plans find ways to limit access.  For example, they say you have to fail psychotherapy first before you can get buprenorphine, or that you have to fail first on a cheaper alternative before you can get to the more expensive treatment. Or they require prior authorization, so doctors can’t prescribe the drug right there.  These policies have big consequences. If people can’t get the medication they need, they are at risk of dropping out of treatment and relapsing.  For addiction, the “fail” in fail first means relapse.  And for opioid addiction, relapse can be fatal. These kinds of policies violate the federal parity rule, unless insurance companies apply the same limitations to medical treatments, and we know they don’t.  It’s really a cost containment strategy.  If the parity rule for Medicaid addresses these issues, many more people will be able to access addiction medications, and many lives can be saved.

Q: Where – meaning in what states – might enrollees feel the most impact in terms of new regulations for Medicaid managed care plans?

A: My sense is that there is huge variability among states.  Some states have identified mental health and addiction treatment as a way to improve cost savings [in their Medicaid programs] and health care outcomes, and they’re already trying to improve access to care. Other states, which for political reasons aren’t expanding Medicaid, will have less coverage for addiction and mental health, because they’re not doing everything they can provide care in the first place.

Q: Do you anticipate there will be opposition to such an effort?

A: There is resistance of course from the insurance industry, especially from managed care companies that contract with Medicaid, who are concerned that parity requirements will increase their costs. For providers [such as doctors and hospitals], there are concerns about whether the rule will be clear enough and will provide enough protection when insurance companies deny care, either because the services aren’t covered at all, coverage is limited or because the insurance company claims the services aren’t necessary. Some parts of parity, for example — not imposing higher co-payments or number of visit limitations on behavioral health care — are very clear and easy to implement. Most insurance providers are already in compliance with these requirements. The more challenging issues are “non-quantitative treatment limitations” like the process for medical necessity review [where insurers determine whether or not a service is necessary] -this is where more clarity is needed.

Q: Could access issues increase as a result of the rule? We hear a lot about shortages of mental health providers. How does this play into that discussion?

A: Ensuring that there are enough mental health and addiction treatment providers to meet patient demand will be a big challenge. Federal rules already require Medicaid managed care plans to ensure there are an adequate number of providers in their network, but states are allowed to define what adequate means. The result is huge variation.  And there is little enforcement.  One reason there aren’t enough providers in Medicaid plans is that the reimbursement rates in Medicaid are very low, and providers say they can’t afford to take many Medicaid patients.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.