by K Pollitz · 2014 · Cited by 33 — of Open Enrollment affords an opportunity to examine the role of Assister Programs in helping marketplace.cms/help-us/complex-cases-sep..

44 KB – 38 Pages

PAGE – 3 ============
Executive Summary . 1 About the Assister Programs Described in this Report .. . 4 Key Findings .. 6 Section 1: Characteristics of Assister Programs . . 6 Section 2. How Many Assisters Are There an d How Many People Did They Help? .. Section 3: How Assistance was Distributed Across State Marketplaces .. . 11 Section 4. Why Did Consumers Seek Help? Section 5: Challenges Facing Assister Programs .. 14 Section 6: What Improvements Do Assister Programs Seek? .. . 18 Section 7: Looking Ahead .. 21 Implications . 2 Methods .. .. 25 Appendix . .. 27

PAGE – 4 ============
Survey Of Health Insurance Marketplace Assister Programs 1 The Affordable Care Act (ACA) provides for a substantial ne w infrastructure of consum er assistance in health insurance. All state Marketplaces are required to have Navigators and other similar Assister Programs to help consumers understand their coverage options, apply for as sistance, and enroll. In addition, comprehensive State Ombudsman or Consumer Assistance Programs (C APs) are established under the ACA to provide a full range of help – outreach and enrollm ent assistance as well as help with post-enrollment problems such as appealing denied claims – to all state residents in all types of group and non-group health plan coverage. Throughout the first Open Enrollment period, public attention focused on the number of people who would enroll in qualified health plans (QHPs) offered through the Marketplace and in Medicaid. People will continue to enroll in coverage throughout the year, and even more pe ople are projected to enroll next year, but the close of Open Enrollment affords an opportunity to examine the role of Assister Programs in helping people to enroll and remain enrolled in coverage. This report is based on findings from the 2014 Kais er Family Foundation survey of Health Insurance Marketplace Assister Programs. This internet survey was conducted from April 24 to May 12, 2014, shortly after the first Open Enrollment period concluded. Fe deral and state-operated Mark etplaces provided email contact information for directors of their Assister Program s, all of whom were invi ted to participate. This report examines the experience of Assister Programs ac ross the states in conducting outreach and enrollment assistance during the first Open Enro llment period for health insurance Marketplaces es tablished by the ACA. Based on responses to this survey extrap olated to the total number of Assis ter Programs, this report offers the first nationwide assessment of the nu mber and type of Assister Progra ms and the number of people they helped. This report also examines the nature of help cons umers needed, both pre- and post-enrollment, and the extent to which Assister Programs could meet consumer needs. In addition, it discusses key factors that impacted the effectiveness of Assister Programs at the outset and the outl ook for consumer assistance in the future. Assistance resources were not evenly distributed across states. In states with State-based Marketplaces (SBM) and Consumer Assistance Partnership Marketplaces (FPM), there were about twice as many Assisters available per 10,000 uninsured, compared to states with a Federally-facilitated Mark etplace (FFM). The number of people helped per 1,000 uninsured was al so greater in State and Partnershi p Marketplaces; SBMs helped about twice as many people relative to the uninsured population compared to FFMs, while FPMs helped about 1.5 times as many relative to the uninsured population. Som e people who were helped enrolled in new QHPs, and some in Medicaid and CHIP. Others who sought help didn’t enroll in coverage, for example, if they were ineligible for both Medicaid an d premium tax credits. Under the ACA, Marketplaces are req uired to support consumer assistanc e through operating revenue. All Marketplaces did directly support Assister Programs in 20 13-2014, but of all Assister Programs established in the first year, most were funded by sources other than Marketplaces. Cert ified Application Counselors (CAC)

PAGE – 5 ============
Survey Of Health Insurance Marketplace Assister Programs 2 Programs, which generally receive no Marketplace fun ding, and Programs sponsored by federal health centers funded by grants from the Health Reso urces and Services Administration (HRS A) together account for 71% of all Assister Programs and account for more than 60% of people who received help. Many consumers in search of health insurance so ught a more human touch to find their way through the enrollment process. Over 80% of As sister Programs report most or near ly all consumers who sought help didn’t understand the ACA or the covera ge choices offered them or simply la cked confidence to apply on their own. Almost 90% of Programs report the majority of consumers they helped were uninsu red. Almost three- quarters of Programs say most consumers who sought hel p struggled to understan d even basic health insurance terms such as “deductible” or “network service.” Balky web si tes also drove consumers to Assister Programs, as did the application process itself, wh ich can require understanding of the tax code, immigration rules, or family law, de pending on a person’s circumstances. Also , because most Marketplaces have not yet completed the single streamlined application that deter mines eligibility for all for ms of subsidized coverage, many consumers sought help obtaini ng Medicaid eligibility determinations. Sixty-four percent of Assister Prog rams reported spending be tween one and two hours helping each consumer, on average. Explaining rules and options to peop le with limited understanding of the ACA and health insurance took time. So did waits on hold with Mark etplace call centers and fr ozen computer screens. Programs also report that often consumer questions about health plans couldn’t be easily answered by information posted on Ma rketplace web sites. Post-enrollment problems range from consumers not having received their insurance card, to not understanding how to use new health insurance or how to appeal a denied claim. Most Marketplace Assisters are not trained to help consumers appe al denied claims or reso lve problems with insure rs. Instead, they are supposed to refer consumers to state ombudsman or CAPs, also established by the ACA. CAPs are funded by federal grants, though the last grants were awarded in 2012 and, as a result, some CAPs have stopped providing services and some others are operating at reduced levels. Many Marketpla ce Assister Progra ms appear to be unfamiliar with CAPs, even where they are still operating. When Assister Programs encounter post- enrollment problems they can’t help with, they mostly refer consumers to the Mark etplace call center or back to their health plan. Assister Programs that collaborated wi th others reported this coordinatio n to be very he lpful, though more than half of Assister Programs seldom or never coordina ted with other Programs. Wh en coordination did take place, it was most often initia ted by Assister Programs themselves or faci litated by outside groups, less often by the Marketplaces. Progr ams report coordination was useful for directing consumers to the nearest Program with available appointments, in stra tegic planning of enrollment and outrea ch events, in sh aring specialized

PAGE – 6 ============
Survey Of Health Insurance Marketplace Assister Programs 3 staff (such as those who could provide interpreter services ), and in troubleshooting and problem solving on complex cases. Some State-based Ma rketplaces also made dedicated cal l centers for Assisters, and built Assister portals into their online appl ication system so that Programs co uld track clients’ status. Programs reported that these features also helped them to work more efficiently. Prior to the first Open Enrollment, 30% of Assister Pr ograms had no prior experi ence helping consumers and just 16% had experience help ing consumers enroll in private health plans. Because so many Assister Programs expect to continue operating next year, the level of experience will likely in crease going forward. If Marketplaces continue to invest in resources to support Assister Programs, there could develop a profession of expert Assisters who understand consumer needs an d how ACA rules and coverage options apply to them. The Congressional Budget Office has projected that 13 mi llion people could enroll in Marketplace health plans in 2015, 5 million more than signed up during the first Open Enrollment period. Increasing enrollment will first require maintaining cove rage for current enrollees. Many people may need help re-applying for coverage or subsidies. Others with post-enrollment problems may need help resolving th em in order to decide if coverage is worth maintaining. Some Assister Programs were already stretched to capacity in 2014. For the first Open Enrollment period overall, most Programs co uld help most of the people who sought help most of the time. Close to 40% of Programs, though, said they could not help all who sought assistance, with 12% saying demand far outpaced capacity. During the final weeks of Open Enrollment almost half of Assister Programs had to turn away at least some consumers. Enrolling millions of new consumers also presents ch allenges. Public underst anding of the ACA remains limited. If the first wave of en rollment in 2014 was comprised of tho se consumers who were the most resourceful and motivated to seek coverage, then investment in consumer assistance will be all the more key in the year to come.

PAGE – 8 ============
Survey Of Health Insurance Marketplace Assister Programs 5 Federally Qualified Health Center (FQHC) refers to Assister Programs op erated by health centers that receive federal funding to provide compre hensive primary care services. These health centers have a mission to treat anyone regardless of their ability to pay; as a result, their patients ar e primarily low-income and many are uninsured. Health centers also have a long history of helping patients apply for Medicai d, the Children’s Health Insurance Progr am (CHIP), or other coverage. In July 201 3, HRSA awarded $150 million to 1,159 health centers in every state and DC to facilitate enrollment of uninsured peop le into new coverage options available under the ACA. In December 2013, HRSA awarded an addition al $58 million in one-time funding to support the anticipated surge in demand for enrollment assistan ce. In addition, HRSA awarded $6.4 million to state and regional Primary Care Associations (PCA) to provide techn ical assistance and other support to FQHC Assister Programs. Some FQHC Assi ster Programs also applied to be Navigators or IPAs and received additional direct funding from Marketplaces. For purpo ses of this report, all FQHCs are categorized as FQHC Assister Programs even if they also served as Navigators or IPAs. Federal Enrollment Assistance Program (FEAP) refers to Assister Programs that contracted with CMS to provide supplemental en rollment assistance services within FFM and FPM states in select communities with large numbers of uninsured. Duties and requirements of FEAPs are similar to those of federal Navigators, except that FEAPs provide “surge” assistance. Most have rolled back staff and operations since Open Enrollment ended. In the fall of 2013, CMS awarded cont racts totaling $37.5 million to two organizations to establish FEAPs in 13 states. 4 FEAP contracts were for one year, with an option for CMS to elect a second year of work by the end of July 2014. In addition to Marketplace Assister Programs, the ACA authorized creation of state-based ombudsman programs, also called Consumer Assistance Progra ms, or CAPs. CAPs offer eligibility and enrollment assistance to all state residents, those seeking to enro ll through Marketplaces as well as people covered under large employer plans and other non- Marketplace coverage. CAPs also help consumers resolve questions and problems with health cove rage once they are enrolled – including ap pealing denied claims on consumers’ behalf – and health plans must include notice about CAP help on all ex planation of benefit (EOB) statements. Under the ACA, Navigators and other Marketplace Assister Programs are required to refer consumers to CAPs for help with such post-enrollmen t problems. Thirty-five state CAPs were established with federal grants in 2010. Subsequent funding awards were made in 2011 an d 2012, but none since. Many CAPs continue to operate, though some at reduced le vels. In addition, some CAPs are wo rking as Navigators, IPAs, and CACs. This report discusses coordination with CAPs by other Assister Programs.

PAGE – 9 ============
Survey Of Health Insurance Marketplace Assister Programs 6 In all, more than 4,400 Marketplace Assister Programs were established to help consumers during the first Open Enrollment. This total is based on Program data provided by all state and federal Marketplaces. Certified Application Counselor Programs (CACs) account for the largest number of Assister Programs, representing 45% of the total Programs and operating in most s tates. These Programs are likely most numerous because they faced fewer requirements to get started, needing only to complete the online training and register with the Marketplace. Programs sponsored by Federally Qualified Health Centers (FQHCs) accounted for 26% of total Assister Prog rams and operated in every Marketplace. Anot her 26% of Assister Programs are In Person Assisters (IPAs) operating in states with State-based Marketplaces (SBMs) and Consumer Assistance Federal Partnership Mark etplaces (FPMs). While Navigators, which operated in states with a Federally-facilitated Marketpla ce (FFM), represented only 2% of the total number of Assister Programs, they were more likely to subcontract with other organizations. As a result, the total number of organizations that operated as Navigat ors is likely somewhat gr eater than this figure suggests (Figure 1). Health care providers, including FQHCs and hospi tals, along with non-profit community-based organizations sponsored the majority of Assister Programs. Although a variety of organizations decided to develop and implement Assister Programs, FQHCs and other health care providers sponsore d 43% of Assister Programs nationwide. Provider organizations have long played a role in connecting consumers to coverage so it is perhaps not surprising that they signed up in large numbers. Nonprofit community service organizations sponsored another 38% of Assister Progra ms nationwide. State and local agencies make up about 8% of Assister Programs, though these mostly operate in states that elected to expand Medicaid eligibility. Churches, legal aid organizations, colleges and universities, and trade associations also sponsored Assister Programs (Figure 2).

PAGE – 10 ============
Survey Of Health Insurance Marketplace Assister Programs 7 Most Assister Programs (70%) report having some prior experience providing consumer assistance. Two-thirds of Programs had experience helping peop le enroll in Medicaid and CHIP prior to Open Enrollment. Just over one-quarter of Programs ha d helped consumers with post-enrollment health coverage problems, such as denied cla ims. Only 16% of Programs had prev iously helped co nsumers enroll in private health insurance. Nine percent reported expe rience helping with tax prepa ration or filing for tax subsidies (Figure 3). Most Assister Programs served specific geographic areas or targeted population groups. Just 13% of Assister Programs operated in a statewide service area, the rest served more targeted regions or populations. 5 Programs that contracted directly with Marketplac es (Navigators, IPAs and FEAPs) were somewhat more likely to report statewide service area s. This is likely because Marketplaces so metimes favored applicants who would operate statewide. Most Assister Programs also operated independently, but one-in -five worked as part of a formal network or coalition of sub- contracting organizations. Navigators, IPAs and FEAPs were more likely to operate as part of a formal coalition (Table 1). Assister Programs varied in size and in the number of consumers they helped . The majority of Programs have a small staff; 71 % have five or fewer full-ti me-equivalent (FTE) staff (paid or volunteer), while 5% of Programs have more than 20 F TE staff. CACs were more likely than other Assister Programs to have small staffs, with 81% reporting fewer than five FTEs. CACs were also more likely to rely primarily on volunteers (18% vs. 2% for FQHC s and 9% for other Programs). Almost half of all Assister Programs report providin g eligibility and enrollment assi stance to no more than 500 people during Open Enrollment, with 20% of Programs helping 100 or fewer people. The CAC Programs were most likely to report help ing smaller numbers of people ; only 19% of CAC Programs said they helped more than 1,000 people. By contrast, 67% of FQHC Programs and 36% of other Ma rketplace Assister Programs reported helping more than 1,000 people during Open Enrollment.

PAGE – 11 ============
Survey Of Health Insurance Marketplace Assister Programs 8 Table 1. Assister Programs by Size, Service Area, a nd Numbers of People Helped Program Characteristics All Assister Programs Program Type CAC FQHC IPA, Navigator, and FEAP Independent vs. part of a coalition Independent 72% 76%c 73%c 64% Part of a coalition 20% 16% 17% 28%ab Don’t know/No answer 8% 8% 9% 8% Statewide vs. specific geographic service area Statewide 13% 12% 8% 18%ab Specific area within state 85% 86% 88% 81% Other 2% 2% 4% 2% Paid staff vs. volunteer Most/all volunteers 11% 18%bc 2% 9%b Most/all paid staff 89% 82% 98% 91% Number of full-time-equiva lent staff and volunteers 5 or fewer 71% 81%bc 63% 64% 6-10 16% 9% 25%ac 18%a 11-20 7% 6% 6% 9% 21-50 3% 1% 3% 6%a More than 50 2% <1% 1% 4%b Don’t know/No answer 1% 1% 1% <1% Number of consumers helped during Open Enrollment 100 or fewer 20% 33%bc 1% 17%b 101-500 29% 35%b 16% 31%b 501-1,000 14% 14% 15% 14% 1,001-2,500 17% 10% 33%ac 13% 2,501-5,000 10% 6% 17%ac 9% More than 5,000 10% 3% 17%a 14%a No answer 1% <1% 1% <1% a indicates a statistically significa nt difference from CAC, p<.05 b indicates a statistically significa nt difference from FQHC, p<.05 c indicates a statistically sig nificant difference from IPA, Navigator, FEAP, p<.05 NOTE: Numbers may not sum to 100% due to rounding. Assister Program budgets were mostly modest. Thirty percent of all Assist er Programs report having an annual budget of $50,000 or less. 6 Almost as many Programs (26%) ha d annual budgets between $50,000 and $200,000. Only 5% of Progra ms reported annual budgets larger th an $500,000. CACs tended to have the smallest Program budgets compared to other types of Assister Programs 7 (Table 2). CACs were most likely to re ly on re-programmed resources from thei r sponsoring organization or on other private sector support. FQHCs relied mo re heavily on grants from HRSA, wh ile Marketplace Assister Programs (IPAs, Navigators and FEAPs) re lied more heavily on direct pa yments from the Marketplaces. 44 KB – 38 Pages