by K Pollitz · 2015 · Cited by 19 — About the Assister Programs and Brokers Described in this Report . Marketplaces/Downloads/Navigator-Grantee-Summaries-UPDATED-05-05-15.pdf.

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E xecutive Summary .. .. .. .. .. 1 About the Assister Programs and Brokers Described in this Report .. .. .. 5 Key Findings .. .. .. .. . 7 Section 1: Characteristics of Assister Programs .. .. .. 7 Section 2: How Many Assisters Are There and How Many People Did They Help? .. .. 11 Section 3: Why Did Consumers Seek Help? .. .. .. 15 Section 4: Challenges Facing Assister Programs .. .. . 21 Sec tion 5: Consumer Assistance by Health Insurance Brokers .. .. .. 27 Discussion .. .. .. .. .. 30 Methods .. .. .. .. .. 32 Assister Programs .. .. .. .. . 32 Brokers .. .. .. .. 33 Toplines and Margin of Sampling Error .. .. .. .. 33 Appendix: Additional Tables .. .. .. . 35 Endnotes .. .. .. .. . 37

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Now in second year, a new infrastructure of consumer assistance in health i nsurance continues to develop. The Affordable Care Act (ACA) provided for new publicly funded consumer assistance entities to help people on an ongoing basis as they apply for health coverage and subsidies and resolve questions and problems with their ins urance once covered. Nearly all Marketplace Assistance Programs established for the first year returned this year to continue helping consumers. These assistance professionals have unique insights into how ACA implementation is progressing, what is chan ging and what challenges remain. How Assister Programs develop in their own right will also likely impact whether consumers can continue to get the help they need. This report is based on findings from the 2015 Kaiser Family Foundation survey of Health Insurance Marketplace Assister Programs and Brokers. The online survey was conducted from March 31 to May 3 , 2015 as the second Open Enrollment period concluded. As was the case last year, Federal and state – operated Marketplaces provided contact informat ion for directors of their Assister Programs, all of whom were invited to participate. Two years of data enable comparison of Assister Programs capacity and experiences from one year Brokers have traditionally helped consumers enroll in private health insurance coverage. In 2014, m any brokers registered to sell coverage through the Marketplace , and nearly all of them returned this year, as well. Returning brokers also offered some ob servations about how this year compare d to the first year, and how it compared to their experience selling non – group coverage prior to ACA. Ninety – one percent of Assister Programs and 86% of brokers this year had also helped Marketplace consumers last year , and most (82% of Assister Programs and 79% of brokers) who returned said the second open enrollment period went better than the first. In particular, Marketplace web sites worked better this year. In 2014, 65% of Assister Programs said most or nearly all consumers sought help, in part, because of technical difficulties with the Marketplace website. This year, 38% of Programs said this was the case. In 2015, more Assister Programs reported they could complete the enrollment process with consumers and s ee their plan choice (71% vs. 61%) Returning A ssister P rograms had also gained a year of experience. By comparison, when the first Open Enrollment period began , only 16% of Assister Programs had previously helped consumers enroll in private health insur ance . More than 4,600 Assister Programs served Marketplace consumers in the second year of health reform, collectively employing 30,400 full time equivalent staff and volunteers . The overall number of Assister Programs and staff increased slightly in the second year . Similar to last year, 15% of Assister Programs were Navigators, funded directly by the Marketplace, while Assister Programs in Federally Qualified Health Centers (FQHCs), supported by grants from the Health Resources Services Administration ( HRSA), comprised another 25% of total Programs. Certified Application Counselor ( CAC ) Programs , which are mostly supported by their sponsoring non – profit organizations or foundations and do not typically receive direct government support for assistance ac tivities, compris ed 60% of total P rograms, and more than 50% of FTE staff. In terms of consumers helped, Navigators and FQHCs provided assistance to the majority of consumers reached during the second open enrollment period. Together, Navigators and FQHC s served 70% of all consumers who received help this year (30% and 40%, respectively), while CACs provided assistance to only 30% of consumers helped.

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Assister Programs helped an estimated 5. 9 million consumers this year . Returning Programs helped 5.8 mil lion of those , or about 19% fewer than last year. This decline was driven by a large drop in the number of people helped by returning CACs. Collectively, returning Navigator and FQHC Assister Programs this year helped about the same number of consumers the y reported helping last year (4 million vs. 4.1 million), while returning CAC Programs helped 1.8 million individuals, 60% of the number they helped last year. These differences suggest that Assister Programs supported by outside grant funding may be in a better position than voluntary Programs to help more consumers and to sustain their capacity over time. The need for in – person consumer assistance remains substantial. Web site improvements notwithstanding, millions of consumers continue to need personaliz ed help to apply for health coverage and subsidies. Seventy – nine percent of Assister Programs this year (and 80% last year) said most or nearly all consumers sought help because they lacked confidence to apply on their own; 82% of Programs this year (83% l ast year) said most or nearly all consumers needed help understanding their plan choices; 74% of Assister Programs (this year and last year) said most or nearly all consumers needed help understanding basic on, this year, like last year, most Assister Programs said it took one to two hours, on average, to help each consumer who was new to the Marketplace. Programs said it took somewhat less time, about an hour on average, to help consumers who were returning to renew Marketplace coverage and subsidies . Consumer demand for help exceeded what some Programs could provide this year , though not by as much as last year. About one – in – five Assister Programs reported having to turn away at least some consumers th is year. For the Open Enrollment period overall, 19% of Programs said they could not help all who sought assistance ; d uring the final two weeks, 22% said they had to turn at least some consumers away. This contrasts with the first year, when 37% of Progr ams were stretched beyond capac ity during Open Enrollment over all, and nearly half had to turn away at least some consumers during the final two weeks. It appears the availability of Marketplace consumer assistance is aligning with demand; however, additi onal capacity may still be needed. In between Open Enrollment period s, returning Assister Programs helped an estimated 630,000 consumers apply for coverage through special enrollment periods, 290,000 consumers report mid – year changes to the Marketplace, an d nearly 800,000 consumers resolve post – enrollment problems. The need for consumer assistance is year – round. Changes in work or family status or income during the year mean some people must enroll in coverage outside of Open Enrollment or apply for new or revised subsidies mid – year. Marketplace Assister Programs are tasked with helping consumers at these times as well. In addition, consumers need help once enrolled, including with questions about how to use their new health insurance, or what to do if th eir provider is not in network, or if a claim is denied. Under the ACA, state ombudsman or Consumer Assistance Programs (CAPs) we re established to provide post – enrollment assistance, though CAP funding has not been appropriated since 2010. Most Assister Programs, therefore, try to help Marketplace consumers with their post – enrollment problems, and 69% said they could successfully resolve problems most of the time.

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Assister Programs report further improvements are still needed in Marketplace websites and Call Centers, and other technical assistance could be strengthened . Most Marketplace online eligibility systems , especially in FFM states, are not yet integrated with Medicaid, so the single, streamlined application for financial assistance envisioned un der the ACA is not yet a reality. As a result, when Marketplaces determine a consumer is likely eligible for Medicaid or CHIP, a new separate application is often required. Sixty – nine percent of Assister Programs will help consumers complete a separate M edicaid application. Most say this can be accomplished during the initial visit, but 45% of Programs say a one or more additional visits are needed, on average , to complete the Medicaid or CHIP application and enrollment process . Assister Programs also cite the need for better information on health plan choices. Thirty – one percent of answered by inf ormation on the Marketplace web site. (Last yea r, 41% of Programs said this was the case.) Programs also reported that technical assistance from the Marketplace Call Centers can be uneven. Half of Programs who said they reached out to Call Centers for help with translation services said help was effe ctive most or all of the time. Among those who sought technical assistance with immigration questions, tax – related questions, or questions about QHP choices, less than half ( 41%, 45%, and 39% , respectively ) said that Call Center technical assistance was e ffective most o r all of the time. Coordination among Assister Programs remains an important, but elusive goal. Ninety percent of Assister Programs said coordination with other Programs is somewhat or very important to their effective operation, but just o ver half of respondents said they seldom if ever coordinate with other Assister Programs. When coordination d id take place this year , similar to last year, most often it was initiated by Assisters themselves or by an outside third party, not by the Market place. Funding uncertainty concerns many Assister Programs. Twenty – seven percent of Assister Programs said they are very certain that funding will be available to support them next year, while 39% are not certain at all. Overall, Marketplaces provided fe wer funding resources for Assister Programs in the second year. The federally run Marketplace cut funding available for Assister Programs in FFM and FPM states by about 10% this year from $67 million in FY 2014 to $60 million in FY 2015. Many State – base d Marketplaces also reduced their Navigator funding from first year levels; in all state – Marketplace funding for Navigators fell by about 15 percent. The Centers for Medicare and Medicaid Services ( CMS ) has announced $67 million will be available for Navi gators in FFM/FPM states in year three the same amount awarded in year one and a 1 2 % increase over year two funding levels. CMS has also indicated there will be additional, as yet unspecified, funding for Federal Enrollment Assistance Programs (FEAPs), which supplement the work of Navigators in some FFM states, in year three. Many state – based Marketplaces have yet to decide the level of consumer assistance resources they will fund in year three. Health insurance brokers continue to help many consumers apply for coverage, mostly through Marketplaces. Before the ACA, private health insurance brokers traditionally offered help to consumers seeking non – group coverage , and they continue to play an important role today . Brokers are paid commissions by insur ance companies for each policy they sell. Many are certified to sell non – group coverage through the Marketplace, and this year, the survey included Marketplace – in this report.) The vast majority of broke rs who sold non – group coverage this year had done so during the first

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Open Enrollment period and prior to 2014, as well. Most (79%) sold non – group coverage both inside and outside of the Marketplace, though on average, brokers helped almost twice as many consumers apply for coverage through the Marketplace compared to outside. Non – group sales have increased for most brokers sin ce Marketplaces opened in 2014. Sixty percent of brokers say they are selling more non – group coverage today than they did prior to 2014. Most reported it takes more time to sell a policy and the revenue they earn per – policy is less; but 40% earn more income overall from non – group commissions than they did prior to implementation of the Marketplaces and another 20% sa id their overa ll non – group commission income is about the same. Brokers and Assister Programs engage in similar consumer assistance activities, with some differences. Both brokers and Assisters help consumers complete Marketplace applications, compare plan choices, and answer tax – related questions. Both also help consumers with post – enrollment problems. However, compared to Assister Programs, brokers less often engage in public outreach and education activities. Brokers also provide less help to consumers applying f or Medicaid and more help to small businesses seeking small – group coverage. B rokers and Assister Programs appear to serve somewhat different populations . Brokers were less likely than Assister Programs to serve Latinos, consumers who needed language tr anslation help, consumers who lacked Internet service at home, or consumers with incomes low enough to be eligible for Medicaid. Brokers were also less likely than Assister Programs to say that most of their clients were uninsured at the time they sought help. However, returning brokers reported a higher degree of client continuity from year one compared to Assister Programs, indicating they may be establishing more ongoing relationships with their clients than Assister Programs have been able to do so fa r.

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for the 2014 plan year with an option for CMS to elect a second year of work. CMS will continue to contract with FEAPs in year three, though the contract amount and work sites have not yet been determined. Finally, in addition to Marketplace Assister Programs, the ACA authorized creation of state – based ombudsman programs, also called Consumer Assistance Programs, or CAPs. The l aw requires CAPs to provide outreach and public education and provide enrollment assistance to consumers in the Marketplace. In addition, CAPs must help all state residents resolve questions and disputes with their private health insurance coverage, inclu ding helping consumers to appeal denied claims. The ACA requires Marketplace Assisters to refer consumers with post – enrollment problems to state CAPs. The law provided initial funding for states to establish CAPs and 35 were established in 2010. However no new appropriations have been enacted since and most CAPs have not received any new federal funding since 2012. Pending additional federal funding, many CAPs remain operational, albeit at reduced levels. Broker refers to a state – licensed professional who sells private health insurance to individuals and/or businesses . B rokers are sometimes called agents or producers. To sell non – group or small group health plans offered through a state Marketplace, brokers must register with the Marketplace annually, sign a participation agreement, and complete required training. Brokers who sell non – group policies through the Marketplace help consumers complete an application for financial assistance and explain coverage options. Brokers are paid a commission by th e health insurance company offering the policy that the consumer selects. Typically insurers pay commissions when a policy is first issued and at renewal for at least several years. Brokers also offer ncluding help with post – enrollment questions and help buying other insurance products or financial services.

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In all, more than 4,600 Marketplace Assister Programs were established to help con sumers during the second Open Enrollment. This total is based on Program data provided by al l state and federal Marketplaces, and represents a 3 % increase in the number of Programs established during the first Open Enrollment. Once again, most Assister Pr ograms that help people enroll in the Marketplace are not funded by Marketplaces. Navigators, which are funded directly by the Marketplace, comprise about 1 4 % of total P rograms. Assister Programs in FQHCs, primarily supported by HRSA grants, comprised a nother 25% and CAC Programs were 6 1 % . Mostly CACs are voluntary P rograms, supported by their sponsoring non – profit organizations, foundations, and other sources. Marketplaces are required to recognize and certify qualified CACs, but are not required to p rovide them financial support. (Figure 1) This distribution of Assister Program types is somewhat different from that during the first Open Enrollment period, and includes a larger proportion of CACs, largely because of a reclassification of Assister Pr ogram types in California. Most Assister Programs this year also helped consumers during the first Open Enrollment. Over 90% of Programs indicated they operated during the first year. As a result, these P rograms were more experienced. Prior to the fi rst Open Enrollment, just two – thirds of Programs had experience helping consumers enroll in Medicaid and CHIP and only 16% of Programs had previously helped consumers enroll in private health insurance. Most Assister Programs served specific geographic or population – based communities. Fourteen percent of all Programs operated in a statewide service area, the same proportion as in year one. However, the number of Navigator P rograms operating statewide increased to 26% in year two (compared to 17% in year o ne). This could be attributable to funding requirements that encourage statewide coverage.

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Assister Programs varied in size and in the number of consumers they helped. Most Programs have a small staff; 68% have five or fewer full – time – equivalent (FTE) staff, either paid or volunteer, while only 6% of Programs have more than 20 FTE staff. CACs were more likely to have small staff, with 71% of such P rograms reporting five or fewer FTE staff, compared to 56% of Navigators. CACs were also more likely to rely primarily on volunteers (19% vs. 4% for other Program types.) These results are similar to year one. Navigator and FQHC Assister Programs were more likely to report helping large numbers of consumers. This year 40 % of Navigators and FQHCs said they helped more than 1,000 people during Open Enrollment. By contrast, 1 3 % of CACs helped more than 1,000 people. This is similar to the distribution in year one . (Table 1) Table 1. Assister Programs by Size, Service Area, and Numbers of People Helped P rogram Characteristics All Assister Programs Program Type Navigator and FEAP FQHC CAC Worked during first Open Enrollment 91% 95% 96% 87%*^ Statewide vs. specific geographic service area State wide 14% 27 % 10% * 13% * Specific area within st ate 80% 68% 87% * 80% *^ Other 6% 5% 3% 7% ^ Paid staff vs. volunteer Most/all volunteers 13% 5% 3% 19% *^ Most/all paid staff 87% 95% 97% 81 % *^ Number of full – time – equivalent staff and volunteers 5 or fewer 68% 55 % 67% * 71% * 6 – 10 17% 19 % 22% 14% ^ 11 – 20 7% 11 % 6% 6% * 21 – 50 5% 9 % 3 % * 5% More than 50 1% 4% 1 % 1% No answer 2% 1% 1% 3 % Mean FTE staff size 6.8 12.2 6.1 5.8 Number of consumers helped during Open Enrollment 100 or fewer 32% 14% 9% 45% *^ 101 – 500 31% 28 % 33% 30% 501 – 1,000 13% 17% 18% 10% *^ 1,001 – 2,500 13% 22% 22% 8% *^ 2,501 – 5,000 5% 8 % 10% 2 % *^ More than 5,000 5% 10 % 8% 3% *^ 1% – 1% 2% Mean number of people helped per Progr am 1,274 2,727 1,929 652 Portion of Consumers helped who were new to Marketplace vs. renewing Most/nearly all renewing or changing 21% 18% 23% 21% About half new/half renewing or changing 22% 26% 27% 20% Most/nearly all new to Marketplace 53% 52% 46% 5 6% *Significantly different from Navigator and FEAP at the 95% confidence level; ^Significantly different from FQHC at the 95% c onfidence level NOTE: Numbers may not sum to 100% due to rounding.

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Assister Program budgets this year were mostly modest . T wenty – nine percent of all Programs reported having an annual budget for consumer assistance of $50,000 or less. Slightly more (31%) had annual budgets between $50,000 and $ 5 00,000. Only 4% of Programs reported annual budgets larger than $500,000. CACs t ended to have the smallest budgets compared to other types of Assister Programs. (Table 2) Navigators were more likely to receive most of their funding from the Marketplace, while FQHCs relied more heavily on grants from HRSA. CACs were most likely to r ely on re – programmed resources from their sponsoring organization or from other sources of private sector support. Table 2. Assister Program Budgets and Sources of Funding, FY 2014 All Assister Programs by Program Type Navigator and FEAP FQHC CAC FY 2015 Program budget Up to $50,000 29% 21% 13%* 38% *^ $50,001 – $200,000 21% 28% 36% 13%*^ $200,001 – $500,000 10% 21% 12%* 7%* $500,001 – $1,000,000 2% 10% 1%* 1%* More than $1,000,000 2% 4% 1% 2% 35% 17% 37% 39% Programs r eceiving most (>50%) of budget from this funding source Grants or other direct payment from Marketplace 13% 42% 3% * 9% *^ Grants from HRSA, other federal agency 21% 10% 53% * 11% ^ Grants or payments from other state agencies 5% 17% 1% * 3% *^ Grants from private foundations 2% 2% – 5% * Grants from other outside private sources 1% – – 2% Funds re – programmed from sponsoring 16% 2% 2% 25% *^ *Significantly different from Navigator and FEAP estimate at the 95% confidence level; ^Sig nificantly different from FQHC at the 95% confidence level NOTE: Columns may not sum to 100% because not all Programs received a majority of funding from a single source. Assister Programs engaged in a range of activities during Open Enrollment. Virtually all Programs provided eligibility and enrollment assistance, helping consumers apply for private health insurance and subsidie s or for Medicaid and CHIP. Eighty percent of Programs also provided outreach and education to consumers. Beyond outreach and e nrollment support, nearly 80% of Programs assisted consumers with post – enrollment questions and problems. Additionally, almost 6 in 10 helped consumers appeal Marketplace eligibility decisions, and new this year, more than 6 in 10 Programs helped consumer s with ACA tax – related questions. (Table 3) These percentages were similar to those reported last year; however, more Assister Programs this year reported helping consumers apply for exemptions from the individual mandate (61% this year vs. 50% last yea r).

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