Self-Pay Patient Eligibility and Enrollment Assistance Considerations under the ACA

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Page 1 Self-Pay Patient Eligibility and Enrollment Assistance Considerations under the ACA by Shanna Hanson, FHFMA Summary One of our industry s reform knowledge leaders overviews some very key self

1 Page 1 Self-Pay Patient Eligibility and Enrollment Assistance Considerations under the ACA by Shanna Hanson, FHFMA Summary One of our industry s reform knowledge leaders overviews some very key self pay patient eligibility and enrollment assistance considerations as a result of the Affordable Care Act (ACA): a bigger job for providers, a need for new systems and procedures, plus who the new eligibility educators will be and how they will function.

2 Page 2 If you build it, will they come? If the past is a good predictor of the future, the answer at least for enrollment in government assistance programs is no, not without help. The Children s Health Insurance Program (CHIP), Medicare Part D and the Massachusetts Medicaid expansion are just three examples of coverage successes that depended heavily on outreach, outreach and more outreach. Despite measures the ACA outlines to simplify application and enrollment processes, uninsured patients still will need enrollment assistance in the reform world. Period! While the need for assistance won t change, what will change is the framework for obtaining this assistance. Under the ACA, this role may be filled by Navigators, In person Assisters (IPAs), Certified Application Counselors (CACs), in person insurance agents/brokers, or web brokers. Hospital and health system staff members will most likely fall into the category of CACs. (See page 3 for more on CACs.) But what does enrollment assistance really mean for providers? Hospitals fully ready to assist patients with enrollment beginning October 1 may have a competitive advantage over those that aren t. Some uninsured patients may be eligible for coverage before January 1, 2014, and that can mean reimbursed medical expenses. For other patients, although their coverage will not begin until January 1, providing enrollment assistance often establishes goodwill and trust that may instill a loyalty to your facility for years to come. For those hospitals tackling the challenges of enrollment assistance, it is necessary to evaluate an evolved financial counseling model or a new one altogether to accommodate the changes as a result of the ACA. Considerations should include: Possibilities of a larger staff focused on this assistance. Staff space allocations and whether they will be centralized or decentralized. Privacy for applicants. Learning how to perform tasks outside of your core business. Initial and ongoing training. Staff certification. Staying current with program and policy changes. Establishing the most efficient and effective processes. A Bigger Eligibility and Enrollment Job Simply put, the job will become bigger and demand more of providers and their staffs. Staff members will need to be knowledgeable about all insurance affordability programs (IAPs) including Medicaid, CHIP and Advanced Payment of Tax Credits (APTCs) in the new marketplace.

3 Page 3 They will need to know how to educate applicants about their coverage alternatives and facilitate their selection of a Qualified Health Plan (QHP) that meets their needs. Hospitals will need processes and resources to manage screening and enrollment for Modified Adjusted Gross Income (MAGI) excepted Medicaid and other specialty programs, such as disability, medically needy or spend down, emergency Medicaid for ineligible aliens, Crime Victims Compensation (CVC) and any others that may be pertinent. Also, under the ACA, hospitals will need their staff to know how to work through the application process with inpatient prisoners who meet eligibility criteria for Medicaid. With all of these changes, it is reasonable to expect denials and appeals perhaps for a time, a much larger incidence of them. Hospitals need to have resources and a process in place to work these effectively. New Systems and Procedures Call centers, navigators and other assisters will access the new marketplaces through a different entry point than individuals who apply on their own. This provides an audit trail, protecting the applicant and enabling the reviewing agency to know the information was entered or changed by an assister and not the consumer directly. It also will verify the assister is authorized to help consumers and, in addition, may provide different tools and functionality to facilitate enrollment. 1 Hospitals will need quick and easy ways to determine who should be directed to the online marketplaces. A reimbursement quick screening process is recommended to financially triage self pay patients to identify the most appropriate processing workflow for each. This is very important for hospital patient financial services management and staff. Why? If a patient or his/her financial counselor outside the hospital enters the patient s information directly through a marketplace portal, the hospital will not have access to that data. This will make it more difficult for the provider to apply for other programs, such as charity care, for the individual. A quick screening process will help ensure none of this important data is missed. Hospitals will also experience challenges tracking the status of these accounts, particularly ones connected with MAGI excepted or other specialty assistance programs. Example: An applicant applies through the marketplace for a subsidized insurance program that is not retroactive. At the same time, he also applies for a MAGI excepted Medicaid program that is retroactive. The eligibility and enrollment process may start in the marketplace, but added work and documentation may be required. 1 Eligibility & Enrollment Systems, An Advocate s IT Toolkit, Tricia Brooks and Julia Silas, Georgetown University Health Policy Institute Center for Children and Families, November 2012, pages 2 4. Also see The Consumer Connection: Navigators, In person Assistors and Consumer Assistance in the ACA, a presentation of Tricia Brooks at the Florida Enrollment Summit, January 18, 2013, accessible at 3FCB 4E26 ABAD 1C9B78BE24BE/0/Tricia_Brooks_2013.pdf

4 Page 4 Tracking and follow up systems/procedures will be needed to make sure self pay patients complete the eligibility enrollment process properly and completely. States have the option, for example, to require hospitals that have been qualified to make decisions based on presumptive eligibility to ensure full enrollment for patients. (Presumptive eligibility provides a patient with either Medicaid or CHIP coverage based on preliminary information, such as income, without the individual having to go through the entire application process.) If full enrollment does not happen at the hospital, the applicant may become uncooperative or non locatable, creating a need for assertive follow up techniques. New Eligibility Educators and Facilitators Navigators, In Person Assisters and Certified Application Counselors Navigators are required for each marketplace in each state, whether the state s marketplace is state run, a state/federal partnership, or a federally facilitated marketplace. Navigators responsibilities include conducting public education and outreach, performing enrollment activities, facilitating consumers choice of a health plan and more. Unlike the Navigator program, In Person Assisters (IPAs) are not required for all marketplaces; they are required only for states that have chosen a state/federal partnership marketplace. States with state based marketplaces may use an IPA program, while states that have opted for a federally facilitated marketplace will not have IPA programs. IPAs may perform similar duties to those of Navigators. As a result, some states may choose to merge their Navigator and IPA programs. All marketplaces are required to establish a Certified Application Counselor (CAC) program. Certification and training will ensure CACs are qualified to help people enroll in any assistance program under the ACA, including Medicaid, CHIP, QHPs, and APTCs. It is notable that this program presents the opportunity for volunteers to obtain certification and perform the duties of a CAC. The term volunteer refers to the fact that these people are not paid by the exchange or a Medicaid agency to perform this role. They may, however, be paid by their employer to act as a CAC. CACs already do exist in some states where they are currently (generally) certified by Medicaid agencies. Under the ACA, Medicaid agencies will still have this option to certify CACs. States choosing this option for Medicaid will need to provide counselors with specific tools and training to effectively assist consumers. A web portal that meets privacy and appropriate security standards is encouraged, but not required, per the recently released final rule. 2 While Navigators and IPAs go through a vetting/selection 2 Medicaid, Children s Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment for Exchanges, Medicaid and CHIP, and Medicaid Premiums and Cost Sharing, Final Rule, Department of Health and Human Services Centers for

5 Page 5 process, there is an opportunity for anyone to go through the Health and Human Services CAC training and get certified. Here is a grid that highlights some of the characteristics of the three aforementioned assister roles and who is responsible for them, based on the type of marketplace: Federally facilitated marketplace State federal partnership marketplace State based marketplace Navigator program development Federal government Federal government State Navigator program management Federal government Federal government with state participation State Navigator funding Federal government awards Navigator grants to a minimum of two entities in the state, one of which must be a community based organization Federal government awards Navigator grants to a minimum of two entities in the state, one of which must be a community based organization State can use federal exchange establishment grants for planning, but cannot use that funding for operations In person assister program development Will not have them Required Optional In person assister program funding Not applicable State can use federal exchange establishment grants to establish and operate the program State can use federal exchange establishment grants to establish and operate the program Certified Application Counselor program development Required for marketplace, optional for Medicaid Required for marketplace, optional for Medicaid Required for marketplace, optional for Medicaid Certified Application Counselor funding None None None Medicare and Medicaid Services, Federal Register, Vol. 78, No. 135, July 15, 2013, accessible at /pdf/ pdf

6 Page 6 Agents and Brokers 3 Insurance agents and brokers, including web brokers, will be able to assist individuals, qualified employers and employees in the application and enrollment process in the new marketplaces where permitted by state law. They will be required to receive training, obtain certification and register with the appropriate agency to receive portal access. In federally facilitated or state partnership marketplaces, they will register with CMS; in state based marketplaces, they will register with the state. In state based marketplaces, compensation for their work will come from the insurance issuer or state based marketplace if a state so chooses; however, in federally facilitated or state partnership marketplaces, compensation will come from the insurance issuer. Agents and brokers may provide assistance directly through the marketplace where there is a federally facilitated or state partnership marketplace or through the insurance issuer s website. In state based marketplaces, it will be up to the state to decide if and how agents and brokers connect to the marketplace. If using the federally facilitated or state partnership marketplace, the individual will establish his/her own account and password to maintain privacy. Once eligibility is established, all plan options will be available to the applicant. The agent/broker will be identified using a unique, CMS assigned identification. If the individual chooses to employ the insurance issuer s website, the agent/broker must disclose to the individual that it represents the issuer s products and let the individual know he/she can access the marketplace independently (where more options are available for evaluation). Agents and brokers will be expected to work with anyone who approaches them. If, in the eligibility determination process, the applicant is determined to be eligible for Medicaid or CHIP, he or she can be referred to the appropriate state agency. Web brokers 4 Web brokers will provide another option for individuals to enroll in Qualified Health Plans (QHPs). Consumers will access a public website, connect securely to the federallyfacilitated or state partnership marketplace for the eligibility determination, and then return securely to the web broker s site to compare plans and select among them. States that choose to run state based marketplaces will decide if and how web brokers will connect to the online marketplace. Web brokers must show all QHPs available through a marketplace in an advertisementfree environment, but they can also offer non QHPs if displayed separately. After the 3 Role of Agents, Brokers and Web Brokers in Health Insurance Marketplaces, Department of Health & Human Services, Centers for Medicare & Medicaid Services, Center for Consumer Information & Insurance Oversight, Washington, D.C., May 1, 2013, accessible via and Guidance/Downloads/agent broker pdf 4 ibid

7 Page 7 consumer selects a QHP and the Advance Payment of Tax Credits (APTC) amount has been determined, the web broker will transmit the individual s or family s QHP selection, including the applicable premium, the APTC amount that will be applied to the premium, and broker identifier, all back to the marketplace. About the Author Shanna Hanson, FHFMA, is Manager of Business Knowledge for Human Arc (Cleveland, OH), an innovation leader in reimbursement and revenue enhancement services for hospitals and health plans nationwide. She has responsibility for research and reporting on all legislative and environmental changes and trends impacting the company s markets, services and product development initiatives. This includes strategic knowledge leadership for the company on national reform and the Affordable Care Act which she has researched for many years. Prior to her present role, Ms. Hanson served 14 years as Human Arc Midwest Operations Leader for its Medicaid eligibility enrollment services. She has been a driving force behind her region s Healthcare Financial Management Association for many years. Ms. Hanson has served as its President and earned the designation of Fellow of the Healthcare Financial Management Association (FHFMA). She holds the organization s Certificate of Advanced Technical Study in Mastering Patient Financial Services as well as the Founders Medal of Honor Award. She is a recognized industry writer and speaker on and related topics, conducts webinars on reform, and is a frequent reform blog contributor. Human Arc 1457 East 40 th Street, Cleveland, Ohio Fax by Human Arc EES

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