Consumer Assistance in Health Benefit Exchanges. Maryland Health Connection - Community Outreach Summit

Size: px

Start display at page:

Download "Consumer Assistance in Health Benefit Exchanges. Maryland Health Connection - Community Outreach Summit"

Jayson James
6 years ago
Views:

1 Consumer Assistance in Health Benefit Exchanges June 5, 2013 Maryland Health Connection - Community Outreach Summit Melinda Dutton Partner

2 2 Overview of Federal Policy and Requirements & Maryland Implementation

3 What is a Health Insurance Marketplace? 3 Must allow individuals to apply online, by telephone, by mail or in person. Marketplaces will: Provide one-stop-shopping for individuals and small businesses seeking health care insurance coverage in transparent, competitive marketplaces. Provide consumer friendly online tools comparing premium rates and benefit packages for health insurance coverage options. Facilitate enrollment in Medicaid, CHIP, insurance subsidies or unsubsidized coverage....bottom line, make it easier to shop for and enroll in health insurance

4 Eligibility and Enrollment Pathways & Assistance Assistance Entities 4 Navigators In-Person Assisters Certified Application Counselors In-person Online Mail Phone Agents/ Brokers/ Producers Enrollment Complete State Agency (e.g., Depts. Of Health / Social Services)

5 Navigators, Assisters, and Application Counselors 5 Navigators ACA requires Exchange to establish a Navigator program to provide in-person education, as well as eligibility and enrollment assistance. In-Person Assisters ACA does not specifically contemplate assisters. Concept first introduced in August 2012 in CMS Exchange Blueprint guidance as an additional mechanism for delivering in-person consumer assistance. May provide a wide range of services, including supporting consumers in filing an application, obtaining an eligibility determination, reporting a change in status, comparing coverage options, and selecting and enrolling in a QHP. Proposed regulations published in April 2013 allow for more robust use of assisters in the first year of State-based Exchanges as they build their Navigator programs. Certified Application Counselors Proposed regulations require Exchanges to certify volunteer application counselors to provide services similar to Navigators and Assisters. May provide information on IAPs and coverage options; assist individuals and employees in applying for coverage; and help facilitate enrollment. States could choose to have application counselors serve Medicaid/CHIP as well.

6 Organization & Terminology in Maryland 6

7 Connector Entity Regions 7 Connector entities are organized into six geographic regions, with one connector entity serving each region. Garrett Allegany Washington Frederick Carroll Baltimore Harford Cecil Howard Baltimore City Kent Montgomery Anne Arundel Queen Anne s Regional Key = Western = Central = Capital =Southern =Upper Eastern Shore =Lower Eastern Shore Charles Prince George s Calvert St. Mary's Talbot Caroline Dorchester Wicomico Worcester Somerset

8 Navigators 8

9 Navigator Duties 9 Federal Regulations (e) Navigators must carry out at least the following duties: (1) Maintain expertise in eligibility, enrollment, and program specifications and conduct public education activities to raise awareness about the Exchange (2) Provide information and services in a fair, accurate and impartial manner. Such information must acknowledge other health programs (3) Facilitate selection of a QHP (4) Provide referrals to for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage (5) Provide information in a manner that is culturally and linguistically In Maryland, navigators will also assist consumers with eligibility determinations and enrollment in the Medicaid and MCHP programs and provide ongoing support to consumers with respect to issues relating to eligibility, enrollment, renewal and disenrollment.

10 Outreach to the Culturally Diverse & Hard to Reach Federal Regulations (e)(5) Navigators must provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange, including individuals with limited English proficiency, and ensure accessibility and usability of Navigator tools and functions for individuals with disabilities in accordance with the Americans with Disabilities Act and section 504 of the Rehabilitation Act. 10 Training must also ensure Navigator expertise in the needs of underserved and vulnerable populations. Maryland connector entities must: Have in-house capability to speak both Spanish and English initially and, in future years, for any other languages that account for more than 3% of applications; Contact the Call Center for language support as needed Provide written materials at a sixth grade reading Provide culturally-appropriate interpretation/translation of written materials for languages that account for more than 3% of the applications; Provide materials and assistance in a way that is accessible to those with disabilities; and Ensure all physical space complies with the ADA.

11 Hand Offs & Referrals 11 Federal Regulations & Navigators must coordinate with Medicaid to either assist or seamlessly transfer individuals eligible for Medicaid or CHIP. Maryland has established standards that require certain hand off/referral procedures between connector entities and the following: Local Departments of Social Services (LDSSs)/Local Health Departments (LHDs) The Call Center State entities, including the MIA, HEAU and the DHMH Office of the Inspector General SHOP navigators Producers

12 Eligible Entities 12 Navigators must: Federal Regulations (c) Have existing relationships, or could readily establish relationships with target populations Meet state licensing or other standards Not have a conflict of interest Comply with the privacy and security standards adopted by the Exchange Exchange must have at least one community based organization /consumer-focused nonprofit serving as a Navigator plus at least one of the following: (1) Trade, industry, and professional associations; (2) Commercial fishing industry organizations, ranching and farming organizations; (3) Chambers of commerce; (4) Unions; (5) Resource partners of the Small Business Administration; (6) Licensed agents and brokers; and (7) Other public or private entities or individuals that meet the requirements of this section, e.g., Indian tribes, tribal organizations, and State or local human service agencies.

13 Training 13 Federal Regulations (b)(2) Exchanges must establish a set of training standards for Navigators to ensure expertise in: (1) The needs of underserved and vulnerable populations; (2) Eligibility and enrollment rules and procedures; (3) The range of QHP options and insurance affordability programs; and (4) The privacy and security standards. Maryland estimates that navigator training will take 120 hours and cover: Policies & Procedures: Overview of ACA, Heath Reform, Health Insurance, QHPs, etc.; Outreach and Education Training, Ethics, Customer Service, Confidentiality, etc. Medicaid and MCHP: Overview of Programs; Hand-Offs with LHDs/LDSSs, Other Agencies; MAGI and non-magi Eligibility Maryland Health Connection: Instruction on the Eligibility and Enrollment System, Including Plan Presentation and Selection; Checkout Procedures and Payment and Processing, etc.

14 Conflicts of Interest 14 Navigators must not (1) Be a health insurance issuer; Federal Regulations (d) (2) Be a subsidiary of a health insurance issuer; (3) Be an association that includes members of, or lobbies on behalf of, the insurance industry; or, (4) Receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any individuals or employees in a QHP or a non-qhp. Proposed regulations would prohibit stop loss insurers, their subsidiaries or those paid by stop loss insurers for enrollment from serving as Navigators. Maryland also requires: Character: Individual and SHOP Exchange navigators should be of good character and trustworthy Steering: Steering or otherwise encouraging individuals or small businesses to enroll in a plan or product on a basis other than the consumer or employer s best interests is prohibited

15 Oversight 15 Guidance SBE: SBEs must develop and hold navigators accountable to standards related to training, conflicts of interest and privacy. They must also ensure that navigators are completing, at a minimum, the duties outlined in federal regulations. The Maryland Health Connection has primary oversight responsibility for the connector entities. Connector entities are also subject to MIA oversight. Participate in routine check in calls Entities must: Submit quarterly progress reports, which will include submitting data on enrollments and performance measures Attend meetings upon request Be available for on-site visits

16 Performance Measures 16 Connector entities must report on the following performance measures: Number of successful, declined, or pending applications into QHPs or Medicaid/MCHP Percent of enrollments into specific QHPs or MCOs Names and numbers of full time and part time certified navigators, assisters and other staff on staff/contracted Number of non-certified personnel, including assisters, on staff/contracted Preferred language of applicant Age/demographic/income data of applicants (with a focus on if applicant qualifies for a tax subsidy or credit) Race/ethnicity of applicants Disabled status of applicant Consumer satisfaction survey (to be coordinated with the MHBE) Number and type of interactions (e.g. community events, one on one assistance, etc.), estimate of population reached by interaction and materials distributed Timeframe from initial interaction with an applicant

17 Funding 17 Federal Regulations (f) Funding for Navigator grants may not be from federal funds received by the State to establish the Exchange. SBE states may use federal exchange grants may for program development and, to the extent navigators assist individuals with Medicaid eligibility/enrollment, the state may request Medicaid matching funds to cover navigator costs. Maryland has implemented fixed grants with a performance-based component. Grantees are eligible for performance awards of 3, 5 or 8% of the base award amount for achieving established enrollment targets. Maryland will leverage Exchange operating funds and Medicaid matching funds to operate the navigator program.

18 Certification/Licensure 18 Federal Regulations (c)(iii) Navigators must meet any licensing, certification or other standards prescribed by the State or Exchange, if applicable. Navigators cannot be required to have a producer license. Maryland requires that Individual Exchange navigators be certified by the Exchange and SHOP navigators be licensed by the MIA. Individual Exchange navigators must be certified by the Exchange. Certification lasts for 2 years, unless renewed. To be eligible, navigators must: Be of good character and trustworthy Be at least 18 years old Complete and comply with ongoing training requirements Comply with all other requirements SHOP navigators must be licensed by the Maryland Insurance Administration. To be eligible, a SHOP navigator must: Be of good character and trustworthy Be at least 18 years old Pass a written exam Not have committed any act that would warren denial, suspension or revocation (identified in law)

19 Privacy Standards 19 Federal Regulations (c)(v) Navigators must comply with the privacy and security standards adopted by the Exchange as required in accordance with

20 In-Person Consumer Assistance ( Assisters ) 20

21 What is an Assister? 21 The federal rules allow states to use assisters to provide navigator-like services. A key difference between navigators and assisters is that, unlike navigators, assisters may be paid out of federal Exchange grant funds. Proposed federal regulations would require that federally-funded assisters be trained and meet the same COI, accessibility and training standards as FFE navigators. In Maryland, non-certified personnel (or assisters ) may provide a range of services, including: Consumer education and outreach Facilitating eligibility determinations and redeterminations for premium tax subsidies, Medicaid and MCHP Facilitating and providing ongoing support with respect to the selection of managed care organization, application processes, enrollment and disenrollment for Medicaid and MCHP Training for assisters is estimated to take hours.

22 Certified Application Counselor 22

23 What is a Certified Application Counselor? 23 Recently proposed regulations would require Exchanges to certify application counselors. Application counselors may: Provide information on insurance affordability programs and coverage options Assist individuals and employees in applying for coverage Help facilitate enrollment States could choose to have application counselors serve the Medicaid and CHIP programs as well. Exchanges would not pay application counselors for their service. HHS has not finalized how much flexibility Exchanges may have with respect to expanding upon the federal standards for counselors.

24 Appendix 24

25 Federal Resources 25 Federal Law: 42 USC 18031(i) / PPACA Section 1311(i): Navigators Federal Regulations: 42 CFR : Consumer assistance tools and programs of an Exchange. 42 CFR : Navigator program standards. 42 CFR Certified application counselors. (PROPOSED) 42 CFR Standards applicable to Navigators and non-navigator Assistance Personnel carrying out consumer assistance functions under (d) and (e) and in a Federally-facilitated Exchange and to non-navigator Assistance Personnel Funded Through an Exchange Establishment Grant. (PROPOSED) Subregulatory Guidance: Guidance on State Partnership Exchanges: General Guidance on Federally Facilitated Exchanges: pdf Frequently Asked Questions on Exchanges, Market Reforms and Medicaid: Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges:

MARYLAND HEALTH BENEFIT EXCHANGE (MHBE) CONNECTOR PROGRAM Grant Solicitation - Regional Connector Entities GRANT SOLICITATION OVERVIEW...

MARYLAND HEALTH BENEFIT EXCHANGE (MHBE) CONNECTOR PROGRAM Grant Solicitation - Regional Connector Entities GRANT SOLICITATION OVERVIEW...3 CONNECTOR PROGRAM OVERVIEW...4 A. Introduction and Background...4