THE INDIANA NAVIGATOR PROGRAM: What Healthcare Providers Need to Know

Transcription

1 THE INDIANA NAVIGATOR PROGRAM: What Healthcare Providers Need to Know Presented by: J Hopkins, Vice President Beth Overmyer, Executive Vice President ClaimAid Consulting Version

2 THE INDIANA NAVIGATOR PROGRAM: The basics of the Indiana Navigator Program How healthcare providers are affected by the program What healthcare providers can do to remain compliant with Indiana Code and regulations Q & A

3 Consumer Assistance The Indiana Navigator Program: Consumer Assistance

4 Fed, State, CACs, ARs, Agents

5 History Consumer Assistance When the Patient Protection and Affordable Care Act (PPACA) was signed into law in 2010, it not only introduced many of the changes coming to Medicaid and the private insurance market, but also introduced the concept of Navigators individuals who will serve as unbiased, knowledgeable resources who can help reduce consumer confusion through outreach, education and enrollment assistance.

6 History State Law On May 11, 2013, Governor Pence signed into law House Bill 1328 (Indiana Code 27-19), which established guidelines for the Federally Facilitated Marketplace operating in Indiana. October 1, 2013 any individual meeting the definition of Navigator in IC and any entity meeting the definition of Application Organization in IC , must become certified by the State of Indiana to assist Hoosier consumers in completing applications for health insurance and health care plans under Medicaid and the Federally Facilitated Marketplace.

7 What is a Navigator? Federal Navigator Received grant funds from the federal Department of Health and Human Services. Only 4 Indiana organizations awarded these one time grant funds.

8 What is a Navigator? (cont.) What did Indiana receive? Affiliated Service Providers of Indiana in collaboration with community mental health centers and Ivy Tech - $897,150 Plus One Enterprises focusing on helping individuals and small employers in Delaware and Madison Counties - $130,875 Health and Hospital Corporation of Marion County focusing on uninsured individuals in Marion County - $590,985 United Way Worldwide working with local United Ways and $424,586

9 What is a Navigator? (cont.) The Indiana Navigator Program Is a separate and distinct program and certification from the federal Navigator program. The two are not affiliated, other than the state of Indiana requires federal Navigators to also be certified as Indiana Navigators.

10 What is a Navigator? (cont.) Communication Issue: Healthcare.gov - Federal Navigator information Indiana Medicaid Application Indiana Navigator Information

11 What is a Navigator? (cont.) Indiana Navigator (IC ) means an individual who: (1) is described in Section 1311(i) of PPACA (42 U.S.C (i)); (Federal Navigator) (2) assists other individuals with application for and enrollment in a health benefit exchange or public health insurance program; (3) performs the functions of a navigator with respect to a health benefit exchange as established by the commissioner.

12 What is a Navigator? (cont.) Indiana Navigators Includes Federal Navigators 771 certified by the state of Indiana (as well as 144 pending applications) as of Proposed Rule

13 Navigator Compensation Federal Navigator : CANNOT be paid by consumer Indiana Navigator: MAY be paid by consumer

14 Navigator Indiana Code Requirements (Proposed) Rule 3. Certification and Registration and Duties 760 IAC Certification and Registration Requirement Authority: IC ; ; Affected: IC Sec. 1 (a) A person shall not assist individuals with application for and enrollment in a health benefit exchange or public health insurance program or otherwise function as a navigator or application organization unless the individual is certified as a navigator or the entity is registered as an application organization.

15 Navigator Who Must? Who MUST apply to become an Indiana Navigator? Any individual meeting the definition of Navigator in Indiana Code must become certified as an Indiana Navigator. This includes, but is not limited to: (1) Federally-funded federal Navigators; (2) Federally-designated Certified Application Counselors; (3) Medicaid Enrollment Center staff or volunteers helping complete insurance affordability program applications; (4) Licensed insurance producers helping complete insurance affordability program applications who do not sell health insurance plans; and (5) Any other staff or volunteers of other organizations who help complete insurance affordability program applications.

16 Navigator Who CANNOT? Who CANNOT become an Indiana Navigator? Individuals receiving compensation for the sale of health insurance or from health insurance issuers cannot become Indiana Navigators. For example, health insurance producers or agents that receive commission for helping someone enroll in a health insurance plan cannot be an Indiana Navigator.

17 Navigator Who CANNOT? (cont.) Who CANNOT become an Indiana Navigator? Individual cannot be an Indiana Navigator if he or she: Has had the following denied, suspended, or revoked: Insurance agent or broker license, Indiana Navigator certification, or equivalent Has been convicted of a disqualifying felony or other crime Decision made by Indiana Department of Insurance (IDOI) and Family and Social Services Administration (FSSA) Has admitted to or been convicted of unfair trade practice or fraud in the insurance business

18 Navigator COI Conflicts of Interest: Conflict of Loyalty Definition: Business or family interest that keeps the Navigator or Application Organization (AO) from acting in the best interest of the consumer Example: Navigator or AO has a relationship with a hospital that prefers certain plans with higher payment rates Report the conflict: If a Conflict of Loyalty exists, the Indiana Navigator and/or AO must: Complete the Conflict of Interest Disclosure form and submit to Indiana Department of Insurance (IDOI) Tell consumers about conflict before assisting them

19 Navigator Program Requirements To become a certified Indiana Navigator, an individual must: (1) Submit application for Individual Indiana Navigator Certification. Application required each year. (2) Pay the non-refundable online application fee ($50 for Indiana residents; $100 for non-residents) and processing fee ($15); (3) Submit the Conflict of Interest Disclosure Form, Privacy and Security Agreement and any other supporting application materials. (4) Complete a criminal background check; (5) Complete a pre-certification course of study with an Indianaapproved trainer; and (6) Pass the Indiana Navigator Certification Exam.

20 Navigator - Reporting While certified as an Indiana Navigator, one must report: (1) A change in legal name or address no later than thirty (30) days after the change occurs. (2) Any of the following actions taken against the Indiana Navigator no later than thirty (30) days after the final disposition of the matter: a. An administrative action against a professional license, certification, or registration the Indiana Navigator holds. b. A federal or state criminal action within any jurisdiction. c. An administrative action or court order requiring payment of state income tax. d. An administrative or legal action related to unfair trade practice or fraud in the business of insurance. e. Any legal action related to the failure to pay a child support obligation. (3) In addition, an Indiana Navigator must report any potential or existing changes in Conflict of Interest status in accordance with the Conflict of Interest Policy for Navigators and Application Organizations, no later than thirty (30) days after the change or new Conflict of Interest occurs

21 Navigator Annual Renewal Indiana Navigator Renewal 60 days before certification expires Indiana Department of Insurance (IDOI) sends reminder to renew certification - Individual Navigator/AO Responsibility 30 days after certification expires Grace period to renew Avoid re-taking pre-certification training Avoid re-taking certification examination May have additional fees Process: Complete renewal application Submit non-refundable renewal fee Complete two (2) hours of continuing education (CE) each year Must take CE with IDOI-authorized trainer IDOI-authorized trainer will report CE completion to IDOI Trainers can be found on IDOI website

22 Navigator Fees Indiana Navigator fees include: (1) Initial online application filing fee ($50 for Indiana residents; $100 for nonresidents) and processing fee ($15); (2) Pre-certification training fees (may vary among different training providers); (3) Certification Exam fee ($84.75 per exam); (4) Background check fee (currently $7-17 for Indiana residents amount subject to change); (5) Annual renewal online application filing fee ($50 for Indiana residents; $100 for nonresidents) and processing fee ($15); 6) Annual continuing education ( CE ) course fees (may vary among different CE providers). Total: $ st year + Cost of Training, Following years $65 + cost of CEs FREE* Pre-Certification & Continuing Ed Available at IndianaNavigators.org

23 Navigators A Navigator CAN: Provide assistance with Medicaid and Marketplace enrollment Get PAID by their employer for doing their job Direct a client to information about insurance plan options Explain which health care providers accept which health plans

24 Navigators (cont.) A Navigator CANNOT: Choose or select a health plan for their client Get PAID by an insurance company for doing their job. Provide incorrect, misleading information on the Indiana Navigator application. Violate Insurance law

25 Navigator Interactions Interaction: Navigator helps a consumer consider healthcare use Example: How often do you go to the doctor? What type of doctors? Acceptable?

26 Navigator Interactions (cont.) Interaction: Navigator helps a consumer compare plan benefits Example: Look at the Summary of Plan Benefits for available plans; Review other consumer feedback posted on federal Marketplace website Acceptable?

27 Navigator Interactions (cont.) Interaction: Navigator helps a consumer estimate out-of pocket expenses for different plans, based on self assessed healthcare utilization patterns Example: Would need to pay $X per month for premiums, plus $X for estimated doctor visits, etc. Acceptable?

28 Navigator Interactions (cont.) Interaction: Navigator directly recommends that a consumer enroll in a specific health coverage plan Example: You should choose Plan X. Acceptable?

29 Application Organizations What is an Application Organization? An organization that employs an Indiana Navigator

30 Application Organizations - Basics Which entities MUST register as Application Organizations? Entities that employ individuals to act as Indiana Navigators must register as Application Organizations. These entities may include: hospitals (including those that offer presumptive eligibility ( PE ) assessments for Medicaid eligibility), community-based social service agencies, Medicaid Enrollment Centers, and any other organizations that employ individuals to act as Indiana Navigators.

31 Application Organizations Basics (cont.) Does my hospital/organization have to become and AO? Do you employee Navigators Directly? Yes Contract? NO

32 AO Basics - Optional Which entities have the OPTION to become Application Organizations? Entities that may, but are not required to, become AOs, include but are not limited to: (1) Presumptive eligibility ( PE ) hospitals employing contractors to assist individuals with health coverage eligibility assessments and applications; (2) Any state agency, division, or subdivision; (3) Entities employing persons to assist individuals who may be eligible for a health insurance program for reasons in addition to the individuals income or assets (e.g., individuals who may be eligible for Medicaid Home and Community Based Waiver services or Medicaid nursing facility services); and (4) Entities employing individuals to assist with applications for health insurance but not to assist with application completion or enrollment.

33 AO Basics Prohibited Entities Which entities CANNOT become Application Organizations? An entity cannot become an AO if the entity, or any owner, partner, officer, director, member, or manager of the entity, receives compensation directly from a health insurance issuer in connection with the enrollment of an individual in a health plan.

34 Application Organizations - COI AO Conflicts of Interest Any actual or potential Conflicts of Interest (i.e., Conflicts of Loyalty or Financial Interests) must be submitted to the Indiana Department of Insurance as part of the AO application process. Any change in the Conflict of Interest status of an AO must be reported to the IDOI within thirty (30) days of a status change. In addition, AOs must disclose any actual or potential Conflicts of Interest to each consumer that is assisted by the Application Organization.

35 Application Organizations - COL AO Conflicts of Loyalty A Person has a Conflict of Loyalty if the person has, directly or indirectly, through business or family, an interest or relationship with a third party that prohibits or inhibits, or potentially prohibits or inhibits, the person from exercising independent judgment in the best interests of the consumer. For example, a Navigator or Application Organization may have a Conflict of Loyalty through a business relationship with an insurance carrier, even if unrelated to plan enrollment, or by having an interest in the consumer's insurance carrier selection based on reimbursement rates or other factor.

36 Application Organization AOs & Navigators must: Submit an annual application to the Indiana Department of Insurance (IDOI) Report Changes: A change in legal name or address no later than thirty (30) days after the change for organization and individual Navigators. Any potential or existing changes in Conflict of Interest status, in accordance with the Conflict of Interest Policy for Navigators and Application Organizations, no later than thirty (30) days after the change or new Conflict of Interest occurs. Any additions or deletions of Indiana Navigators associated with the Application Organization no later than thirty (30) days following the change.

37 AO Ongoing Responsibilities In addition to annual application renewals for navigators, AOs must monitor/report: 1) A change in legal name or address no later than thirty (30) days after the change occurs. (2) Any of the following actions taken against the AO no later than thirty (30) days after the final disposition of the matter: a. An administrative action against the organization s professional license, certification, or registration. b. A federal or state criminal action within any jurisdiction. c. An administrative action or court order requiring payment of state income tax. d. An administrative or legal action related to unfair trade practice or fraud in the business of insurance. (3) Any potential or existing changes in Conflict of Interest status, in accordance with the Conflict of Interest Policy for Navigators and Application Organizations, no later than thirty (30) days after the change or new Conflict of Interest occurs. (4) Any additions or deletions of Indiana Navigators associated with the Application Organization no later than thirty (30) days following the change.

38 AO Ongoing Responsibilities - Privacy (From proposed rule) If a security breach or improper disclosure of personal information occurs, the navigator or application organization shall: (1) take immediate steps to mitigate any potential harm related to the security breach or improper disclosure; (2) notify the affected individual or individuals of the security breach or improper disclosure, no later than sixty (60) days following the discovery of such security breach or improper disclosure, by U.S. first class mail or electronic mail if the affected individual or individuals have elected to receive notices or correspondence from the navigator or application organization via electronic mail; (3) report any security breach or improper disclosure of personal information, no later than sixty (60) days following the discovery of such security breach or improper disclosure, to the commissioner; and (4) Comply with state and federal law related to security breaches if applicable, including but not limited to IC et. seq. (e) Navigators and application organizations shall make available their internal privacy practices and policies upon request by the commissioner.

39 Penalties for Non-Compliance Title 27 of the Indiana Code gives IDOI Commissioner the authority to: (1) reprimand a Navigator or an Application Organization; (2) levy a civil penalty against a Navigator or an Application Organization; (3) place a Navigator or an Application Organization on probation; (4) suspend a Navigator's certification or an Application Organization's registration; (5) revoke a Navigator's certification or an Application Organization's registration for a period of years;

40 Application Organization What steps do I take to register as an Application Organization? Submit online the New Application for Application Organization Registration; Pay the non-refundable online application fee ($50 for Indiana business; $100 for AOs with non-indiana address) and processing fee ($15); and Submit the Conflict of Interest Disclosure Form, AO Privacy and Security Agreement, and any other supporting application materials to the Indiana Department of Insurance.

41 CAC Organizations, CACDOs, CDOs What is a Certified Application Counselor (CAC)? A CAC is a federal certification granted by Certified Application Counselor Designated Organizations through a contract with the Centers for Medicare & Medicaid Services (CMS)

42 CAC Organizations, CACDOs, CDOs (cont.) Certified Application Counselor Designated Organization Optional federal program for Healthcare providers, non-federal government agencies, designated Medicaid application assistance providers, 501(c) organizations and others.

43 CAC Organizations, CACDOs, CDOs (cont.) Certified Application Counselors (CAC) Facilitate enrollment in individual Marketplace and SHOP (Small Business Health Options Program) Primary role is enrollment assistance don t have to do outreach and don t have to comply with the same CLAS (culturally and linguistically appropriate services) and conflict of interest standards as federal Navigators Act in the best interest of the applicant Can be trained and certified by the Marketplace or by a Certified Application Organization Find out more at

44 CAC Organizations, CACDOs, CDOs (cont.) CAC Organization program Application to CMS is required at: CACs are required by state law to be certified as Indiana Navigators CAC Organizations must sign a contract with CMS (Called the CMS-CDO agreement) CACs must sign a contract with CAC Organization. Several requirements of CMS-CDO contract

45 CAC Organizations, CACDOs, CDOs (cont.) CMS-CDO Contract Requirements Assign Unique CAC ID Number Issue Certificate to CAC including name and unique CAC ID Number Ensure that CAC has completed CMS approved Training Ensure that CAC has completed CMS approved Exams Require each CAC to sign CDO-CAC Agreement Maintain a Registration Process for CACs Maintain a method to track the performance of CACs that includes unique CAC ID Number Provide to CMS the Names and CAC ID Numbers assigned by CDO Upon Request Establish procedures to disclose all potential conflicts of interest to Consumers Directly or through Navigators or Call Center provide information via ADA Establish procedures to ensure consumers are informed of the functions and responsibilities of CACs Establish procedures to ensure consumers give authorization before CACs access PII Establish procedures to ensure consumers may revoke authorizations Establish procedure to withdraw CAC no later than 20 days after identification or notification of noncompliance with CDO-CAC Agreement Establish procedure notify withdrawn CAC certification no later than 20 days to cease "holding out him or herself" as a CAC and cease providing CAC services Establish procedure to protect PII of consumers Not impose a charge on consumers for assistance related to the Exchange (Marketplace) Comply with Privacy and security standards. Ensure CACs Display Certificate Ensure CACs inform Consumers of CAC functions & responsibilities Ensure CACs obtain the authorization required by 45 CFR (f) and section III.d Ensure CACs maintain a record of the authorization Ensure CACs provide their unique CAC ID Number to consumers and include on ALL applications (partial or fully completed) Ensure CACs comply with Privacy and Security Standards

46 New Programs & Indiana Navigators Hospital Presumptive Eligibility (PE) Transition to 1634 (2014 MEDICAID DISABILITY ELIGIBILITY CHANGES) 46

47 Indiana Navigators and Hospital PE New Presumptive Eligibility Hospital PE Presumptive Eligibility applies to BOTH Pregnant women and other low-income categories. 47

48 Indiana Navigators and Hospital PE (cont.) Beginning January 1, 2014, the HPE process will allow acute care hospitals to enroll with the Indiana Health Coverage Programs (IHCP) as HPE Qualified Providers (QPs) for the purpose of making presumptive eligibility determinations for IHCP. 48

49 Indiana Navigators and Hospital PE (cont.) 49

50 Indiana Navigators and Hospital PE (cont.) HPE allows staff of QPs to make eligibility determinations presumptively based on preliminary information that the applicant attests to. This allows hospitals to enroll individuals for temporary coverage with the expectation that an Indiana Application for Health Coverage will follow the presumptive decision. 50

51 Indiana Navigators and Hospital PE (cont.) Acute care hospitals also agree to the following: Affirm that this organization understands and will abide by any published guidance regarding the performance of HPE activities Affirm that this organization will not knowingly or intentionally misrepresent client information in order to inappropriately gain presumptive eligibility Affirm understanding that all HPE enrollment activities undertaken in this hospital must be performed by a hospital employee or hospital designee 51

52 Indiana Navigators and Hospital PE (cont.) 52

53 Indiana Navigators and Hospital PE 53

54 Transition to 1634 On June 1st, 2014, the state of Indiana plans to transition its Medicaid program from 209(b) to 1634 status. As a result, major changes are planned for the Medicaid for the Aged, Blind, & Disabled program

55 Transition to 1634 (cont.) Spend Down to be eliminated Indiana will no longer be required to operate its spend down program under 1634 status. Approximately 76,000 people in Indiana are currently enrolled in Medicaid using the spend down program. Depending on the income level and the specific program of eligibility, these individuals may remain eligible for their current category of Medicaid or may be transitioned to another Medicaid program. Some will no longer qualify for Medicaid and will be referred to the Health Insurance Marketplace or advised to purchase a Medicare Supplement Plan.

56 Transition to 1634 (cont.) Disability determinations will be made by the Social Security Administration Indiana will require application to the Social Security Administration (SSA) for Disability benefits as part of the Medicaid for the Disabled application. Applications for Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) are complex and typically take longer than the state Medicaid Disability process. The Indiana Office of Medicaid Policy & Planning (OMPP) has stated that they will not eliminate the state Medicaid Medical Review Team (MMRT) process, though the SSA determination will be ultimately be used for program eligibility. In most determinations the MMRT will defer to the Social Security Administration s ruling of an applicant meeting the disability definition.

57 Transition to 1634 (cont.)

58 Transition to 1634 (cont.)

59 Transition to 1634 (cont.)

60 Steps to Prepare - Assess Organization Wide Assessment Communication is key this is still a new program. Good place to start: Anyone who touches a Medicaid application In addition to traditional financial assistance roles, Hospitals should look at case managers, social workers, transition support, senior care, oncology and cardiology clinics, etc. How will changes to Medicaid process impact discharge planning?

61 Steps to Prepare - Plan Develop a plan Certify and become AO or Contract? Cost Benefit Analysis Hospital PE Qualified Provider? Will your organization participate? Process integration Training & Administration What are your initial and on-going resources/costs? Compliance Who is going to be responsible for this? Who will monitor to ensure compliance? HR, Staff Affairs, Rev Cycle, Legal, Compliance

62 Steps to Prepare - Review Review Annual Cycles for AOs and Navigators Address, Name, Conflict Changes within 30 Days Cycles are based on 12 month certification, meaning that over time there will not be 1 annual cycle. Changes in regulations Changes in training requirements Changes in reporting requirements

63 Resources IndianaNavigators.org CACOrganizations.org Healthcare.gov Marketplace.CMS.gov Indiana Department of Insurance Navigator Website Indiana Navigator FAQs Indiana Code Indiana ACA Updates

64 Questions? J Hopkins jhopkins@claimaid.com or x126 Beth Overmyer bovermyer@claimaid.com or x102