Navigators and the Affordable Care Act Stacey Pogue, Senior Policy Analyst, Center for Public Policy Priorities pogue@cppp.org 512-823-2863 Webinar February 22, 2013 CPPP.org
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Presenter Stacey Pogue Senior Policy Analyst Center for Public Policy Priorities pogue@cppp.org 512-823-2863
Terminology Navigator Health Insurance Marketplace (formerly known as the Exchange)
Texas Enrollment Opportunity As of 2010, 6.2 million Texans were uninsured. This is how those individuals would likely gain coverage under the ACA: Number of Uninsured Persons 0 0.5 1 1.5 2 2.5 3 Marketplace with help 2.6M Marketplace at full cost 610k Medicaid adults: newly eligible 1.4M Medicaid/CHIP kids: eligible now but not enrolled 600k Left uninsured 1.1M *Eligibility based on income only
Texas Enrollment Challenge As of 2011, 6.1 million Texans were uninsured. ~5 million will likely be eligible for coverage in the Marketplace. 89% of uninsured have incomes < 400% FPL. 16% 971,000 11% 689,000 26% 1.6 million 47% 2.8 million people < 150% FPL (< $33,525 for a family of four) 150-250% FPL ($33,525 - $55,875) 250-400% FPL ($55,875 - $89,400) > 400% FPL (> $89,400) 6.1 million includes 1.7 million non-u.s. citizens, 1.1 million of whom are likely undocumented and thus not eligible for coverage. U.S. Census, CPS, 2012
In-Person Enrollment Assistance in 2014 In-person Assistance: Agents/Brokers Navigators Certified Application Counselors Safety Net Providers
What is an ACA Navigator? Entities that will offer knowledgeable, in-person enrollment assistance to consumers and small employers in the Health Insurance Marketplace. Will help people learn about their coverage options in the new Marketplace, and to enroll in Medicaid, CHIP, or private coverage. Navigators and their duties are outlined in Section 1311(i) of the Affordable Care Act (ACA). Each Marketplace (aka Exchange) is required to have a Navigator program.
Types of ACA In-Person Enrollment Assistance 3 categories in ACA statute and regulation. Slightly different roles and/or funding: Navigators More broad based, comprehensive consumer assistance. Grants funded by the Marketplace. Certified Application Counselors (little guidance so far) Hospital and clinic based. Help enroll patients who go to that provider. Could also be community organizations? Provide info about coverage options, and assist with computer process to enroll in Medicaid/Exchange options; but no public outreach/education. Unfunded In-person Assisters Role similar to Navigators, but funded by Exchange planning grants Only available in state-based or partnership Exchanges so NOT Texas.
What Will Navigators Do? Conduct outreach and public education on Marketplace coverage options and financial assistance Distribute fair and impartial information on enrollment, plan options, and subsidies. This includes options from the Marketplace as well as public programs, such as Medicaid and CHIP Facilitate enrollment in Marketplace health plans Provide referrals for any grievance, complaint, or question about their health plan, post-enrollment. Provide information that is culturally and linguistically appropriate, and accessible to those with disabilities * Guidance expected to clarify that a Navigator entity must support all functions, but not every individual Navigator must perform each function; i.e. how the entity divides the work is up to them.
Who Can Be a Navigator? Community and consumer-focused nonprofit groups Trade, industry, professional associations Commercial fishing industry organizations Ranching and farming organizations Chambers of commerce; Unions Partners of the Small Business Administration Licensed insurance agents and brokers Others The Navigator programs in each state Marketplace must include at least one communitybased and consumer-focused nonprofit and at least one other type of public or private entity. Navigators cannot be health insurers or have affiliations with health insurers, as this may create a conflict of interest. Navigators cannot be any form of payment from an insurer. Navigators must demonstrate that they have relationships with the uninsured.
The Need for Navigators Nationally, 75% of the newly eligible said that they wanted in-person assistance to learn about and enroll in coverage. (Enroll America Research, 2012). The profile of Marketplace enrollees is unique. Nationally: 65% previously uninsured 77% have high school diploma or less Lower income than insured today 81% will receive subsidies Median income is 235% FPL ($54k for a family of 4) More racial and ethnic diversity 23% do not speak English at home Kaiser Family Foundation, A Profile of Health Insurance Exchange Enrollees, March 2011
The Need for Navigators In Texas: One in four residents is uninsured We will need every available enrollment expert both health insurance agents and Navigators to effectively reach out and provide in-person assistance to enrollees. Navigators will: Help meet the increased demand for in-person enrollment assistance Tailor outreach efforts to the unique needs of the new enrollee population.
Funding for Navigators Funded through federal grants. The Texas Navigator program will be funded through grants from the operating budget of the federal Marketplace In FFE s, like Texas, the state has no input regarding Navigator selection or grant distribution. All funding and grant oversight will come from the federal government. Federal guidance states that exchanges should make sure that their Navigator programs have sufficient funds to ensure that all potential enrollees have access to assistance. The funding formula will be announced, and will be similar to that used for Consumer Assistance Programs. Based on number of uninsured in the state, with a floor. We do not yet know how much funding will be available for Texas.
Navigator Grants and Rules Timeline *Dates are tentative and have not yet been formally announced, with the exception of the Enrollment Period dates.
Registering for Grants.gov Registration process can take UP TO 30 DAYS, so register NOW. You should not wait for the Navigator grant announcement to come out to register. For information about registering your organization, go to: grants.gov/applicants/organization_registration.jsp Includes information on important steps: 1. Obtaining a DUNS Number 2. Registering with the System for Award Management (SAM) 3. Creating your Authorized Organization Representative (AOR) profile and 4. AOR Authorization
Navigator Training and Support Training will likely be 20-40 hours, and include the following topics: Health Insurance 101 Compliance with conflict of interest standards Reporting requirements Cultural and linguistic competency Disability access Components on privacy and security Components on Medicaid and CHIP, tax credits, and affordability programs Web portal account creation and maintenance Web-based training and certification exam Training, certification, and enrollment activity tracked for each individual Navigator through unique log-on credentials to the Exchange portal Certification test likely at the end of each training module. Minimum score needed to certify. State many be able to add some modules to federal training that cover state-specific information Continuing education anticipated. Re-certification may be required to maintain grant.
Navigator Oversight in the Federal Marketplace For Texas, the federal government will perform the following oversight duties: Selecting grantees Administering a grant reporting system Setting standards (conflicts of interest, cultural competency) Training (application for assistance, understanding coverage) Certification/licensing (exam) Directing activities Administering complaint tracking system Monitoring activity through Web Portal
Navigator Oversight: The State s Role The state s oversight role in the FFE: Optional and limited. Cannot conflict with federal law. For example, states cannot require that all Navigators be licensed as health insurance agents. Opportunity for improving coordination and authorizing navigators in state law. Ideally, states efforts should not duplicate federal efforts or create barriers to participation.
Texas Legislation Related to Navigators House Bill 459 Sponsor: Rep. Ryan Guillen (D - Rio Grande City) Senate Bill 1795 Sponsor: Sen. Kirk Watson (D - Austin)
Spread the Word! Marketplace Enrollment begins October 1, 2013! Community groups are needed! Funding will be available in the near future. Please pass this information along!
More Information: Healthcare.gov www.healthcare.gov/marketplace
Resources Preparing Navigators Tool Kit, Families USA, January 2013 http://www.familiesusa.org/resources/tools-for-advocates/preparing-navigators-tool-kit/ Final Rule and Interim Final Rule on the Establishment of Exchanges, Department of Health and Human Services, March 2012 http://www.gpo.gov/fdsys/pkg/fr-2012-03-27/pdf/2012-6125.pdf Frequently Asked Questions on Exchanges, Market Reforms, and Medicaid, Centers for Medicare and Medicaid Services, December 2012 http://cciio.cms.gov/resources/files/exchanges-faqs-12-10-2012.pdf Guidance on Federally-Facilitated Exchanges, Center for Consumer Information and Insurance Oversight, May 2012 http://cciio.cms.gov/resources/files/ffe-guidance-05-16-2012.pdf