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All Hands on Deck:Navigators, Brokers & Community Assistors

Tricia Brooks

Georgetown University

Health Policy Institute

Center for Children and Families

2Come October 2013, We Need All Hands on Deck

o One-third of a million New Mexicans are expected to secure coverage through Medicaid or the Exchange in 2014

o An initial six-month open enrollment period for Exchange coverage starts October 1, 2013

3Some, if Not Many, Will Need Individualized Assistance

o Becoming aware of new options and personal responsibility to have coverage

o Determining if they are eligible and how to applyo Overcoming language, cultural or accessibility

barrierso Choosing an insurance plano Understanding implications of premium tax

credits and cost-sharing subsidieso Maneuvering multiple sources of coverage within

a family or when changes occur

Paths to Coverage in New Mexico

Source: Urban Institute, “Health Reform Across the States: Increased Health Insurance Coverage and Federal Spending on the Exchanges and Medicaid,” March 2011

Medicaid Current Eligible; 36,000

Medicaid Newly Eligible;

148,000

Exchanges with Premium Subsidies;

127,263

Exchage without Premium Subsidies;

49,560 Income under 138%FPL

$14,945 for an individual

$25,268 for a family of three

Almost half are under 200% FPL

$21,660 for an individual

$36,620 for a family of three

An estimated 70% of parents have children eligible for Medicaid

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The Basics

o Navigator programs are a required function of Exchanges

o Exchanges make grants to eligible entities that meet standards set by the state

o Funding for Navigators must be from Exchange operational funds, not federal exchange establishment grants

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THE LAW AND THE REGULATIONS

NAVIGATORSBROKERS

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Final Regulations Clarify Roles

Does this end the tug of war between navigators and brokers?

8Key Clarifications in Final Regulations

o States cannot require Navigators to be “licensed brokers” or carry omissions/errors liability insurance

o Navigators cannot receive consideration directly or indirectly from insurers for enrollment in QHPs or plans outside the Exchange

o States must select at least two types of eligible entities as navigators• One must be community or consumer focused

nonprofits

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What Entities Can Be Navigators?

Explicitly excludes:o Health insurance issuerso Subsidiaries of issuerso Associations with members,

or that lobbies on behalf of, the insurance industry

o An entity or individual with a conflict of interest

Must include, in addition to at least one community or consumer-focused nonprofit, one entity from:o Chambers of commerceo Licensed agents and brokerso Trade/industry associationso Commercial fishing, ranching

and farming organizationso Unionso SBA resource partnerso Other public/private entities (i.e.

tribal organizations or state/local government offices

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Navigator Eligibility

o Be capable of carrying out the dutieso Have relationships or can easily establish

relationships with those likely to be eligible for enrollment in a QHP• Employers and employees• Consumers (including uninsured and underinsured)• Self-employed individuals

o Meet licensing, certification or other standards prescribed by the state or Exchange

o Have no conflicts of interestso Comply with privacy and security standards

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Required Navigator Duties

o Maintain expertise in eligibility, enrollment and program specifications

o Conduct public education activitieso Provide information in a manner that is fair,

accurate and impartialo Facilitate selection of a QHPo Provide referrals for grievances, complaints and

questions regarding coverageo Provide information that is accessible and is

culturally and linguistically competent

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What about Brokers/Agents?

o Cannot serve as Navigators if they receive direct or indirect compensation from an insurer inside or outside the exchange• Effectively means brokers would need to give up

commercial business to be navigatoro States may use brokers in their traditional role

• Payment could be from Exchange or directly from insurer

o Must be trained on range of QHP options and Medicaid, CHIP and BHP (if applicable)

13Requirements for Brokersin the Exchange

o Enter into an agreement with Exchangeo Use the Exchange website for eligibility

determination and QHP enrollment• Exchange transmits enrollment to QHP

o Assist individuals in applying for advance premium tax credits, cost-sharing subsidies• Interim final rule released for comment

o Comply with privacy and confidentiality standardso Comply with applicable State law related to agents

and brokers, including applicable State law related to confidentiality and conflicts of interest

14Final Rules Open Doorto E-brokers

o Subject to other broker requirementso Must use Exchange website for eligibility and

enrollmento If e-broker uses its own website, it must:

• Disclose information about all QHP’s• Not provide financial incentives such as rebates and

giveaways• Maintain audit trails and records for 10 years• Allow individuals to withdraw from process and use

Exchange’s website at any time

15Requirements for Navigators and Brokers under Federal Rules

o Navigators Brokers

Knowledge of all QHP options, as well as Medicaid, CHIP and BHP (if application)

Maintain Expertise

Receive Training

Conduct outreach and education ✔

Provide fair, impartial information ✔

Provide information on all QHP options ✔

Provide information in manner that is culturally and linguistically, and accessible for people with disabilities ✔

Comply with privacy and security standards ✔ ✔

Have no conflicts of interest ✔

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CREATING A NAVIGATOR PROGRAM

Meeting the Needs of Consumers

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Overarching Design Questions

Who needs help and what kind of assistance do they need?

How robust will the Exchange and Medicaid IT infrastructure be?

18Key Steps in Creating a Navigator Program

① Engage stakeholders② Assess needs of

consumers③ Build on existing

infrastructure④ Develop standards

• Competencies & duties

• Training• Conflicts of interest• Privacy and security

⑤ Evaluate funding and payment strategies

⑥ Determine performance metrics

⑦ Develop web-based tools

⑧ Recruit, train and certify

⑨ Promote assistance⑩ Assess and address

gaps

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Structural Considerations

o Integrated or coordinated?• Medicaid and QHPs• Individual Exchange and SHOP

o Modular or tiered?• Outreach and public education• Eligibility assistance• QHP selection and tax counseling

o Navigators and brokers?o Hub and spoke concept

• Key organizations coordinating otherso Targeted or all comers?

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Additional Duties and Competencies

o State Exchanges can strengthen the requirements

o Additional duties and competencies• Medicaid managed care plan enrollment• Post-enrollment responsibilities

Access and use of health care services Handling complaints, grievances, appeals Assistance with non-MAGI and safety net programs

• Ongoing client support Changes, renewals

• Ongoing feedback loop

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Training Considerations

o Oversight• Who designs, delivers, updates?• Mechanism, frequency

o Policy content• Programs and process• Assisting with verifications when needed• Current monthly vs. projected annual income• Tax implications• Immigration status

o Use of technologyo Coordination between programs, changes

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More Training Considerations

o Brokers • Needs of low-income families• Complexities of income eligibility• Families split between coverage options

o Community-based application assistors• Choosing a plan• Understanding private insurance cost-sharing

o Everyone• Implications of premium tax credits, cost-sharing

reductions• Access to essential minimum coverage• Jumping the firewall

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Funding and Payment Strategies

Fundingo State fundso Assessments on carrierso Dedicated funding

streamso Community benefitso Medicaid administrative

fundso Foundations

Paymento Fixed grantso Fixed grants plus

performance based bonuses

o Per person/per application set fee

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States Making Headway

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o Builds on existing infrastructure• Community based assistors and “independent”

insurance agents integrated as part of the Exchange’s customer services

o Exchange will collect and redistribute insurance agent commissions

o Secure agent/navigator portalo Intent to provide training by June/July 2013o Special hotline within call center to serve

assistors

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o Exchange legislation includes both navigators and brokers• Navigators will be separate in Individual Exchange

and SHOPo Extends certain navigator requirements to

brokers• Cultural/linguistic competency• Focus on meeting needs of the consumer

o Carriers will pay brokers

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Takeaways

o Above all else, assistance whether through brokers or navigators, must serve the consumer.

o Assistance should cover the full continuum of education, application, enrollment and ongoing support.

o Handoffs should be minimized to avoid people slipping through the cracks.

o Effective oversight requires ongoing assessment of and addressing gaps in assistance.

28Georgetown Health Policy InstituteCenter for Children and Families

o Tricia Brooks, Senior Fellow• pab62@georgetown.edu• 202-365-9148

o Our Website: http://ccf.georgetown.edu/

o Say Ahhh! Our child health policy blog:http://www.theccfblog.org/