All Hands on Deck: Navigators, Brokers & Community Assistors

1. All Hands on Deck:Navigators, Brokers & Community Assistors Tricia BrooksGeorgetown University Health Policy InstituteCenter for Children and Families

2. Come October 2013, We Need All Hands on Deck • An initial six-month open enrollment period for Exchange coverage starts October 1, 2013 One-third of a million New Mexicans are expected to secure coverage through Medicaid or the Exchange in 2014

3. Some, if Not Many, Will Need Individualized Assistance Becoming aware of new options and personal responsibility to have coverage Determining if they are eligible and how to apply Overcoming language, cultural or accessibility barriers Choosing an insurance plan Understanding implications of premium tax credits and cost-sharing subsidies Maneuvering multiple sources of coverage within a family or when changes occur

4. Paths to Coverage in New Mexico 4 Income under 138% FPL 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 $14,945 for an individual $25,268 for a family of three Source: Urban Institute, “Health Reform Across the States: Increased Health Insurance Coverage and Federal Spending on the Exchanges and Medicaid,” March 2011

5. The Basics Navigator programs are a required function of Exchanges Exchanges make grants to eligible entities that meet standards set by the state Funding for Navigators must be from Exchange operational funds, not federal exchange establishment grants

6. THE LAW AND THE REGULATIONS NAVIGATORS BROKERS

7. Final Regulations Clarify Roles Does this end the tug of war between navigators and brokers?

8. Key Clarifications in Final Regulations • States cannot require Navigators to be “licensed brokers” or carry omissions/errors liability insurance • Navigators cannot receive consideration directly or indirectly from insurers for enrollment in QHPs or plans outside the Exchange • States must select at least two types of eligible entities as navigators • One must be community or consumer focused nonprofits

9. What Entities Can Be Navigators? Explicitly excludes: Must include, in addition to at least one community or consumer-focused nonprofit, one entity from: Chambers of commerce Licensed agents and brokers Trade/industry associations Commercial fishing, ranching and farming organizations Unions SBA resource partners Other public/private entities (i.e. tribal organizations or state/local government offices • Health insurance issuers • Subsidiaries of issuers • Associations with members, or that lobbies on behalf of, the insurance industry • An entity or individual with a conflict of interest

10. Navigator Eligibility • Be capable of carrying out the duties • 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 • Meet licensing, certification or other standards prescribed by the state or Exchange • Have no conflicts of interests • Comply with privacy and security standards

11. Required Navigator Duties Maintain expertise in eligibility, enrollment and program specifications Conduct public education activities Provide information in a manner that is fair, accurate and impartial Facilitate selection of a QHP Provide referrals for grievances, complaints and questions regarding coverage Provide information that is accessible and is culturally and linguistically competent

12. What about Brokers/Agents? • 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 navigator • States may use brokers in their traditional role • Payment could be from Exchange or directly from insurer • Must be trained on range of QHP options and Medicaid, CHIP and BHP (if applicable)

13. Requirements for Brokersin the Exchange • Enter into an agreement with Exchange • Use the Exchange website for eligibility determination and QHP enrollment • Exchange transmits enrollment to QHP • Assist individuals in applying for advance premium tax credits, cost-sharing subsidies • Interim final rule released for comment • Comply with privacy and confidentiality standards • Comply with applicable State law related to agents and brokers, including applicable State law related to confidentiality and conflicts of interest

14. Final Rules Open Doorto E-brokers • Subject to other broker requirements • Must use Exchange website for eligibility and enrollment • 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

15. Requirements for Navigators and Brokers under Federal Rules

16. CREATING A NAVIGATOR PROGRAM Meeting the Needs of Consumers

17. Overarching Design Questions Who needs help and what kind of assistance do they need? How robust will the Exchange and Medicaid IT infrastructure be?

18. Key Steps in Creating a Navigator Program • Engage stakeholders • Assess needs of consumers • Build on existing infrastructure • Develop standards • Competencies & duties • Training • Conflicts of interest • Privacy and security • Evaluate funding and payment strategies • Determine performance metrics • Develop web-based tools • Recruit, train and certify • Promote assistance • Assess and address gaps

19. Structural Considerations • Integrated or coordinated? • Medicaid and QHPs • Individual Exchange and SHOP • Modular or tiered? • Outreach and public education • Eligibility assistance • QHP selection and tax counseling • Navigators and brokers? • Hub and spoke concept • Key organizations coordinating others • Targeted or all comers?

20. Additional Duties and Competencies • State Exchanges can strengthen the requirements • 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

21. Training Considerations • Oversight • Who designs, delivers, updates? • Mechanism, frequency • Policy content • Programs and process • Assisting with verifications when needed • Current monthly vs. projected annual income • Tax implications • Immigration status • Use of technology • Coordination between programs, changes

22. More Training Considerations • Brokers • Needs of low-income families • Complexities of income eligibility • Families split between coverage options • Community-based application assistors • Choosing a plan • Understanding private insurance cost-sharing • Everyone • Implications of premium tax credits, cost-sharing reductions • Access to essential minimum coverage • Jumping the firewall

23. Funding and Payment Strategies Funding Payment Fixed grants Fixed grants plus performance based bonuses Per person/per application set fee • State funds • Assessments on carriers • Dedicated funding streams • Community benefits • Medicaid administrative funds • Foundations

24. States Making Headway

25. Builds on existing infrastructure • Community based assistors and “independent” insurance agents integrated as part of the Exchange’s customer services • Exchange will collect and redistribute insurance agent commissions • Secure agent/navigator portal • Intent to provide training by June/July 2013 • Special hotline within call center to serve assistors

26. Exchange legislation includes both navigators and brokers • Navigators will be separate in Individual Exchange and SHOP • Extends certain navigator requirements to brokers • Cultural/linguistic competency • Focus on meeting needs of the consumer • Carriers will pay brokers

27. Takeaways Above all else, assistance whether through brokers or navigators, must serve the consumer. Assistance should cover the full continuum of education, application, enrollment and ongoing support. Handoffs should be minimized to avoid people slipping through the cracks. Effective oversight requires ongoing assessment of and addressing gaps in assistance.

28. Georgetown Health Policy InstituteCenter for Children and Families • Tricia Brooks, Senior Fellow • pab62@georgetown.edu • 202-365-9148 • Our Website: http://ccf.georgetown.edu/ • Say Ahhh! Our child health policy blog:http://www.theccfblog.org/