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Consumer Assistance Programs CAPs: Helping Consumers Through the Maze of Private Health Insurance

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Consumer Assistance Programs CAPs: Helping Consumers Through the Maze of Private Health Insurance

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    1. Consumer Assistance Programs (CAPs): Helping Consumers Through the Maze of Private Health Insurance Holly Whelan Consumer Support Group Center for Consumer Information and Insurance Oversight Centers for Medicare and Medicaid Services July 5, 2011 1

    2. Background Section 1002 of ACA appropriated CAP funds Initial funding of $30 million to states and territories to establish or expand consumer assistance or ombudsman activities 2

    3. Where are the CAPs? 33 states, DC and 4 territories 3

    4. 4 The previous slide showed a map of the United States. Each state and territory is shaded one of three colors to indicate whether they have a CAP program and whether that CAP is currently in operation. CAPs exist in the following states and territories: Arkansas, American Samoa, California, Connecticut, Delaware, District of Columbia, Georgia, Guam, Iowa, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Montana, North Carolina, New Hampshire, New Jersey, New Mexico, New York, Nevada, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia, Virgin Islands, Washington, West Virginia The following states and territories do not have CAP programs: Alabama, Alaska, Arizona, Colorado, Florida, Hawaii, Idaho, Indiana, Louisiana, Minnesota, Nebraska, North Dakota, Northern Marianas Islands, Ohio, South Dakota, Utah, Wisconsin, Wyoming

    5. Who are the CAPs? State agencies Departments of Insurance Offices of the Governor Offices of the Attorney General Independent consumer assistance agencies Other state agencies State agencies in partnership with non-profit organizations (13 CAPs) Programs projected to assist 99 million people in the first year 5

    6. How CAPs Help Consumers Assist consumers with the filing of complaints and appeals against health plans Help consumers enroll in health insurance coverage Educate consumers about their rights for getting and keeping health insurance Collect, track, and quantify inquiries and problems encountered by consumers CAPs must provide detailed quarterly reports to the Secretary Data will be used to identify patterns and strengthen oversight 6

    7. Outreach Fact sheets on ACA consumer protections: http://cciio.cms.gov/resources/factsheets/index.html#capg Brochure on CAPs for partners Poster on CAP for consumers Interactive map tool: www.HealthCare.gov/consumerhelp 7

    8. 8

    9. The previous slide shows a screenshot of the website http://www.healthcare.gov/consumerhelp. This website shows a clickable map of the United States. When a state or territory is selected, users will be brought to an individual page for that state or territory that lists either the contact information for the CAP, or a list of alternate resources for states without consumer assistance programs. 9

    10. Challenges Faced by CAPs Lack of Consumer Awareness Administrative Requirements Sustainable Funding 10

    11. CAPs and SHIPs Similar activities – different populations CAPs coordinate with SHIPs Ex: KY, NC, NV, SC, WA SHIPs can refer to CAPs as appropriate 11

    12. CAPs Make the ACA Real… …in New York A woman’s husband passed away after an extended, severe illness. His treatment included expensive intravenous therapy, which insurance advised would be covered. After he died, however, she was billed by providers for more than $30,000 in denied claims. She tried to sort the problem out herself, but got different answers from the insurer each time she called and had trouble keeping straight all the forms. Despondent over the loss of her husband, the thought she might lose everything else to medical debt was too much. Then she heard about the New York CAP. When she called, a caseworker told her to bring in the piles of forms and said he would sort it out. Eventually, he got the insurer to pay all the claims. 12

    13. CAPs Make the ACA Real… … in Georgia The Georgia CAP helped a consumer who had applied for PCIP coverage but was ineligible because he had prior creditable coverage. The man contacted his CAP for help. The CAP investigated further and realized the man’s prior coverage was actually a discount plan, not health insurance. In addition to helping him enroll in coverage, the CAP reported this situation to CCIIO. Follow up discussions ensued to clarify the definition of creditable coverage within the PCIP program so other consumers would not encounter similar difficulties. 13

    14. CAPs Make the ACA Real… … in Michigan The Michigan CAP was contacted by a consumer whose adult daughter had lost coverage because she reached her 25th birthday. The daughter had rheumatoid arthritis with monthly prescriptions and medical care costs of $2500 - $3000. The consumer had been told by her employer that the daughter would not be eligible to enroll back in the plan until open enrollment the following year.  The CAP contacted the insurance provider directly, and was able to get the daughter re-enrolled retroactive to her birthday, thus avoiding any gap in coverage. 14

    15. Thank you! Holly Whelan holly.whelan@cms.hhs.gov 301-492-4220 15

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