OCTOBER 2014 Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment By JoAnn Volk, Sabrina Corlette, Sandy Ahn and Tricia Brooks Support for this report was provided by a grant from the Robert Wood Johnson Foundation Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendationsfor the Next Year of Enrollment 2 Authors JoAnn Volk The Center on Health Insurance Reforms (CHIR), based at Research Professor and Project Director Georgetown University’s McCourt School of Public Policy, is Center on Health Insurance Reforms composed of a team of nationally recognized experts on private Georgetown University Health Policy Institute health insurance and health reform. We work regularly with a multidisciplinary group of faculty and staff dedicated to conducting Sabrina Corlette, J.D. Research Professor and Project Director research on issues related to health policy and health services. Center on Health Insurance Reforms CHIR faculty and staff study health insurance underwriting, Georgetown University Health Policy Institute marketing and products, as well as the complex and developing Sandy Ahn, J.D. relationship between state and federal rules governing the health Research Fellow insurance marketplace. CHIR provides policy expertise and Center on Health Insurance Reforms technical assistance to federal and state policy-makers, regulators Georgetown University Health Policy Institute and stakeholders seeking a reformed and sustainable insurance marketplace in which all consumers have access to affordable and Tricia Brooks adequate coverage. Senior Fellow Center for Children and Families Georgetown University Health Policy Institute The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve health coverage for America’s children and families. As part of the University’s McCourt School of Public Policy, Georgetown CCF provides research, develops strategies, and offers solutions to improve the health of America’s children and families, particularly those with low and moderate incomes. In particular, CCF examines policy development and implementation efforts related to Medicaid, the Children’s Health Insurance Program (CHIP) and the Affordable Care Act. Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 3 Introduction The Affordable Care Act (ACA) ushered in the largest the Marketplaces have to weigh differences in cost- coverage expansion since the creation of Medicare and sharing, provider networks, benefit design and drug Medicaid in 1965. The Congressional Budget Office formularies. As a result, enrolling in Marketplace coverage estimates the ACA will reduce the number of uninsured is complicated even for individuals and families with the by 26 million by 2024.1 More than 8 million people simplest, most straightforward circumstances. enrolled in private coverage through the Health Insurance The rules governing eligibility for Marketplace plans, Marketplaces in the initial open enrollment period premium tax credits, and Medicaid are, by necessity, that ended March 31, 2014, and 4.8 million enrolled designed for the generic applicant and cannot possibly in Medicaid and CHIP.2 At the same time, the ACA imposed new rules for employer-sponsored coverage address the myriad ways in which households are formed, and insurance sold to individuals, and instituted new income is gained, and coverage is accessed. The first open responsibilities for individuals and employers. enrollment period for the Marketplaces made clear that many people require intensive assistance to navigate the While previous large coverage expansions relied on coverage options and applicable rules of the ACA.3 publicly administered coverage programs such as Medicare and Medicaid, the ACA expands coverage With support from the Robert Wood Johnson through both publicly administered Medicaid and private Foundation, Georgetown University policy experts insurance plans offered in new Marketplaces, with the provided technical assistance to Navigators and assisters aim of seamless coverage for individuals, no matter in five states–Arkansas, Arizona, Florida, Georgia, their income, age, health, or employment status. Merely and Ohio–during and after the 2014 open enrollment processing applications for the millions who enrolled in season, as they fielded questions from consumers about coverage this first year was an enormous undertaking. eligibility and enrollment. This report draws on that The eligibility and enrollment rules are complicated, work to provide a picture of how applicants’ lives align– taking into account income, household size, tax-filing or often don’t align–with eligibility rules and application status, immigration status and, in the case of eligibility requirements, and shares lessons learned during the for premium tax credits, access to other coverage. In first year of enrollment regarding what is required to addition, health insurance is an inherently complicated help people understand their coverage options and product; applicants for the private insurance plans of successfully enroll. Background Throughout the first year of enrollment into new coverage partnership (FPM), but all Marketplaces must maintain options under the ACA, various types of consumer some form of assister program. assisters have worked to ease the transition of millions of All Marketplaces must have a call center, accessible to individuals into appropriate health insurance coverage. those with disabilities and limited English proficiency, While the availability and extent of consumer assistance and websites, with health plan and related cost varies, recently issued reports showcase the importance of information.5 Rules and guidance implementing the ACA consumer assistance for the approximately 10.6 million also contemplate in-person consumer assistance in the individuals who sought help enrolling in health insurance form of Navigators, In-Person Assisters (IPAs), Certified coverage through a Marketplace in its first year.4 Application Counselors (CACs), and agents and brokers during the pre-enrollment and enrollment phases.6 For The ACA includes a number of provisions to support purposes of this paper, Navigators, IPAs and CACs are effective outreach and enrollment of consumers into referred to generally as “assisters.” In addition, the ACA coverage. As implemented, these programs may vary appropriated $30 million in funding for Consumer depending upon the type of Marketplace model, federally Assistance Programs (CAPs), which in addition to facilitated (FFM), state based (SBM), or a federal enrollment assistance are tasked with helping consumers Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 4 once they are enrolled and using their coverage, for While the ACA envisioned that Navigators would largely example, assisting consumers with appeals when an be limited to helping with enrollment, the vast majority insurer denies coverage for a service.7 of enrollment assisters, including Navigators, have been called upon to address post-enrollment questions Regardless of label, assisters were all charged with from consumers about their coverage and benefits.13 Yet helping consumers understand their options and enroll consumer assisters are neither trained nor funded to in coverage. For the 2013-2014 enrollment season, the handle these questions, with the expectation that they FFM awarded $67 million in Navigator grants to 105 would be able to refer consumers to CAP or consumer organizations, and federally qualified health centers ombudsman programs. The ACA funded states in 2010 (FQHCs) received $208 million to serve as CACs.8,9 to establish or support the CAPs, specifically designated SBM states determined the level of funding for their to handle post-enrollment questions, but Congress has assister programs and ran their own processes for selecting not appropriated funding for this program since then.14 grantees. During the 2013-2014 enrollment season, SBMs The lack of funding has caused 22 of the 33 states that outspent FFMs on consumer assistance, accounting for had CAPs to discontinue their programs. As a result, 50 percent of spending, even though they only had 31 consumer assisters have an additional burden of providing percent of all uninsured.10 consumers with post-enrollment help without financial Assisters must complete a minimum level of training on support for training and operation. State Departments Marketplace eligibility and enrollment rules, available of Insurance have consumer support divisions to health plan options, other available insurance programs answer consumers’ coverage questions and help resolve like Medicaid or CHIP, and eligibility and benefit rules.11 problems, but few consumers know they exist and they Other standards or requirements may apply to the range are often under-resourced. Many consumers, once they’ve of assisters depending on the type of Marketplace and established a relationship with an assister to help them state law.12 enroll in coverage, are likely to return to the assister when Type of Assister Scope of Work Where they Work Funding Source Navigators •• Serve as experts on eligibility, enrollment, SBM Marketplace grants and Marketplace plans (state and federal) FFM •• Conduct outreach and education activities to raise awareness about Marketplaces FPM •• Facilitate enrollment into Marketplace plans, including financial assistance, in a fair, accurate, and impartial manner •• Refer consumers to applicable entities to assist with post- enrollment questions •• Provide information that is culturally and linguistically appropriate to the populations they serve In-person Assisters •• Similar to Navigators SBM Federally funded Marketplace FPM establishment grants Certified •• Facilitate enrollment into Marketplace plans, including SBM Some operate Application financial assistance without funding; FFM Counselors •• Provide information on Marketplace plans, and other Federal grants coverage options like Medicaid or CHIP FPM available for FQHCs only Agents and •• Facilitate enrollment into Marketplace plans, including SBM Insurers Brokers financial assistance FFM •• Provide post-enrollment assistance with coverage problems FPM Consumer •• Assist with filing complaints and appeals, including 11 grantee states Federal CAP grants Assistance providing information about the external appeals process Programs •• Collect data on consumer problems and questions •• Educate consumers about their rights and responsibilities with health insurance •• Assist with enrollment into Marketplace plans •• Resolve problems related to obtaining tax credits Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 5 they have a coverage problem. Enrollment assisters will likely to have fluctuations in income because of unstable continue to be stretched thin as they start preparing for or intermittent employment, “shared” households that the second year of enrollment.15 include non-immediate family members, low educational attainment, and more frequent changes in address. These Year One of the ACA: Who Needed Consumer circumstances tend to require additional assistance with Assistance and Why? enrolling into Medicaid or Marketplace coverage with tax While the ACA has saturated the news, many Americans credits and cost-sharing assistance.24 are unfamiliar with key provisions of the health reform Another characteristic of the Medicaid and Marketplace law and health insurance in general.16 Prior to the start populations is that many consumers will switch among of open enrollment, the uninsured and low-income various types of coverage–Medicaid, Marketplace, and adults had a very low knowledge of the Marketplaces employer-sponsored insurance (ESI)–throughout the year and Medicaid expansion.17 Younger, Hispanic, low- because of changes in income or family circumstances, income and uninsured individuals also have very low referred to as “churning.” Churning already occurs understanding of basic health insurance concepts. between Medicaid and CHIP and is expected to increase Almost two out of three adults targeted for Marketplace under the ACA.25 Half of low-income adults who do not enrollment had difficulty understanding terms like receive ESI will likely experience a change in income “provider network,” “deductible,” and “premium.”18 or family circumstance that switches their eligibility As predicted, most consumers during the first year of between Medicaid and Marketplace coverage throughout Marketplace enrollment were lower-income and an the year.26 Although the data currently do not tell us the estimated six in ten were previously uninsured, with little extent of “churning” during the first year of Marketplace knowledge of how health insurance works.19 Consumers’ coverage, churning among eligibility for Medicaid, limited understanding of, and confusion about plan Marketplace, and ESI could affect nearly 29.4 million choices was one of the primary reasons they sought people a year.27 personal assistance during the 2014 open enrollment period, and ninety percent of individuals seeking help This snapshot of the first year’s market consumer were uninsured.20 Another reason consumers sought translated into a need for consumer assistance. Sixty-four personal assistance was to get help applying for premium percent of assisters spent, on average, one to two hours tax credits and cost-sharing reductions.21 Eight out of 10 helping each consumer, but many required more time and consumers using the Marketplaces were eligible for a tax multiple sessions–nearly a quarter of assisters reported credit or cost-sharing reductions, with incomes between spending more than 2 hours on average with each 100 percent and 400 percent of the federal poverty level.22 consumer.28 In addition to the time needed to explain While the FFM and most states have not yet released eligibility rules, the different forms of financial assistance, data on the income ranges of enrollees, one state–New and plan options, assisters faced technical difficulties York–has reported that 53 percent of its enrollees were with Marketplace websites and long wait times with call below 200 percent of federal poverty.23 Families living centers; these all translated into a significant amount of below 200 percent of the federal poverty line are more time spent with each consumer.29 Project Overview During the first year of enrollment, Georgetown The questions presented in this brief are just a subset policy experts supported assisters in four FFM states of the most challenging questions assisters sent to (Arizona, Florida, Georgia and Ohio) and one FPM state Georgetown for technical help. Although the assister (Arkansas), providing technical assistance for the more programs were organized differently across the five states complex cases and questions among the many answered and had different levels of financial support, we observed by assisters. This brief draws on some of those questions that the same types of questions came up often and across to illustrate the complex nature of the eligibility and the five states, suggesting that assisters nationwide were enrollment process for many individuals and families. grappling with many of the same issues. Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 6 Georgetown worked primarily with certified Navigators assisters. Nonetheless, the questions presented in this and application counselors in FQHCs. However, there brief illustrate the diverse and complicated situations were many others providing enrollment assistance to that assisters faced when helping consumers, and they consumers, including insurance agents and brokers, highlight the critical need for a sustained investment in tax preparers, Medicaid agencies, providers, and personalized assistance to help ensure people obtain the many others who volunteered in their communities. right coverage at the right cost. Answers to the below Our work did not capture the experiences of these questions are provided in Appendix A. Consumer Assistance in the First Year: Observations from the Field The ACA provides financial assistance for qualified tax filers, Medicaid takes a different approach, and does individuals to purchase Marketplace plans. It is this not include in the definition of household dependents assistance, provided in the form of premium tax credits who are not immediate family members, even if they and subsidies for out-of-pocket costs, that helps put live in the home. Exceptions to the tax-filer rules further coverage in financial reach for millions of low- and complicate Medicaid eligibility determinations for some moderate-income families. However, determining tax dependents.30 eligibility for financial help is also one of the most In real life, it can be difficult for applicants and their complicated aspects of the enrollment process, with assisters to figure out how these nuanced differences nuances that aren’t always adequately captured by the in program rules apply to often complicated family application. As a result, Navigators and assisters are relationships and tax filing status. For example, one finding it necessary to gain mastery over complex rules assister had to evaluate a household in which a 22-year- for income calculation, household size and definition, old was living with his grandmother and applying for tax filing status, and eligibility for other coverage. Other Medicaid. The grandmother claims her grandson as a tax rules, such as those related to open and special enrollment dependent, which would make him part of her household periods and the ability to keep or change health plans, in applying for premium tax credits. However, under evolved over the course of the year, requiring assisters to Medicaid rules, because he is claimed as a dependent by stay regularly abreast of the ever-changing landscape of federal and state policymaking. Determining “Household” Determining Household Size Parent as dependent: Alice* is a 50-year-old woman An initial step in the application process for premium who lives with her 28-year-old daughter, Jane, and tax credits is to first screen for Medicaid eligibility; if cares for Jane’s two children (Alice’s grandchildren). an applicant is eligible for Medicaid, they are ineligible Jane claims Alice as a dependent on her taxes. for premium tax credits. However, there are differences Jane has insurance from her employer that covers between key definitions in the eligibility process for her and her children, but it won’t cover Alice. When Medicaid and premium tax credits. Both Medicaid and Alice applies for coverage, should she include her premium tax credit eligibility are based on Modified daughter’s income and list all four members of the Adjusted Gross Income (MAGI), a measure of income household? created by the ACA, which is consistently applied for Non-custodial parent: Robert wants to buy a most tax filers. However, Medicaid uses different ways to Marketplace plan for himself and his son, John, who establish the size of an applicant’s household for purposes lives with his ex-wife. His divorce agreement requires of determining eligibility for non filers and for individuals him to provide coverage for John, but he doesn’t claim who meet specific exceptions. To determine household him as a dependent on his taxes. What are Robert’s size for premium tax credits, the Internal Revenue options to buy a plan that covers them both? Service (IRS) includes in the household anyone who is *All names used in this and later examples are a dependent for tax filing purposes, regardless of family pseudonyms used to protect the identity of the relationship or whether they live in the home. For non individuals seeking assistance. Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 7 someone other than a spouse or parent, he is evaluated on afford the rent. Must she count the rental assistance in his own based on non filer rules. her household income? •• Frank and Ellen are retired and don’t file taxes. Their Calculating Income children contribute to their household costs, but none Determining income is also complicated. The MAGI claim the parents as dependents. When Frank and income methodology is used to determine eligibility for Ellen apply, do they list the financial help from their most children and non-disabled, non-elderly adults, but children as part of their income? the pre-ACA non-MAGI income methodology still applies to people who are aged or disabled. Further complicating •• Shauna and Bob live with their adult son, Bill, who the process is that Medicaid looks at an individual’s claimed them as dependents on his 2013 tax return. current income in determining eligibility, while premium Bill provides them shelter but they pay their own food tax credits are based on projected income for the tax year. and health care costs. Shauna and Bob make less than Individuals applying for premium tax credits must 133 percent of the federal poverty level and would understand what income to count in defining “household qualify for Medicaid. Does Bill’s help and tax filing income,” project income over the course of the tax year, affect their Medicaid eligibility? and provide acceptable documentation to substantiate the •• Grace is a 63-year-old woman whose family pays estimate if federal data sources cannot verify the projected her $500 per week to care for the 98-year-old family annual income. Those who get the estimate wrong and matriarch. Should Grace count the family’s payments project a lower income than they actually earn will have as earnings when applying for coverage? to repay any excess tax credits received during the year when they file their taxes. On the other hand, those Access to other coverage who overestimate their household income may pay more out-of-pocket than they should if they are wrongly found Consumers applying for tax credits must also provide ineligible for cost-sharing reductions or receive less cost- information about any other coverage to which they may sharing reductions than they should. have access. Those who are eligible for other coverage may be ineligible for premium tax credits. But even here, there are variations on the rules that make it difficult for Estimating Uncertain Income individuals to evaluate their other coverage options and Jessica is a dog walker and paid hourly. She projects understand what it may mean for eligibility for premium income over 100 percent of the federal poverty level, tax credits. qualifying her for premium tax credits. But she’s worried that if she gets less work than she expects, Generally, those eligible for and enrolled in employer- and her actual income is less than 100 percent of sponsored coverage, Medicare, Medicaid, high risk pool the federal poverty level, she’ll have to pay those tax coverage, a student health plan, COBRA, or retiree credits back. coverage are considered to have minimum essential coverage (MEC) and cannot qualify for premium tax The rules themselves are complicated, and so too are credits. However, if the employer plan is unaffordable or people’s lives. Individuals may be part of a multi- inadequate, an individual can turn down their employer generation household or live apart from their parents or plan and enroll instead in a Marketplace plan and get children. Many individuals have uncertain or fluctuating premium tax credits. To be “affordable” under the ACA, income over the course of the tax year, particularly those the employee’s share of the premium for self-only coverage who work part time, have seasonal work, or are between in the lowest cost plan must be less than 9.5 percent jobs. Others may receive income from sources other of household income. But what was “affordable” to than wages. For example, assisters helped consumers sort congressional drafters may not be considered affordable by through the rules as they applied to the many different many low- and moderate-income people with many other ways applicants for coverage received financial help from bills to pay. Some consumers who have sought assistance family members: are not enrolled in their employer plan because it costs too much. Others have asked if they can opt out of an •• Jackie gets help on her rent from a family member who employer plan that doesn’t cover providers in their area, lives with her. Without the assistance, she couldn’t won’t cover a procedure they need, or doesn’t include key Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 8 level. However, because of system flaws, many of these Questions about Other Coverage individuals received incorrect eligibility determinations and Premium Tax Credits that resulted in denials of the premium tax credits Student Health Plan: An older PhD student, Anna, is and cost-sharing reductions and were referred back to told her student health plan won’t cover her shingles Medicaid even though they did not meet Medicaid’s vaccine or a colonoscopy. Is that allowed? Can she immigrant eligibility requirements. get a Marketplace plan instead? Retiree plan: Sandra retired at 55 and has an offer The application process for immigrant families is of retiree coverage for herself and her husband and further complicated for mixed status families, which 19-year-old son. The plan would be a good deal for are households in which different family members her, but is too expensive for her husband and son have different immigration or citizenship statuses. For to join. If Sandra enrolls in the retiree plan, can her example, one parent may be undocumented, another husband and son still apply for Marketplace coverage may be in the U.S. on a visa, an adolescent child is in the with premium tax credits? Deferred Action for Childhood Arrivals program, and Medicaid Breast and Cervical Cancer Program: a younger child may be U.S.-born. A report published Jane was uninsured when she was diagnosed in 2010 estimated one quarter of children in the United with breast cancer and was found eligible for the States is in a household with at least one foreign-born Breast and Cervical Cancer Program (BCCP) parent.32 In addition to the technical issues that arise with under Medicaid. She wouldn’t qualify for Medicaid mixed status families, the differences in immigration based on her income. Does enrollment in the status may lead to mixed program eligibility. BCCP program make her ineligible for Marketplace coverage because it’s Medicaid coverage? Mixed Status/Mixed Program Families benefits. Still others have coverage that is affordable for A family applying for coverage includes two parents the employee, but get no employer contribution for family who have been lawfully residing in the U. S. for three coverage. For premium tax credit eligibility, however, years and two children, Esteban, who has been none of these situations factors into the Marketplace lawfully residing in the U.S. for three years, and a evaluation of whether an employer plan is unaffordable daughter, Celia, who is U.S.-born. The parents and Esteban are eligible for a Marketplace plan, but or inadequate. only Celia is eligible for Medicaid. Why can’t both In other cases, merely being eligible for qualifying children get Medicaid? Or can they add Celia to the coverage does not disqualify an individual for premium Marketplace plan with premium subsidies? tax credits; it is only if the individual is enrolled in the plan–such as student health coverage or a retiree Changing Plans plan–that they are ineligible for financial help. However, eligibility for most but not all categories of Medicaid Under the ACA, health insurers selling individual makes an individual ineligible for premium tax credits. coverage are required to sell a plan to all applicants, with certain limited exceptions. One of the most important Immigrants exceptions allows insurers to limit the amount of time during the year that policies are available. Once enrolled Eligibility for the Marketplace is limited to citizens and in a plan, an individual is also limited in their ability nationals of the U.S. and lawfully-present immigrants. to change plans. For the most part, only those who Throughout open enrollment, immigrants faced technical experience life changes, such as marriage, loss of job, or difficulties with the processes for verifying identity and the birth or adoption of a child can qualify for a special immigration and citizenship status, and for submitting enrollment period (SEP), which gives them the right to documentation of their immigration and citizenship sign up for a plan or change plans outside of the open status when it could not be verified electronically.31 But enrollment period.33 there was also confusion about who was eligible for marketplace coverage. Most lawfully present immigrants Navigators and assisters heard from consumers who with income under 100 percent of the federal poverty wanted to change plans, typically because they discovered level, who were ineligible for Medicaid based on their after they enrolled that their providers are not in-network, immigration status, are eligible for premium tax credits that their providers left the network for the plan they even though their income is below the federal poverty chose, or their health needs changed and they wanted Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 9 access to providers they hadn’t anticipated. Under federal in COBRA disqualifies an applicant from receiving rules, individuals can change plans only under limited Marketplace financial assistance. However, because of circumstances. Once they have paid the first premium concerns that many consumers were not aware of these and the coverage has taken effect, an enrollee cannot rules, federal officials later determined that COBRA change plans. For most people, changing plans is only enrollees could qualify for a short-term enrollment period possible if the coverage hasn’t taken effect and it is still for subsidized Marketplace coverage through June 30, within the open enrollment period. 2014. But most consumers don’t know about these special enrollment opportunities and are unable to effectively Throughout the initial open enrollment period, CMS use them to avoid gaps in coverage, without personalized issued guidance designating new “limited circumstance” assistance. For those who are seriously ill, even a small special enrollment periods. Navigators and assisters gap in coverage can lead to substantial costs or a threat to had to stay abreast of these new special enrollment their health. periods, understand to whom they would apply, and help consumers navigate through the process to request a SEP. One such SEP was allowed for those who enrolled Avoiding a Gap in Coverage in a plan with a network that wouldn’t meet their needs. Sally lost her job and her insurance coverage at the However, the SEP was very limited; it only applied where end of April and got a new job with coverage that the individual was changing to a plan with the same wouldn’t begin until July. In the meantime, she was insurance company, within the same metal level, to gain diagnosed with breast cancer and was scheduled access to a broader network, and the change would occur for surgery in early May. Would she be able to get within open enrollment. Marketplace coverage in time for her surgery or would she have a gap in coverage? Should she enroll in COBRA to fill the gap between job-based plans? Changing Plans Brenda selected a plan knowing that the hospital in Post-Enrollment Issues her area was not on the plan, but her primary care doctor was. She had not yet heard from the plan Although Navigators and assisters do not technically about her enrollment and had not yet paid her first have within their scope of work a responsibility to assist premium when she was diagnosed with cancer and consumers with questions that come up about their was referred to specialists and an oncologist that are coverage, most have been called upon to provide this help. not covered under her plan. Can Brenda change to In a survey of assisters conducted after open enrollment, a different carrier that would include the providers 90 percent of assister programs reported being re- she needs? contacted by consumers with post-enrollment problems and questions.34 In some cases, consumers returned with Other SEPs were enumerated in the final push to enroll in questions about their plan, i.e., if they hadn’t received Marketplace coverage prior to the end of the initial open their insurance card or a premium invoice. In other cases, enrollment period on March 31st. One such SEP applied consumers had questions about using their coverage. to those who applied for Medicaid prior to March 31st Of those surveyed, 44 percent of assister programs were but were then denied Medicaid after March 31st. These contacted by consumers who didn’t understand how to individuals were granted a 60-day SEP to apply to the use health insurance, and 37 percent were contacted by Marketplace following their Medicaid denial. consumers who discovered that their providers weren’t in their plan’s network.35 In other cases, consumers needed help transitioning to a Marketplace plan from other coverage, such as a job-based Many consumers were concerned about access issues– plan, retiree coverage, or a student health plan. An update how to access out-of-network providers, or what does it to the federal rules this year allows individuals who are mean if a drug is not covered under the formulary. Other losing minimum essential coverage (MEC) to qualify for consumers wanted to understand what would happen a SEP that begins 60 days prior to the loss of MEC and if they missed a premium payment. Still others had continues for 60 days after the loss, which is helpful in questions about why their non-Marketplace plan would avoiding a gap in coverage. Many individuals losing access not pay for benefits they expected to be covered, often to job-based coverage are eligible for both COBRA and hoping such a problem would qualify them for a special Marketplace coverage, but under federal rules enrollment enrollment opportunity to enroll in a better plan. Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 10 Surveys indicate many people still are unaware of key Post-Enrollment Questions features of the ACA, including the availability of financial Drug formulary: Jack purchased a plan through the help to buy coverage.36 This is particularly a problem FFM that does not cover a specialty tier drug that he among the uninsured who have the most to gain from needs for a chronic condition. Does that mean Jack expanded coverage options under the ACA. A recent is responsible for the full cost of that prescription drug, and the out-of-pocket cost will not be included study of low-income individuals who remain uninsured as part of his out-of-pocket maximum? after the first open enrollment period found only three Provider network: Janice has learned that her out of five had heard of the Marketplaces and only two in health plan no longer includes the county hospital. five had heard about the subsidies.37 It is not likely these The closest hospital that takes the insurance is 26 consumers would be able to understand what is required miles away. What are her options? to apply for financial help and choose a plan without the Benefits that fall short: Mary is pregnant and has kind of intensive help that is provided through Navigators learned that her insurance does not cover maternity and assisters. care. Can she apply for a SEP since this is a required essential health benefit? Lessons for Open Enrollment Round Two The next open enrollment period will bring new consumers–even those without an income change–may challenges to this already complicated enrollment miss out on lower cost-sharing if they don’t update their process. An estimated 5 million more people will enroll eligibility because the federal poverty levels are updated in coverage in the open enrollment period that begins each year. November 15, 2014.38 The remaining uninsured, To compound the challenge of enrolling 5 million more including those who are projected to enroll for the first individuals, including hard-to-reach populations, and re- time this fall, may be more difficult to reach than those enrolling millions more, this effort must take place within who sought and enrolled in coverage during the first a shorter period than the first open enrollment. Open open enrollment. They are also more likely to be Spanish enrollment for coverage that begins in 2015 runs from speakers and to have less than a high school education. November 15, 2014 to February 15, 2015–half the time They are more likely to live in the South, where most of the 2014 open enrollment period, and with the major of the Marketplaces are federally run and have, to date, end-of-year holidays competing for consumers’ attention. had fewer resources for consumer assistance than states A key finding of the first open enrollment period is that operating their own Marketplace or in partnership with consumer assistance works, particularly to help enroll the federal government.39 those who are hardest to reach and previously uninsured. In addition, the more than 8 million individuals currently Those who sought information and help from sources enrolled in Marketplace plans will need to renew their other than the website–including Navigators, application coverage. Under federal rules, most can be automatically assisters, and insurance agents–were more likely to enroll renewed in their current plan with the same amount of in coverage.41 Building upon this successful feature of the tax credits as they received in 2014 and based on projected first open enrollment period will be essential in tackling rather than actual 2014 income.40 But all may–and the next one successfully. probably most should–revisit the Marketplace to compare plan options for 2015 and update their household and Wanted: More Predictable Funding tax information to ensure they receive the right level of and Technical Support financial assistance. Even individuals and families whose It is penny wise and pound foolish for Marketplaces not income and household information has not changed to heavily invest in consumer outreach and assistance. could be renewed with an incorrect amount of premium Yet both the FFM and many SBMs are reducing the tax credits, simply because the price of the benchmark level of support. The second round of federal grants was plan in their area has changed. Equally important, some awarded in mid-September, and the level of support has Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 11 dropped from $67 to $60 million. Colorado’s 2015 budget Assisters have many demands on their time and the first for consumer assistance is $12.3 million less than the year’s enrollment was particularly difficult for assisters marketplace spent in 2014, and Connecticut’s assisters are to stay up to speed on a constantly evolving set of federal seeing an 80% cut in funding.42 rules and procedures. One Navigator described the process as “learning to fly the plane while it is being In addition to providing adequate resources, state and federal policymakers should seek to professionalize built.” Support could be provided through programs Navigators through sustainable and predictable funding, such as Georgetown’s, or by the Marketplaces themselves, and with enhanced training and support. The first- through a dedicated call-in line, or web portal. For year grants for federal Navigators ran through August example, New York’s Marketplace had a twice-weekly call 15, 2014, and were non-renewable. Because of limited with lead assister organizations, allowing assisters to get resources and the uncertainty of future funding, many answers and address individual issues as well as systemic organizations may have laid off Navigators or cut back problems as they arose. Other SBMs allow organizations on their hours soon after the close of the first open to serve a coordinating role for assisters to help funnel enrollment. Navigators from SBM states are similarly complex questions and cases to the right technical experts, struggling with funding challenges. Most FFM Navigator similar to how Georgetown offers its support. But in the entities received a second year of funding, but as many as FFM states, federal rules require all Navigator entities to one-third are new. Even for those with renewed funding, perform all the required functions of a Navigator. This many will need to hire and train new individuals to leads to significant inefficiencies in the program and serve in this critical role prior to November 15th. At a allocation of resources. Organizations that would be best minimum, navigator grants should be renewable at the positioned to play a policy support or technical assistance option of the Marketplace or should be awarded on a role are not eligible grantees because they do not have the multi-year basis, with new grant opportunities offered staff or capacity to perform the other required functions, with sufficient lead time to avoid gaps in funding and such as outreach and education. Likewise, organizations subsequent layoffs of trained navigators. that could help reach niche populations with effective outreach may not have the capacity to provide assistance The Marketplaces should also offer multiple levels of with applying for financial assistance or plan selection. training. The first level would be for new assisters who have not been through training before. The second level should Furthermore, Navigators and assisters are not trained be designed for assisters who have already served and have a or resourced to provide extensive post-enrollment help, good foundation in Marketplace and Medicaid operations but consumers are returning to Navigators and assisters and rules. This second tier of training should be more with questions about their coverage. Marketplaces should advanced, allowing assisters to build expertise in complex provide support for Navigators and assisters on post- federal tax rules, the definition of household, immigration- enrollment issues such as benefit denials and questions related issues, and the rules for consumers with access to about networks, formularies, and covered services. other coverage. A third level of training could be designed States should also encourage their Departments of to develop an elite cadre of experts who could provide Insurance (DOIs) to better coordinate with Navigators. in-house, real-time support on some of the more complex, These agencies have traditionally provided assistance difficult questions presented to assisters in the field. to consumers with coverage problems and oversee all Marketplaces should work to professionalize these roles to commercial plans sold in the state, including those sold encourage retention, ensure continuity, and build a strong through the Marketplaces. Consumer assisters could base of knowledge within the assister community. become important sources of information for state In the short term, while in-house expertise is being regulators and help them perform their oversight role. developed, Marketplaces could provide assisters with real‑time policy expertise and technical assistance to ensure Wanted: Improved Enrollment Process full understanding of federal and state rules as they apply Assisters could also be more efficient and cost-effective if to consumers’ individual circumstances. In some cases, the process for enrolling was simplified and streamlined. assisters will be helping families in unique situations, and For example, a simplified, consumer-tested application will face complicated questions that may only come up would not only help assisters move through the process once or twice during an enrollment season. In other cases, more quickly, it might also make it possible for more they may need assistance to understand how a new federal people to enroll on their own so assisters can focus on the or state rule will affect a much broader range of clients. most complex cases that require individualized help. For Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 12 example, applicants may be confused about whether they required to fund brokers; brokers earn their income from are “eligible” for minimum essential coverage through health plan commissions. There are benefits to using their employer if they are not enrolled and their plan is not brokers to assist individuals in enrolling in coverage. currently open for enrollment. Help text and rewording of Whereas Navigators are prohibited from recommending questions would guide consumers on accurately projecting a plan, brokers can recommend a plan for a consumer annual income by including non-tax social security benefits that has complicated health needs and limited ability but excluding key deductions and pre-tax contributions, to understand their plan options. But there are also such as child care or retirement savings. potential downsides to relying on brokers for Marketplace enrollment. Many will not be affiliated with all the In addition, Marketplaces can improve enrollment plans offered in the Marketplace and so may steer tools for assisters. Assisters should be able to provide consumers only to those plans for which they will receive phone application assistance, with access to co-browsing a commission. capability to work with consumers logging in from a different location. Also, the system should alert assisters Providers have an existing pathway to promote enrollment and consumers when and why an application fails for as certified application counselors. Many have pursued reasons not related to eligibility so that the consumer this pathway because they have an interest in enrolling can correct and resubmit the application. Doing so could their patients in coverage in order to get reimbursed for reduce the number of consumers who file an eligibility the services they provide. They are important partners appeal, a labor-and time-intensive process that may result for enrollment efforts because they have specialized in critical gaps in coverage. knowledge of consumers’ needs, and in many cases a prior Marketplaces could also simplify consumers’ selection relationship with the consumers who would most benefit among plan options by limiting the number offered from the ACA’s subsidized coverage options. within a benefit tier and/or requiring standardized Consumers can also benefit from other professionals with benefit design. Several SBMs have already done so to help specialized knowledge. Tax preparers can help consumers streamline the shopping experience for consumers.43 understand how their federal tax filing status can affect eligibility for premium tax credits, and family law attorneys Wanted: Leveraging a Broader Range can provide advice for non-custodial parents who have an of Consumer Assisters obligation under a divorce agreement or medical support Meeting the challenges of this next open enrollment order to provide health coverage to their children. period and beyond may require a broader view of Policymakers should consider ways in which a broader set consumer assistance. Federal resources are limited and of enrollment partners could get training and be certified states are struggling to identify stable and sufficient to enroll individuals in Marketplace coverage–and sources for funding for consumer assistance. In light provide incentives for them to do so. These incentives of this, policymakers must tap into a broader array do not have to be financial. For example, one common of people with an incentive to help enroll individuals complaint among agents and brokers was that their in coverage, such as insurance agents and brokers, time spent enrolling people into a plan was not always providers, and tax preparers. or accurately reported to the insurer, preventing them Brokers may provide an effective complement to from being appropriately compensated. Marketplaces Navigators in a time of constrained federal and state should work to ensure that brokers’ enrollment assistance funding. While Marketplaces have to devote a portion is correctly attributed to the applications of consumers of their budget to Navigator programs, they are not they’ve assisted. Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 13 Conclusion The first open enrollment period was challenging for decline in the uninsured after the first year of enrollment assisters and consumers. Changing rules, balky websites, into Marketplace coverage.44 Marketplaces have an and consumers’ unfamiliarity with key provisions of opportunity to build upon that success and strengthen the ACA all contributed to a difficult first year. But and extend consumer assistance to help people understand consumer assistance helped make it more successful than their plan options and enroll in coverage. experts predicted it would be, resulting in a significant Acknowledgments The authors gratefully acknowledge the editorial contributions of Kevin Lucia, Karen Pollitz, Judy Solomon and Mara Youdelman. Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 14 Appendix A: Examples of Consumer Assistance Questions in the First Year Determining Household Size for the year. In fact, she may get money back when she Parent as dependent: files her taxes once the tax credits she received based on Alice* is a 50-year-old woman who lives with her projected income are reconciled with what she should 28-year-old daughter, Jane and cares for Jane’s two have received based on actual (lower) income. As long children (Alice’s grandchildren). Jane claims Alice as as her eligibility for the premium tax credit was based a dependent on her taxes. Jane has insurance from her on a determination that her income would be between employer that covers her and her two children, but it 100 and 400 percent of the federal poverty level, she won’t cover Alice. When Alice applies for coverage, won’t be required to pay back credits if it turns out her should she include her daughter’s income and list all actual income is below 100 percent of poverty. The four members of the household? reconciliation process provides for a tax refund if her income goes down. Answer: Since Alice is claimed as a dependent on Jane’s taxes, Jane (i.e., the tax filer) should complete Rental assistance: the application because eligibility for Alice will be based Jackie gets help on her rent from a family member who on Jane’s income and household size. Since Jane and her lives with her. Without the assistance, she couldn’t afford children have employer-sponsored insurance, she should the rent. Must she count the rental assistance in her indicate that she is NOT applying for herself and her household income? children, only for her mom who is a tax dependent. She Answer: Probably not. Rental assistance from her family should also indicate NO when answering whether Alice member would be considered a gift. If Jackie claims this has access to employer sponsored insurance. If the state rental assistance as part of her income, then it should in which this family resides has expanded Medicaid, be reported. Alice would likely qualify for Medicaid because she has no income. Retired with financial help from children: Frank and Ellen are retired and don’t file taxes. Their Non-custodial parent: children contribute to their household costs, but none Robert wants to buy a Marketplace plan for himself claim the parents as dependents. When Frank and Ellen and his son John, who lives with his ex-wife. His divorce apply, do they list the financial help from their children agreement requires him to provide coverage for John, but as part of their income? he doesn’t claim him as a dependent on his taxes. What are Robert’s options to buy a plan that covers them both? Answer: No, the financial help that Frank and Ellen receive from their children would not be counted Answer: Robert can buy a plan for himself and his son as income. through the Marketplace, but since he doesn’t claim John as a dependent, he is ineligible to receive premium Adult child with dependent parents: tax credits for John’s coverage. Shauna and Bob live with their adult son, Bill, who claimed them as dependents on his 2013 tax return. Calculating Income Bill provides them shelter but they pay their own food Lower than projected income: and health care costs. Shauna and Bob make less than Jessica is a dog walker and paid hourly. She projects 133 percent of the federal poverty level and would qualify income over 100 percent of the federal poverty level, for Medicaid. Does Bill’s help and tax filing affect their qualifying her for premium tax credits. But she’s worried Medicaid eligibility? that if she gets less work than she expects, and her actual Answer: No, although Bill claims his parents as income is less than 100 percent of the federal poverty dependents, for Medicaid eligibility purposes, Shauna level, she’ll have to pay those tax credits back. and Bob meet an exception to the rules because they Answer: Jessica would not have to pay back premium tax are claimed by someone who is NOT their parent or credits if her income goes down from what she projected spouse. Their eligibility for Medicaid will be based on Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 15 their household and income, using the rules for non tax test for affordability and adequacy of employer-based filers. Their household would include Shauna and Bob coverage does not apply to retiree coverage. and their income will be whatever source of income the two of them receive. They would have had to earn less Access to Medicaid: than $3,900 each for Bill to have claimed them on his tax Jane was uninsured when she was diagnosed with breast return, and would have had to indicate they were claimed cancer and was found eligible for Breast and Cervical as tax dependents by someone else. Cancer Program (BCCP) under Medicaid. She wouldn’t qualify for Medicaid based on her income. Does Family payments: enrollment in the BCCP program make her ineligible for Grace is a 63-year-old woman whose family pays her $500 Marketplace coverage because it’s Medicaid coverage? per week to care for the 98-year-old family matriarch. Answer: No. Although not specifically listed in regulations, Should Grace count the family’s payments as earnings the BCCP is not considered a type of comprehensive health when applying for coverage? insurance that would be considered minimum essential Answer: Yes, if Grace is reporting the $500 per week as coverage. Jane is eligible for Marketplace coverage and taxable income then it should be counted when she applies could qualify for premium tax credits, assuming she meets for coverage on the Marketplace. Grace should seek tax the income and eligibility requirements. advice on whether she should be reporting it as income. Immigrants Access to Other Coverage and Eligibility for Mixed Status/Mixed Program Families: Premium Tax Credits A family applying for coverage includes two parents who Student Health Plan: have been lawfully residing in the U. S. for three years An older PhD student, Anna, is told her student health and two children, Esteban, who has been lawfully residing plan won’t cover her shingles vaccine or a colonoscopy. Is in the U.S. for three years, and a daughter, Celia, who that allowed? Can she get a Marketplace plan instead? is U.S.-born. The parents and Esteban are eligible for a Answer: It depends on whether or not her student health Marketplace plan, but only Celia is eligible for Medicaid. plan is self-funded. In general, under the ACA, student Why can’t both children get Medicaid? Or can they add health plans are required to cover preventive care with no Celia to the Marketplace plan with premium subsidies? cost-sharing, including colonoscopies and the shingles Answer: Under Medicaid, there is a five year waiting vaccine (if she’s over 50). Self-funded student health plans, period for lawfully residing children before they can be however, do NOT have to comply with the preventive eligible for Medicaid, so Esteban is currently not eligible. services standard under the ACA. A self-funded student The family cannot add Celia to the Marketplace plan plan is one in which the risk is borne by the college or with premium subsidies because she would be enrolled university. These plans are notoriously skimpy. into Medicaid. Yes, Anna could get a Marketplace plan and may also be eligible for financial assistance. If she wants Changing Plans to apply for a Marketplace plan, she will have to wait Provider not in network: for Open Enrollment unless she qualifies for a special Brenda selected a plan knowing that the hospital in her enrollment period. area was not on the plan, but her primary care doctor was. Retiree plan: She had not yet heard from the plan about her enrollment Sandra retired at 55 and has an offer of retiree coverage and had not yet paid her first premium when she was for herself and her husband and 19-year-old son. The plan diagnosed with cancer and was referred to specialists and would be a good deal for her, but is too expensive for her an oncologist that are not covered under her plan. Can husband and son to join. If Sandra enrolls in the retiree Brenda change to a different carrier that would include plan, can her husband and son still apply for Marketplace the providers she needs? coverage with premium tax credits? Answer: Yes, Brenda has not technically enrolled into her Answer: Yes, her husband and son can still apply for plan because she has not paid her first month’s premium, Marketplace coverage with premium tax credits as long as and it is before the effective date of coverage. Given her their household income is less than 400 percent of federal diagnosis, however, she should be careful to make sure poverty level ($78,120 for a family of three in 2013). The she gets into another plan (i.e., pays her first month’s Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 16 premium to get enrolled) before she terminates coverage the out-of-pocket cost will not be included as part of his so that the specialist and oncologist visits are covered. out-of-pocket maximum? Answer: Non-covered drugs do not count toward the out- Avoiding a Gap in Coverage of-pocket limit and even if covered, specialty tier drugs Waiting for new job-based plan to start: could come with significant cost-sharing if it requires Sally lost her job and her insurance coverage at the end co-insurance rather than a fixed dollar co-payment. Under of April and got a new job with coverage that wouldn’t current federal rules, however, all Marketplace plans must begin until July. In the meantime, she was diagnosed have procedures in place to allow enrollees, like Jack, with breast cancer and was scheduled for surgery in early to request and to gain access to clinically appropriate May. Would she be able to get Marketplace coverage in drugs not covered by the plan, especially in exigent time for her surgery or would she have a gap in coverage? circumstances. The rule requires that a health plan make Should she enroll in COBRA to fill the gap between coverage determinations within 24 hours of receiving a job-based plans? request, and in the meantime, requires the health plan Answer: Yes, Sally could get Marketplace coverage since to provide the drug during the duration of the exigent loss of her employer-sponsored insurance (minimum circumstance. essential coverage) would trigger a special enrollment Consistent with the Medicare Part D program, the period. In this scenario, if she applied for a Marketplace Centers for Medicare and Medicaid Services (CMS) plan at the end of April, her coverage would be effective suggests that a drug is clinically appropriate, and should on the first day of the following month, May 1st. be covered, if an oral or written supporting statement Since Sally’s timelines are so close to May 1st and the is submitted by a prescriber, and establishes that the consequences for NOT getting coverage by May 1 are requested prescription drug is clinically appropriate to severe, Sally should get confirmation of coverage from treat the enrollee’s disease or medical condition, based on both the call center and the insurer with whom she one or more of the following criteria: chooses to enroll. i.All of the covered drugs on any tier of the plan’s If there is any reason this doesn’t work, COBRA is an covered drug list for treatment for the same condition option for her. She has 60 days to enroll, and her coverage would not be as effective for the enrollee as the would be retroactive. She would have to pay the full requested drug, and/or would have adverse effects premium until her new employer coverage kicks in, but for the enrollee, or that is still preferable to going uninsured for the month ii.The number of doses available under a dose restriction she has her surgery. Also, to the extent she has a treating for the prescription drug: provider she wants to continue to see, COBRA allows her a.Has been ineffective in the treatment of the to keep her same network of providers, while plans on the enrollee’s disease or medical condition or, Marketplace may have different provider networks. b.Based on both sound clinical evidence and Last but not least, she may not be eligible for Medicaid medical and scientific evidence, the known based on income, but she MAY be eligible for the relevant physical or mental characteristics of Medicaid Breast and Cervical Cancer Treatment Program the enrollee, and known characteristics of the (BCCTP) based on her diagnosis. State laws on this drug regimen, is likely to be ineffective or program vary in terms of who is eligible and what it adversely affect the drug’s effectiveness or patient covers so Sally should check with her state’s Medicaid compliance; or agency and also ask about how long the enrollment iii.The prescription drug alternative(s) listed on the process will take. covered drug list or required to be used in accordance with step therapy requirements: Post-Enrollment Issues a.Has been ineffective in the treatment of the Drug formulary: enrollee’s disease or medical condition or, based Jack purchased a plan through the Federally Facilitated on both sound clinical evidence and medical and Marketplace that does not cover a specialty tier drug that scientific evidence, the known relevant physical or he needs for a chronic condition. Does that mean Jack is mental characteristics of the enrollee, and known responsible for the full cost of that prescription drug, and characteristics of the drug regimen, is likely Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 17 to be ineffective or adversely affect the drug’s she apply for a special enrollment period since this is a effectiveness or patient compliance; or minimum essential health benefit? b.Has caused or, based on sound clinical evidence Answer: No. Under current rules, pregnancy is not a and medical and scientific evidence, is likely qualifying event that would trigger a special enrollment to cause an adverse reaction or other harm to opportunity. The birth of her child, however, is a the enrollee. qualifying event for a special enrollment period and she can enroll her child with an effective coverage date of Provider network: her child’s birth date. There are a few things to note for Janice has learned that her health plan no longer includes Mary’s coverage and health plan. If her current plan is an the county hospital. The closest hospital that takes the individual plan, she should know that she’ll have a 30-day insurance is 26 miles away. What are her options? window from when her policy renews to find a new plan Answer: According to federal guidance, Janice can either on or off the Marketplace. She will want to find change plans if all of the following criteria are met: out when her policy renews. Note that all plans on the Marketplace must cover maternity as an essential health 1. She’s changing to another plan by the same insurer; benefit. 2.She’s changing to another plan offered at the same Also, if her health plan is through her employer, she metal level and cost sharing reduction level, if should know that under federal law (the Pregnancy applicable; Discrimination Act), large employers are required to cover maternity services in parity with other medical services. 3.She’s changing in order to move to a plan with a If the employee’s health plan is skimpy on coverage, more inclusive provider network or for other isolated however, the maternity will also be skimpy. One available circumstances determined by CMS, and option is to contact the U.S. Department of Labor 4.She’s requesting the change within the initial open because it’s possible the employer is in violation of the enrollment period. Pregnancy Discrimination Act. She can contact the Dept. of Labor’s Employee Benefits Security Administration Janice must go to the insurer and initiate the change. (EBSA) at http://www.dol.gov/ebsa/contactEBSA/ Benefits that fall short: consumerassistance.html. Mary is pregnant and has learned the insurance she *All names used in these examples are pseudonyms used to has does not include coverage for maternity care. Can protect the identity of the individuals seeking assistance. Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 18 Endnotes 1 Congressional Budget Office, “Updated Estimates of the Effects of the 12 45 CFR § 155.210(b)(2)(iiii). Navigators are also required to meet licensing, Insurance Coverage Provisions of the Affordable Care Act,” April 2014. certification, or standards under state law or marketplace rules as long as Available at http://cbo.gov/sites/default/files/cbofiles/attachments/45231- they are consistent with the overall purpose of the ACA. For example, a state ACA_Estimates.pdf. law that would require additional licensure (e.g., become agents or brokers) 2 Office of Assistant Secretary for Planning and Evaluation (ASPE), or limit assister functions so that ACA implementation is obstructed would Department of Health and Human Services, “Health Insurance Marketplace: be prohibited. See HHS Final Rule, Patient Protection and Affordable Care Summary Enrollment Report for the Initial Annual Open Enrollment Act; Exchange and Insurance Market Standards for 2015 and Beyond, 79 Period,” May 1, 2014. Available at http://aspe.hhs.gov/health/reports/2014/ Fed. Reg. 30240, May 27, 2014; Tim Jost, “Implementing Health Reform: MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf; Centers for Final 2015 Exchange and Insurance Market Standards Rule,” Health Affairs Medicare and Medicaid Services, Medicaid & CHIP: March 2014 Monthly Blog, May 17, 2014. Available at http://healthaffairs.org/blog/2014/05/17/ Applications, Eligibility Determinations, and Enrollment Report, May 1, implementing-health-reform-final-2015-exchange-and-insurance-market- 2014. Available at http://www.medicaid.gov/AffordableCareAct/Medicaid- standards-rule/. Agents and brokers must also follow whatever state laws that Moving-Forward-2014/Downloads/March-2014-Enrollment-Report.pdf. apply to them. 45 CFR § 155.220(g)(iii). 3 Karen Pollitz, Jennifer Tolbert, and Rosa Ma, “Survey of Health Insurance 13 Supra n. 3. Marketplace Assister Programs,” Kaiser Family Foundation, July 15, 2014. 14 Center for Medicare and Medicaid Services, Center for Consumer Available at http://kff.org/health-reform/report/survey-of-health-insurance- Information and Insurance Oversight, Consumer Assistance Program Grants. marketplace-assister-programs/. Available at http://www.cms.gov/cciio/Resources/Funding-Opportunities/ 4 Fredic Blavin, Stephen Zuckerman, and Michael Karpman, “Obtaining index.html#Consumer%20Assistance%20Program%20Grants. Information on Marketplace Health Plans: Websites Dominate but Key 15 Natalie Villacorta, “Who will help the newly insured?,” Politico, Feb. 14, Groups Also Use Other Sources,” Urban Institute, June 9, 2014. Available at 2014. Available at http://www.politico.com/story/2014/02/obamacare-newly- http://hrms.urban.org/briefs/obtaining-information-on-marketplace.html; insured-103645.html#ixzz2tmCZUVTN. Karen Pollitz, Jennifer Tolbert, and Rosa Ma, “Survey of Health Insurance 16 Sharon Long and Dana Goin, “Most Adults are Not Aware of Health Reform’s Marketplace Assister Programs,” Kaiser Family Foundation, July 15, 2014. Coverage Provision,” Urban Institute, Feb. 6, 2014. Available at http://hrms. Available at http://kff.org/health-reform/report/survey-of-health-insurance- urban.org/briefs/awareness-of-provision.html; Consumers Union, “Measuring marketplace-assister-programs/. Health Insurance Literacy: A Call to Action,” Feb. 2012. Available at http:// 5 45 CFR § 155.205 (a) and (b). consumersunion.org/pub/Health_Insurance_Literacy_Roundtable_rpt.pdf; 6 45 CFR § 155.210; HHS Final Rule Patient Protection and Affordable Care Marissa Evans, “Survey: Americans Have Low Health Insurance Literacy,” Act; Exchange Functions: Standards for Navigators and Non-Navigator Kaiser Health News, Aug. 29 2013. Available at http://capsules.kaiserhealth Assistance Personnel; Consumer Assistance Tools and Programs of an news.org/index.php/2013/08/survey-americans-have-low-health-insurance- Exchange and Certified Application Counselors, 78 Fed. Reg. 42824, July 17, literacy/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed 2013. Available at http://www.gpo.gov/fdsys/pkg/FR-2013-07-17/pdf/2013- %3A+Capsules-TheKhnBlog+(Capsules+-+The+KHN+Blog). 17125.pdf. 17 Sharon Long and Dana Goin, “Most Adults are Not Aware of Health 7 Center for Medicare and Medicaid Services, Center for Consumer Reform’s Coverage Provision,” Urban Institute, Feb. 6, 2014. Available at Information and Insurance Oversight, “Summary of Consumer Assistance http://hrms.urban.org/briefs/awareness-of-provision.html Program Grant Data from October 15, 2010 through October 14, 2011,” 18 Linda Blumberg, et al., “Public Understanding of Basic Health Insurance June 7, 2012. Available at https://www.cms.gov/CCIIO/Resources/Files/ Concepts on the Eve of Health Reform,” Urban Institute, Dec. 2013. Downloads/csg-cap-summary-white-paper.pdf. Available at http://hrms.urban.org/briefs/hrms_literacy.html. 8 Center for Consumer Information and Insurance Oversight, Navigator Grant 19 Kaiser Family Foundation, Survey of Nongroup Health Insurance Enrollees, Recipients, August 2013. Available at http://www.cms.gov/CCIIO/Programs- June 19, 2014. Available at http://kff.org/private-insurance/report/survey-of- and-Initiatives/Health-Insurance-Marketplaces/Downloads/navigator- non-group-health-insurance-enrollees/. list-10-18-2013.pdf. 20 Supra n. 3. 9 Health Resources and Services Administration, Outreach & Enrollment 21 Supra n. 3. Assistance Awards to Health Centers, FY 13 and FY 14. Available at 22 Supra n. 2. http://www.hrsa.gov/about/news/2013tables/outreachandenrollment/. 23 New York State of Health, “2014 Open Enrollment Report,” June 2014. 10 Daniel E. Polsky, Janet Weiner, Christopher Colameco, and Nora Becker, Available at http://info.nystateofhealth.ny.gov/2014OpenEnrollmentReport. “Deciphering the Data: State-Based Marketplaces Spent Heavily to Help Enroll Consumers,” Leonard Davis Institute of Health Economics, University 24 See Brandon Roberts, Deborah Povich, and Mark Mather, “Overlooked and of Pennsylvania, April 2014. Available at http://ldihealtheconomist.com/ Underpaid: Number of Low-Income Working Families Increases to 10.2 media/state-based_marketplaces_spent_heavily_to_enroll_consumers.pdf. Million, The Working Poor Families Project,” Winter 2011-12. Available at http://www.workingpoorfamilies.org/pdfs/Overlooked_Dec2011.pdf; 11 45 CRF §§ 155.215, 155.225. National Housing Conference, Center for Housing Policy, “Should I Stay or Should I Go? Exploring the Effects of Housing Instability and Mobility on Children.” Available at http://www.nhc.org/child_mobility.html; Carmen DeVavas-Walt, Bernadette Proctor, and Jessica Smith, “Income, Poverty, and Health Insurance Coverage in the United States: 2012,” U.S. Census Bureau, Sept. 2013. Available at http://www.census.gov/prod/2013pubs/p60-245.pdf. Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment 19 Endnotes 25 Benjamin Sommers and Sara Rosenbaum, “How Changes in Eligiblity 36 Id. May Move Millions Back and Forth Between Medicaid and Insurance 37 Adele Shartzer, et. al., “Who Are the Remaining Uninsured as of June 2014?,” Exchanges,” Health Affairs, 2011. Matthew Buettgens, Austin Nichols, Urban Institute, July. 2014. Available at http://hrms.urban.org/briefs/who- and Stan Dorn, “Churning Under the ACA and State Policy Options for are-the-remaining-uninsured-as-of-june-2014.html. Mitigation,” Urban Institute, June 2012. Available at http://www.urban.org/ 38 Supra n. 1. UploadedPDF/412587-Churning-Under-the-ACA-and-State-Policy-Options- for-Mitigation.pdf. 39 Supra n. 43. 26 Id. 40 45 CFR §155.335. 27 Of the 29.4 million potentially affected, 6.9 million people may move from 41 Stephen Zuckerman, et. al., “Navigating the Marketplace: How Uninsured Medicaid to Marketplace coverage and vice versa, 19.5 million people may Adults Have Been Looking for Coverage,” Urban Institute, July 2014. move from Medicaid and ineligibility of all insurance subsidy programs Available at http://hrms.urban.org/briefs/navigating-the-marketplace.html; because of income over the 138 percent of FPL and ESI offers, and 3.0 million Enroll America, “In Person Assistance Maximizes Enrollment Success.” people may move between Marketplace coverage and ineligibility for all Available at https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/ programs. Matthew Buettgens, Austin Nichols, and Stan Dorn, “Churning uploads/2013/12/In-Person-Assistance-Success.pdf. Under the ACA and State Policy Options for Mitigation,” Urban Institute, 42 Covered California, Covered California Announces Community Outreach June 2012. Available at http://www.urban.org/UploadedPDF/412587- Campaign for 2015, September 15, 2014. Available at http://news.coveredca. Churning-Under-the-ACA-and-State-Policy-Options-for-Mitigation.pdf. com; Arielle Levin Becker, Future of Obamacare Enrollment Assistance Still 28 Supra n. 3. Being Determined, The Connecticut Mirror, August 21, 2014. Available at http://ctmirror.org/future-of-obamacare-enrollment-assistance-still-being- 29 Id. determined/. 30 Center on Budget and Policy Priorities, “The Health Assister’s Guide 43 Christine H. Monahan, Sarah J. Dash, Kevin W. Lucia, and Sabrina Corlette, to Tax Rules: Determining Income & Households for Medicaid and “Realizing Health Reform’s Potential: What States are Doing to Simplify Premium Tax Credits,” July 2014. Health Plan Choice in the Insurance Marketplaces,” Commonwealth Fund, 31 Odette Yousef, “Immigrants Face Barriers on Health Care Site,” WBEZ91.5, December 2013. Available at http://www.commonwealthfund.org/~/media/ February 13, 2014. Available at http://www.wbez.org/news/immigrants-face- Files/Publications/Issue%20Brief/2013/Dec/1720_Monahan_what_states_ barriers-health-care-site-109698. are_doing_simplify_rb.pdf. 32 Ajay Choudry and Karina Fortuny, “Children of Immigrants: Family and 44 Sharon Long, et. al., “Taking Stock at Mid-Year: Health Insurance Coverage Parental Characteristics,” The Urban Institute, May 2010. Available at under the ACA as of June 2014,” Urban Institute, July 2014. Available at http://www.urban.org/UploadedPDF/412132-children-of-immigrants.pdf. http://hrms.urban.org/briefs/taking-stock-at-mid-year.html. 33 For a list of special enrollment period qualifying events, see Healthcare.gov, “Apply with a Special Enrollment Period.” Available at https://www.healthcare.gov/how-can-i-get-coverage-outside-of- open-enrollment/special-enrollment-period/ (accessed Sept. 17, 2014). 34 Supra n. 3. 35 Id. Georgetown University Health Policy Institute 3300 Whitehaven Street, N.W., Suite 5000 Washington, DC 20007 Telephone (202) 687-0880 http://chir.georgetown.edu/