Health insurance enrollment: Navigators to play key role in Obamacare [Behavioral Healthcare]

Navigator funding limited in states using federal insurance marketplace model

Not long ago, President Obama soft-pedaled concerns about the Affordable Care Act (ACA) - concerns that two surveys released that month had raised. One, from a national association of actuaries, was that premiums would cost much more than anyone thought. The other, from the Kaiser Family Foundation, was that the vast majority of Americans knew little about how the ACA would actually affect them.

"According to Census estimates, nearly 85 percent of the population had some form of health insurance in 2007 and more than two thirds of those people received coverage through an employer," Mark Weber, spokesman for the Department of Health and Human Services (HHS), told Behavioral Healthcare. "Public programs, like Medicare and Medicaid, cover the elderly, the disabled and veterans, along with many children and low-income people."

The ACA has already affected millions, said Weber. "Because of the Affordable Care Act, 17 million children can no longer be denied insurance because of a preexisting condition, like depression or bipolar disorder," he said. In addition, more than 6.6 million young adults have been able to go on their parents' insurance plan "at a critical age when we know behavioral health issues are likely to emerge or progress." The ACA has also made it possible for more than 71 million people, including 18.3 million children, to get free preventive services including screenings for alcohol abuse and depression.

Despite all this, "there is more work to do," said Weber.

Getting people enrolled

One of the key areas the Obama administration is tackling next is communicating the plan, especially the insurance marketplaces which will be running in every state. The HHS Center for Medicare and Medicaid Services (CMS) is jump-starting this effort in two ways. In June, it launched a revamped website (www.healthcare.gov) that introduces the national system of health insurance marketplaces to consumers. And, in mid-August, it will announce the award of ACA-funded grants for "navigators" - organizations or people who will help people to select and sign up for health insurance from the marketplaces.

The ACA allotted $54 million for navigator grants, but those funds must cover all 37 states that are not setting up their own marketplaces. That's a pittance compared to what states that are setting up their own marketplaces are spending: Maryland alone, for example, has assigned $24 million in grants to its navigator contractors.

In fact, there isn't enough money for adequate navigator services because many states have decided not to set up their own marketplaces. HHS Secretary Kathleen Sebelius even made fundraising calls to the Robert Wood Johnson Foundation and H&R Block to get help with navigators, Politico reported.

Under the Affordable Care Act, states must establish a "navigator" program to help people learn about their options and to enroll, according to Families USA. Under the law, navigators have five tasks: educating the public about qualified health plans; distributing impartial information about enrollment, tax credits, and subsidies; helping people enroll; referring people who need additional help to another agency that can help with an appeal; and providing culturally appropriate information.

For states that have decided not to set up their own marketplaces - which includes marketing them - the federal government has offered to do it for them. Families USA noted that it's important that consumers get reliable health-plan information from navigators, who will help people understand cost-sharing, benefits, and plan-network limitations. Navigators also need to explain income requirements and help estimate correct tax credits/premium subsidies for those who qualify. Otherwise, consumers will have to repay incorrect tax credits for the subsidies.

Families USA noted that in programs where volunteers already help consumers with health insurance or tax issues, the "enrollment entity" . must assume liability for any risks related to the assistance that they offer. The state of California, for example, requires this for groups that contract with its Healthy Family program.

The CMS grants are called the Cooperative Agreement to Support Navigators in Federally-facilitated and State Partnership Marketplaces. There is a total of $54 million in these grants. Grantees will receive on-line training in the Affordable Care Act and will answer questions posed by consumers with CMS-scripted language, prompting criticism from one broker interviewed by Behavioral Healthcare·. "Canned speeches - just what people need to navigate the marketplaces."

Politics as usual

Republicans opposed to Obamacare are taking advantage of confusion about the law by targeting the navigator grants in particular. Republications say that the navigators could be anyone - even felons - who could "then make offwith reams ofpersonal information" such as Social Security numbers, birth dates of family members, income data, and more, The Hill reported May 21. Democrats say that attacking the navigator program is a way for Republicans to derail health care reform, helping it to fail and thus improving their political position for upcoming elections.

In a hearing held May 21, HHS official Gary Cohen said he didn't know whether background checks would be performed on navigators or whether they would be required to have a high school diploma.

According to Congressional Quarterly, insurance brokers who are based on the web want access to navigator money as well. But one concern about using internet-based agents and brokers is that they may steer companies or individuals to their own products.

Understanding health insurance coverage is hard enough: navigators and assisters will also be required to explain it to people who may not speak English and who have never had health insurance. Ifthey have behavioral health challenges as well, it will be all the more important to reach out to them and explain the need for insurance.

Small business has been opposed to Obamacare because they are afraid the premium costs will be too high. Some brokers are advising their small business clients to make their workers part-timers (under 30 hours a week) and send them to the marketplaces to buy their own health insurance. The ACA does not allow employers to throw full-time workers off of health insurance. Whether part-time workers who currently do not have health insurance will sign up - even with generous subsidies offered by Obamacare - depends on the ability of the navigators and assisters to find these people and get them enrolled. *

IN STATES THAT REFUSE THE FEDERAL MEDICAID EXPANSION, THERE WILL BE MANY WHO WILL REMAIN INELIGIBLE FOR MEDICAID COVERAGE, AND WHOSE INCOMES WILL FALL BELOW THE THRESHOLD NEEDED TO OBTAIN EXCHANGE-BASED HEALTH INSURANCE. PROVIDING BEHAVIORAL HEALTHCARE TO THESE PEOPLE LIKELY WILL PRESENT MAJOR NEW CHALLENGES.

For-profit navigators see marketplace opportunity

In addition to insurance navigators funded by federal ACA grants, there are other navigators out there too - navigators who will provide healthcare coverage adviceforafee. Nashville,Tennesseebased Bernard Health, which has been in business since 2006, is now setting up what founder Alex Tolbert describes as "H&R Block-type storefronts" where people can walk in and get advice. "Butinstead of givingtax advice, we give health insurance advice," Tolbert told Behavioral Healthcare. There are already two stores in Nashville. Other stores will open in Cleveland, Ohio and Austin, Texas this summer, with a total of nine stores by early 2014.

The chain of health care retail stores is only one of Bernard Health's three business units, but it is one specifically geared to play into the confusion created by the ACA's health insurance marketplaces. The stores will also help people enroll in Medicaid.

Advice for behavioral health providers

Traditionally, behavioral health care providers have had the option to help their patients get enrolled in Medicaid-that's the only way they will get paid if the patient is eligible - so it is in their interest to help with this time-consuming enrollment. Enrolling for private health insurance is even more difficult, since there is always a waiting period for coverage. Yet, when someone presents with a mental or substance use disorder, it is usually an emergency.

Before those emergencies occur, Tolbert said, providers should be thinking about the best way to help patients get signed up for coverage quickly. "You have to ask, 'What's my risk for being in a situation where I'm providing uncompensated care, or losing revenue because I'mturning patients away?'" Ifthatriskissignificant for your organization, it may be time to get help.

"A place like Bernard Health isn'tthe only option," said Tolbert. You could hire someone in-house to enroll patients, he suggested, or connect consumers to a grant-funded navigator in your region.

Different choices

InTennessee emergencydepartments,a social workerissupposed to sign people up for TennCare - the state's privatized Medicaid program. But there is only one TennCare option available at present. "The ACA is going to be a lot different," he said. "Staying up to speed on all that is going to be challenging."

Tolbert was in school at Vanderbilt University, earning an MBA and a law degree, when he started Bernard Health in 2006 out of an interest in health savings accounts. Then, along came President Obama and health care reform. Tolbert saw consumers' need for advice, and recognized that as some state laws cut fees to insurance brokers (states are disbursing the navigator grants, using federal dollars), brokers were dropping out of the field. "We want to be the national brand for health insurance advice," said Tolbert, capable of providing health insurance quotes, selfservice insurance applications, or complete advice and service packages.

A hand to hold

For those who need help selecting among health insurance plans, there is a fee. "Most people decide to buy one of our service products, which cost either $199 or $299," said Tolbert. Typical questions that consumers are asking now involve issues like Medicare, employer benefits, and COBRA. Starting in October, Tolbert expects that many of the questions will undoubtedly be about eligibility and sign-up for either the Medicaid expansion or marketplace-based health insurance policies.

The stores will not tell people what policy or coverage option to choose - that will be up to the consumer - but they will help people sift through the options. "All of the advisors in our stores are independentand non-commissioned,"saidTolbert,notingthat regulations prohibit charging customers for advice and receiving a sales commission.

For consumers with incomes at 400% or less of the Federal Poverty Limit (FPL), there will be two challenges: calculating whether they are eligibleforthe Medicaid expansion (income at 138% or less of FPL), or if not, calculating what their income-based insurance subsidy will be for purchasing insurance via the marketplaces. Tolbert is bettingthatfirst-timersto health insurance would rather have a hand to hold (via telephone) than face the decision alone. And with health care reform, we're all first-timers.