PowerPoint Presentation

In the Mix: Preparing to be AssistersPrepared by California Coverage and Health Initiatives (CCHI)June 20131

[This presentation is very much a work in progress and will be updated as we know more.]

Introduce yourself, explain purpose of presentation1Our Agenda2Enrolling Californias Uninsured in Health CoverageRole of the Exchange in Shaping the Assister/Counselor RolesEnrollment Entity Roles and ResponsibilitiesIn-Person AssistersNavigatorsCertified Application CounselorsWhich Role is Right for You?Training Opportunities

The presentation today will give you more information about how California is addressing the enrollment challenges that lie ahead.

We hope the information will guide you in understanding the new programs being developed, and the many roles your organization can play.

Information is changing every day and CCHI has been closely following health care reform developments. It is challenging to synthesize such changing information, but this webinar is representative of what we know now. There are many areas that are not fully nailed down yet. So, stay tuned and we will continue to refine this presentation with additional information over the coming months.

Finally, a goal of this presentation is that you can take these slides, adapt them as needed in your community, and use them to educate your boards, partners and staff about the new roles coming and how your organization is thinking about adapting to the new enrollment roles.2Enrollment System Guiding Principles3CCHI believes Californias enrollment system should:Build off the strengths of existing organizationsInvolve small CBOsHelp assisters/enrollment counselors in their role

Before we get started, we should highlight a few things we think the enrollment system should do in California.

1. It should leverage the strengths of organizations that serve the uninsured2. It should avoid unnecessary barriers or obstacles that would prevent small CBOs from being involved3. And it should prioritize the development of a CALHEERS portal that provides additional functionality to IPAs and Navigators

CalHEERS (The California Healthcare Eligibility and Enrollment and Retention System) will be up in August and available to assisters and navigators to register.3Californias New Health Insurance Marketplace4

www.healthexchange.ca.govhttp://www.dhcs.ca.govwww.coveredca.com

Covered California is the state agency offering insurance as a marketplace in California. The Exchange is responsible for implementing a statewide program that will motivate consumers to enroll into Covered California. Department of Health Care Services (DHCS) is Californias Medicaid agency and will be responsible for ensuring that Californias newly eligible will be enrolled in in Medi-Cal after the Medi-Cal expansion takes effect.

For purposes of todays webinar, we will focus on the enrollment programs being developed by Covered CA.4Who Will Need Help Enrolling in Coverage?Source: Covered California5In 2014, 5.3 million Californians will be eligible to purchase insurance through the exchange :2.6 million will qualify for premium assistanceAll will benefit from guaranteed coverage

As of 2014, about 2.6 million Californians will qualify for federal financial assistance through tax credits and an additional 2.7million who do not qualify for assistance will benefit from guaranteed coverage through Covered California or from an insurance company in the individual market. Anestimated 2.3 million California residents will enroll in a health plan through Covered California by 2017.

All health plans purchased through Covered California must cover a range of services called Essential Health Benefits. And all will benefit from the Affordable Care Acts many reforms like the right to guaranteed issue (no underwriting, no exclusions for pre-existing conditions) and community rating (individuals charged rate based on where they live not their individual health history), etc.

5Who Are Californias Uninsured?6By ethnicity:

Source: Covered CaliforniaThere are about 7 million Californians who are currently uninsured.

We arent going to dive deeply into the demographics of the uninsured populations here, except to point out that there is incredible ethnic diversity in the uninsured population.

Vast majority of uninsured are low-income and many may never have had health insurance before.

Population will present challenges to enrollment. This diversity will require development of new outreach and engagement skills especially to find and enroll the millions of adults who will be newly eligible for Medi-Cal.6Enrollment Assistance in California7Covered California has several types of Enrollment entities and Assister/Counselors:Paid Assisters/Counselors In-Person Assisters NavigatorsUnpaid Assisters/Counselors

These programs are taking shape under guidance from Covered California and in partnership with DHCS.

Theres been lots of confusion and many changes regarding the terminology related to the developing programs. Youve heard the words Assisters IPAs Navigators and on and on. Covered CA has recently tried to clarify all these terms and make it simpler. Here is the new terminology all assister programs will be called the Enrollment Assistance Program. All paid assisters regardless of program (IPA vs. Navigators) will be called Certified Enrollment Counselors and will be employed by Certified Enrollment Entities.

So now lets go back to the slide Covered CA has two types of assisters paid and unpaid. Lets focus first on the paid the will be the organizations and individuals working in the Enrollment Assistance program. They will do this work through two sub-programs the In Person Assister program and the Navigator program. Well talk more about these two programs in a few minutes.

There will also be agencies and individuals who will do enrollment assistance but not be paid by Covered CA such as agents and health care providers, also perhaps some health plans but discussions on that are still in process.7What Does the Enrollment Assistance Program Aim to Do?Source: Families USA8It engages Enrollment Entities and individual counselors who:Conduct outreach and education to help people figure out their coverage optionsHelp consumers and small employers learn about and enroll in coverageHelp with the application process, translate materials and breakdown barriers

The Enrollment Assistance Program is designed to:

Conduct outreach and enrollment and help Californians learn about coverage optionsHelp consumers and small business understand the coverage and get enrolledFacilitate enrollment into coverageTranslate materials and provide culturally and linguistically appropriate assistanceUltimately break down the barriers to getting Californians covered8Who Can Be an Enrollment Entity?9Community Based Organizations (CBOs) and other consumer focused groupsOrganizations with existing relationships with key eligible populations Assisters/Counselors cannot:Have conflicts of interestBe health insurers or accept any form of payment from insurers related to enrollment

Covered CA has articulated the following groups as Enrollment Entities under the Enrollment Assistance Program CBOs, Community Health Centers (clinics), ranching and farming organizations, county social service agencies not providing health services, labor unions, Chambers of Commerce, Tribal organizations, Community Colleges and Universities, faith based organizations, School Districts, Trade Industry and Prof organizations. There are other groups who can be Certified Enrollment Entities but who will not be paid by Covered California to do enrollments (licensed health care providers/institutions and potentially others).

Certified Enrollment Entities/Certified Enrollment Counselors (CECs) must have trusted relationships with target populations, or be able to readily create those relationships

CEE/CECs cannot have conflicts of interest and cannot be health insurers or accept any form of payment from insurers related to enrollment

Covered CA (CC) is currently working on a plan based enrollment strategy to allow plans who will be offered on CC to help their enrollees apply for subsidies. There are 600K people currently enrolled in a plan that will be sold on CC who will be subsidy eligible. CC also looking at how to let Medi-Cal Local Initiative Health Plans and web-based enrollment entities do CC enrollment.

9What Will the Enrollment Entities and Enrollment Counselors Role Look Like?10Covered California is in the process of determining:What types of entities are eligible to be Navigators/IPAsHow they will be paidOversight and monitoringHow Enrollment Assistance Program will work with the Medi-Cal population

Much in flux, but here is what we know now:

Already decided who can be Certified Enrollment Entities in the final regulations Section 6652.

For IPAs they have already decided how they will get paid speak to that in a moment. There is still questions here for navigators who will be paid through grants.

Regulations have some clarifications about roles and responsibilities, what they can and cannot do in Section 6664 and Section 6666 Conflict of Interest Standards.

Still much discussion about how Enrollment Entities will work with Medi-Cal population. Enrollment Entities must enroll across the full spectrum of insurance affordability programs including Medi-Cal and HFP and premium assistance/tax credits, however CC will not pay for this work. The California Endowment has proffered millions to the State to pay for Medi-Cal enrollments under a similar structure as the IPA and Navigator programs. However, the details of this are still being worked out and it is unclear at this point how these funds will be used and operate.10Program Overview11Here is an overview diagram of the Enrollment Assistance Program It is complicated. On the left you have groups who will be Unpaid by CC to do enrollments.

On the right you have the paid programs the IPA and Navigator programs.

Just to restate what weve already talked about, IPAs paid $58 per enrollment, Navigators by grants. We dont yet know how big Navigator grants will be, indications are that this will be a $5 million program but we dont know what period it will cover yet.

A Certified Enrollment Entity will not be able to be both an IPA entity and a Navigator entity. You will have to choose. But we know that you will be able to switch if you desire to.

Indications are that the same set of rules and restrictions will apply to both groups that are getting paid and those not getting paid by CC. They will all have to:

Be entities not individualsTraining, registered and certified by Covered CaliforniaHelp Enroll in all insurance affordability programs commercial coverage, Medi-Cal, premium assistance/tax creditsConfidentiality and assister guidelines agreementsFollow code of conductFingerprinting and background checksInsurance obligations

11In-Person Assistance Program (IPA) Overview12IPAsFunding Source Establishment CostsCompensationFee-for successful initial enrollment into Covered California QHP ($58) or renewal ($25)Program starts:October 2013

Source: Covered CaliforniaNow lets turn to some specifics on the IPA program. You see it laid out here. CalHEERS will be available at the latest in August for entities to apply to be IPAs. There is currently an assister interest form that you can fill out on the California Health Benefit Website indicating your interest in being a Certified Enrollment Entity. The IPA program will begin in October 2013.

12IPA Program Timeline13

Source: Covered CaliforniaJuly 9 tentative application release at the latest by August, Training over the summer, Program start up in October 2013 through March 2014.13Navigator Requirements

14There are six major navigator requirements: Provide outreach and educationAssist with enrollmentExpertise in eligibility and enrollment Offer services in a fair and impartial mannerProvide referrals to ombudsmen or other consumer assistance programsMake available information in a manner that is culturally and linguistically appropriate

Now some specifics on the Navigator program. Here are the requirements that all Navigator programs must do from the ACA.

Provide outreach and educationAssist with enrollmentExpertise in eligibility and enrollment Offer services in a fair and impartial mannerProvide referrals to ombudsmen or other consumer assistance programsMake available information in a manner that is culturally and linguistically appropriate

The IPA and Navigator functions are nearly the same, but Assisters (IPAs) will not provide outreach and education. Navigator programs are just another subset of the Enrollment Assistance Program.

This information is shown visually on slide #17.14Navigator Program Overview15NavigatorsFunding Source Fees on Health PlansCompensationGrant program based on enrollment targetsProgram starts:January 2014, but initial payments may be delayed

Source: Covered CaliforniaThere is $5 million grant program, but we dont know how long the money is planned for or how they will spend this money. We will know a lot more soon when CC holds webinars and for sure by August 2013 when Covered CA Board will release the proposed regs on the Navigator Program.

15Navigator Program Timeline

16

Source: Covered CaliforniaNavigator Program Webinars in Early-July and Early-AugustProposed Navigator Regulations for Board Approval and Action August 22, 2013File Navigator Regulations with Office of Administrative Law August 30, 2013Navigator Regulations Effective (Tentative) September 9, 2013

Additional Dates: The Request for Proposals is intended to go out in the Fall planned for early October with awards in early DecemberWe also know that the Navigator training will begin in the WinterProgram will begin in January 201416Comparing IPA and Navigator Programs17Roles & ResponsibilitiesIPA Program Navigator Program Conduct public education activities to raise awareness of the availability of Covered California products XDistribute fair and impartial information concerning enrollment into qualified health plans XXFacilitate enrollment into qualified health plan available through Covered California XXProvide referrals to Consumer Assistance Programs XXProvide information that is culturally and linguistically appropriate XX

Source: Covered CaliforniaHere you see graphically the difference between what IPAs will do and what Navigators will do.

IPAs will perform similar functions as navigators. IPAs duties may include helping consumers with: filing an application, receiving an eligibility determination, reporting changes during the coverage year, renewing coverage, comparing and selecting a coverage option, and enrolling in a QHP.

17Enrollment Assistance Application Process18Eligible organizations and their employees may apply to register for the In-Person Assistance or Navigator Program by: Submitting a completed applicationPassing the Assister Fingerprinting and Criminal Record CheckCompleting the required training established described in Section 6660 and pass the exam

IPA PROGRAM application process

Eligible organizations may apply to register for the In-Person Assistance Program according to the following process

1.The organization must submit a completed Application, including an executed agreement conforming to the Roles and Responsibilities in Section 6664 and proof of general liability insurance with coverage of not less than $1 million dollars per occurrence, automobile insurance and workers compensation insurance.

2.The Exchange shall review the Application according to the Criteria Considerations identified in the proposed State Regulations. If applicable, the Exchange shall request any additional or missing information necessary to determine the status of the organizations EE Application.

3.Organizations which meet the Criteria Considerations shall be notified of available times by the Exchange to complete the training requirements described in Section 6660 Training Standards. Get fingerprinted and background checked.

4.Organizations which complete and pass the training requirements established by the Exchange and do al this shall be registered as an Enrollment Entities by the Exchange.

The enrollment process is expected to be the much the same for the IPA and Navigator roles.

CalHEERS (The California Healthcare Eligibility and Enrollment and Retention System) will be up in August and available to potential Enrollment Entities to begin this process. You can go on the California Health Benefit Exchange website now and fill out the assister interest form. Here is the link:

https://assisters.ccgrantsandassisters.org/

18A Third Role: Certified Application Counselors (CACs)19Covered California and DHCS will certify staff and volunteers to become CACs, who will:Help consumers apply and enroll in Exchange coverage and Medi-CalProvide the same core application assistance services and have similar training requirements and conflict of interest standards to other enrollment assistance rolesNot be paid by the ExchangeBe unable to charge fees to consumers

And now this is something completely different but remarkably similar.

The Centers for Medicare and Medicaid Services (CMS) has outlined a third assister role in new regulations that they call Certified Application Counselors. Not to be confused with the new terminology CC is using to talk about all those who do assistance under the IPA and Navigator programs Certified Enrollment Counselors. There is no final rule from CMS on the Certified Application Counselors role so this is all still quite unclear at the moment.

However, many feel that the creation of CACs is acknowledgement of the role that Certified Application Assisters (CAAs) have played in California since 1997, as well as in other states that have a similar program.

This program is still taking shape, but it may be a good role for groups that are currently doing CAA work, but not planning to pursue the IPA or Navigator roles.

We will watch any developments on this front and try to keep the CAA community posted on what is happening in California related to this new development.

19What is the Role of Insurance Agents?20In California agents or brokers will:Enroll individuals and small employers in qualified health plans and public programsAssist individuals in applying for premium assistance/tax credits and cost-sharing reductions in exchanges

Scope of agent roles in the Covered California appears settled, but this is subject to change when regs come out in the next few months.

Under Section 1312 of the ACA, insurers may continue to pay agents and brokers for their services. Covered CA seems to have to a certain extent embraced the role of insurance agents in both the SHOP exchange and the individual exchange. In fact, agents will be the exclusive one on one assistance in the SHOP program.

While the yet-to-be-issued regulations will clarify how this will work, it appears that agents and brokers can be paid by insurers for enrollments (as they are now) in the individual exchange, and in the SHOP exchange Covered California will collect the commissions from plans and distribute them to agents and brokers.

It should also be noted that in its recent listing of entities who can be enrollment entities in the Enrollment Assistance Program Covered California has not listed agents and brokers.

20Agents and Enrollment Entities Working Together21Nonfinancial working partnerships between agents and Enrollment Entities are encouragedRegulations prohibit financial relationships between CEEs and CECs and anyone who holds a current license from California Department of Insurance

There has been much discussion about what relationship insurance agents will have with Enrollment Entities and Enrollment Counselors. How will they work with Counselors to enroll people? Regulations disallow any kind of financial relationship between insurance agents and Enrollment Entities and Counselors, but policy encourages non financial partnerships.

Covered California encourages non-monetary partnerships among all groups offering enrollment assistance. With regard to financial arrangements that could increase overall marketing and enrollment costs, staff recommend adoption of the following recommendations:

1. Prohibit grantees and Counselors from accepting payment or other valuable consideration from agents for referrals and/or enrollment services; and 2. Prohibit agents trained and certified by Covered California from providing payment or other valuable consideration to grantees, EEs, Counselors and other community-based groups for referrals and/or enrollment services as a condition of program participation.

This was adopted in Section 6666 (b) Conflict of Interest Standards: Certified Enrollment Entities and Certified Enrollment Counselors shall not employ, be employed by or be in partnership with, or receive any remuneration arising out of functions performed under this Article from any individual or entity currently licensed by the California Department of Insurance.21Which Role to Play?22Organizations will not be able to pursue both the IPA and Navigator role and should consider the following:

Does your organization want to offer IPA and collect a per successful application fee that is only funded until 2015?ORGo after a grant that is likely to be funded over a longer period of time?

What is the best role for your organization?

Some additional issues to consider: We dont fully know the scope of the Navigator program or how large the grants will be.

Will IPA get funded beyond 2015? Nobody knows at this point.

We do have written assurance from CC that if you have registered as in the IPA program and later decide to be a Navigator your organization can switch.22Requirements in Process23Covered California has finalized the IPA portion of the Enrollment Assistance Program regulations. These provide guidance on:Background checks, fingerprinting and liability insurance for individual assistersTypes of trainings and training topicsRelationships between agents and Certified Enrollment EntitiesFull-text of the regulations can be found here: http://www.healthexchange.ca.gov/BoardMeetings/Documents/June%2020,%202013/Enrollment%20Assistance%20Regulations%20(FINAL).pdf

Once you decide which role you want to play, you will need to get more familiar with what will be required of you:

The Exchange is going to require fingerprinting and background checks as well as liability insurance for all EEs and Counselors.

The precise details of these requirements will be forthcoming, but are important to monitor.

23Training and Oversight 24Training standards for Certified Enrollment Entities and Counselors include: Addressing the needs of underserved and vulnerable populationsFamiliarity with qualified health plans (QHPs), public insurance programs, premium assistance/tax credit and cost sharingUnderstanding eligibility and enrollment rules and procedures Adherence to privacy and security requirements

Oversight and training will be needed to ensure that assisters are qualified and prepared to aid consumers, know how to handle personal information and make seamless handoffs when necessary. Uniformity in training across programs can ensure consistency in information for all consumers.

24Enrollment Program Training TopicsBasic concepts about health insurance and the exchange, enrollment and individual responsibilityOutreach methods and strategiesEligibility, application requirements and appealsEnrollment procedures, processes and tracking systemsQHP/Medi-Cal/Healthy Families operations, plan options and benefit limits

Premium assistance/Tax Credits, deductibles and cost-sharing requirementsUnderstanding of cultural and linguistic standards and the needs of underserved and vulnerable populationsAccess standards for individuals with disabilitiesReferral to appropriate agencies for additional informationCode of Conduct and EthicsCustomer services standardsPrivacy and security standards25

In the recently released regulations from CC, there is a list of many topics that will be included in the training for CEE and CECs.

Weve attempted to summarize them here and get it all on one slide.

These topics provide a great initial checklist for CCHI members and partners to use to prepare themselves for any of the forthcoming roles. Some of these topics are areas where CCHI members and partners already have tremendous expertise, while others are new areas that will require steep learning curves.

NOTE TO PRESENTER: Read the list of training topics in the slideBasic concepts about health insurance and the exchange, enrollment and individual responsibilityOutreach methods and strategiesEligibility, application requirements and appealsEnrollment procedures, processes and tracking systemsQHP/Medi-Cal/Healthy Families operations, plan options and benefit limitsPremium assistance/Tax Credits, deductibles and cost-sharing requirementsUnderstanding of cultural and linguistic standards and the needs of underserved and vulnerable populationsAccess standards for individuals with disabilitiesReferral to appropriate agencies for additional informationCode of Conduct and EthicsCustomer services standardsPrivacy and security standards

It is a lot! And we know that the training for Outreach and Education grantees is going to be 2.5 days. So we are not sure at this time how long the CEC training will be.

25CCHI Member/Partner Areas of Expertise26Premium assistance/Tax Credits, deductibles and cost-sharing requirementsUnderstanding of cultural and linguistic standards and the needs of underserved and vulnerable populationsReferral to appropriate agencies for additional informationAccess standards for individuals with disabilitiesCode of Conduct and EthicsCustomer services standardsPrivacy and security standards

Basic concepts about health insurance and the exchange, enrollment and individual responsibilityOutreach methods and strategiesEligibility, application requirements and appealsEnrollment procedures, processes and tracking systemsQHP/Medi-Cal/Healthy Families operations, plan options and benefit limits

CHIs and partners have important experience in a lot of the areas Covered California will be doing training on. You see them here highlighted in orange. We are especially skilled at outreach methods, know all about Medi-Cal and enrollment, and serving the needs of underserved populations with linguistically and culturally appropriate services.

But there will be a lot more to learn26New Skill Sets27

Basic concepts about health insurance and the exchange, enrollment and individual responsibilityOutreach methods and strategiesEligibility, application requirements and appealsEnrollment procedures, processes and tracking systemsQHP/Medi-Cal/Healthy Families operations, plan options and benefit limits

Premium assistance/Tax Credits, deductibles and cost-sharing requirementsUnderstanding of cultural and linguistic standards and the needs of underserved and vulnerable populationsAccess standards for individuals with disabilitiesReferral to appropriate agencies for additional informationCode of Conduct and EthicsCustomer services standardsPrivacy and security standardsThere are, however, a number of other topics and areas where CHIs and partners will need to learn more or take on entirely new skill sets. Those training topics include:

Basic concepts about commercial insurance, the exchange, enrollment and the individual mandateProgram eligibility and application requirementsEnrollment procedures, processes and tracking systemsQHP Unsubsidized/QHP Subsidized Operations, Plan Options and Enrollment Program premium, deductibles, and cost sharing requirements Premium Assistance/Tax Credits, deductibles, cost-sharing

And a lot more.

27Next Steps for Your Organization28Educate your Board and community partners about the programsConsider your organizational structure and what role might work best for your organizationDevelop a plan that includes training, goals and a readiness timelineComplete the Enrollment Entity Interest form here: https://assisters.ccgrantsandassisters.org/Officially apply to become a Certified Enrollment Entity

Think about how you can employ these next steps to get your organization and community educated and ready to play a new role in enrollment. 28Reports Referenced in Presentation29Covered California, Assisters Program: In-Person Assistance and Navigator WebinarsFamilies USA, Interested in helping with enrollment in the federal insurance marketplaces?State Health Reform Assistance Network, Designing Consumer Assistance Programs: Resources from the FieldCCHI and others, Health Benefit Navigator Credentialing, Training and Quality Assurance in California

Just some of the key reports that were helpful in putting this presentation together.29Who to Contact:30INSERT your organizations contact information HERE

Feedback or Questions about this Presentation?31Suzie ShupeExecutive DirectorCalifornia Coverage & Health Initiatives707-527-9213sshupe@cchi4families.orgwww.cchi4families.org

CCHI is always happy to be a resource to our member and partner organizations as you begin making the shift to these new roles under the Affordable Care Act.

Happy ACA implementation!31