Survey of Health Insurance Marketplace Assister Programs

The establishment of extensive new consumer assistance resources under the ACA is a significant development in the insurance system.  Many consumers have traditionally relied on insurance agents and brokers to help enroll in private coverage and answer insurance-related questions.  Even so, consumers have long faced challenges understanding how to navigate coverage options, and have had difficulties understanding their coverage and how to use it once enrolled.  And now, for millions of consumers, applying for coverage also requires a new process of applying for financial assistance.   Professional Assisters not only can help consumers answer questions, apply for help, and connect to coverage, they can serve as an interface between consumers and Marketplace officials and regulators, providing feedback on what consumers need and how well Marketplaces and health plans are working.During the first Open Enrollment, Assister Programs played a key role in achieving first year enrollment results that exceeded most expectations.  In the second year, when Open Enrollment (November 15, 2014 to February 15, 2015) is only half as long, the demand for consumer assistance may very well increase.  The Congressional Budget Office projects 13 million people will enroll in QHPs in 2015, compared to 8 million who enrolled during the first Open Enrollment.¹Increasing enrollment will depend first on retention of those already enrolled.  Many who are already enrolled may require help renewing their coverage and subsidies, particularly if they experience a change in income or family size that affects their eligibility for subsidies.  In addition, nearly all Assister Programs report seeing post-enrollment problems, such as denied claims, missed premiums, or inability to afford cost sharing.  Such problems, if not addressed, could prompt some consumers to drop coverage.Ramping up enrollment will also require reaching millions of new people, educating them about what the ACA offers and requires, and getting them enrolled.  If it is the case that first year enrollment included people who were most highly motivated or aware of the ACA, then the next increment of enrollment could be somewhat harder to achieve.  Assister Programs already working at capacity may be stretched even further in light of these potential increases in consumer demand.  In FFM states, especially, where there were fewer Assisters relative to the size of the uninsured population, continued investment in consumer assistance will matter.

Marketplaces can take a number of steps to improve the overall efficiency of Assister Programs.  Officials can be encouraged that so many Assister Programs and staff intend to stay on the job.  Experience can only enhance Assister efficiency.  Marketplaces can seek other ways to foster the professional development of Assisters so that they continue this work over the long term.  In addition, Marketplaces can take steps improve their web sites and call centers to reduce delays for both consumers and Assisters.  Building Assister portals into online Marketplace application systems could reduce Assister time on hold with call centers and enhance ability to follow up with clients and ensure completed enrollments.   Marketplaces can also expand training and technical assistance resources to enhance efficiency of Assister Programs.

Financial support of Assister Programs will also surely matter.  The ACA requires that all Marketplaces establish Navigator Programs and pay for them out of Marketplace operating revenues – in effect, building the cost of consumer assistance into the overall cost of coverage.  Because Marketplaces did not have operating revenues in time for the first Open Enrollment, this is not how most Programs were financed in the first year.  Instead, about $100 million in funding came from Exchange establishment grants, another $208 million came from HRSA grants to FQHCs, and $105 million came from CMS ACA implementation funds.

In fiscal year 2015, CMS expects to collect about $1.2 billion in operating revenue through an assessment on insurers that participate in FFM states.²  For the 2014-2015 cycle, CMS has announced that $60 million will be available for grants to Navigators in FFM states, 90% of the first year total.   CMS has not specified the source of this funding or indicated whether an ongoing portion of Marketplace operating revenue may be set aside for consumer assistance or in what amounts.³   In addition, no decision has yet been announced on whether to continue funding for FEAPs for a second year.  Most states have yet to announce what the amount or source of their Marketplace Assister Program funding will be for next year.  For 2015, HRSA anticipates that health center funding for outreach and enrollment will continue at about the level awarded in July 2013 ($150 million).  The level of financial resources for Marketplace Assister Programs (and for CAPs tasked with addressing post-enrollment problems) available in the future remains to be seen.