Exchanges must fund navigators

New state-based insurance exchanges are likely to encounter a “Catch 22” with the navigator program. While the federal government mandates the use of service providers to help steer consumers through the many benefit options, it also prohibits states from funding the program with grants designated for establishing an exchange.

Eventually, insurance exchanges will tap their operating funds to pay for navigator services, but the resource won’t be available until the exchanges are actually up and running in 2014. Exchanges can also use grant money to pay organizations-such as advocacy groups, not-for-profit providers or local public health departments-to help new enrollees.

The navigator organizations must belong to a qualified entity, authorized by law. Navigators also cannot be paid with commissions.
“Navigators are the ‘boots on the ground’ of the exchange,” says Phil Poley, managing director, Medicaid and state insurance exchanges for Accenture, a global management consulting and technology services company.

Open enrollment begins in October, so exchanges must find out how to frontload their navigator capacity in advance of the first official benefit year.
Jim Riesberg, Colorado’s commissioner of insurance, reported during an exchange board meeting that the state will need enough navigators to enroll 800 beneficiaries per day, 24 hours a day for at least six months. Colorado is considering using grant funds to pay its navigators.

In the interim, some states are relying on an alternative in-person assistance program to help early enrollees file applications, determine eligibility and compare coverage options. The program, which is not mandatory, may be funded through establishment grants and does not face limitations.

Utah
Utah’s exchange, Avenue H, received its conditional approval earlier this year.

However, its exchange predates the health reform law, and has been operating since 2008, catering to small businesses. Employers participate in a defined-contribution arrangement and members can compare, choose and enroll in commercial health insurance online.

As of 2012, the exchange hosted 326 businesses representing 8,000 lives.

Patty Conner, director, Utah Office of Consumer Health Services which maintains the state’s insurance exchange, says Utah still needs to put some significant pieces into place, including establishing a navigator program as mandated by the Department of Health and Human Services (HHS); setting the premium tax credit, which is based on the premium of the second lowest cost silver plan; and creating a funding mechanism to support the exchange.

While Utah’s early adoption of an exchange has given it a leg up, it also has some rework to do to achieve federal standards in the Patient Protection and Affordable Care Act (PPACA). Avenue H must expand to allow individuals to enroll in health plans, for example.

“Our version is a model for the HHS Small Business Health Options Program (SHOP) limited to employers with 50 or fewer employees,” Conner says. “The PPACA exchange should be a market-based solution that provides tools for consumers to make informed decisions across a variety of qualified health plans. We want to give consumers the option to elect public or private insurance rather than requiring that they enroll in Medicare if they are eligible under the new rules.”

Conner and a taskforce, consisting of a variety of stakeholders including community groups, drafted legislation to build a navigator program.  It includes how navigator organizations should be licensed, who will be eligible for the position, how will they be compensated and what kind of training is necessary.

“Navigators are a part of our overall customer service strategy,” Conner says.

She anticipates that they will focus on newly insured residents entering into the marketplace by ensuring they understand their options and by emphasizing a culturally competent approach.

Thus far, the exchange has not sought any grants to support navigators nor has it settled on a compensation structure. Many exchanges will consider paying navigators a fee based on the number of enrollees brought into the exchange.

Conner says the Utah legislature is opposed to accepting any federal assistance for its exchange and therefore, must rely on state or private funding.

Although Conner admits the state has not yet met all exchange requirements, she says that Utah is a bit resistant in making changes.
“The federal government is dictating every step,” she says. “Instead of just telling us how to implement changes, it should also let us know what the expected outcomes should be.”

Conner says determining subsidies will be a challenge. Although the state exchange is willing to identify who is eligible for a premium tax credit, it does not want to be responsible for calculating the amount nor for fielding appeals if the determination is inaccurate.

“We don’t want to play ‘big brother’ nor handle the waiver process,” she says. “It is impossible to check up on everyone. We want to help in the effort but not enforce coverage; it should be a voluntary market.”

Washington
The Washington Health Benefit Exchange received a conditional approval in early December and expects to sign on at least 130,000 individuals in 2013, increasing to 280,000 in the 2014 enrollment period.

Michael Marchand, director of communications, Washington Health Benefit Exchange, says that a navigator program will be fully functional by 2015. In the meantime, the exchange will rely on in-person assistors.

Using a block grant mechanism, the exchange is gearing up for RFPs targeting about 20 lead organizations, which will be responsible for building networks serving specific geographic areas or populations-an unusual model, according to Marchand. Interested organizations will have to demonstrate how they can serve the targeted populations by leveraging other navigator groups.

Lead organizations will be responsible for coordinating outreach and education efforts; training navigators; monitoring performance and service quality; resolving consumer complaints; submitting required data and reports; and distributing grant dollars to network organizations to help them reach necessary performance targets.

Marchand says the state will pay close attention to geography because Washington has some counties that have unique needs, including Native American tribes.

The Washington exchange will implement both a base pay model-focusing on outreach activities, educational presentations, information, application enrollment assistance and navigator training and certification-and one tied to outcomes based on enrollment facilitation goals.
“We don’t want to minimize effort even if the result is not enrollment. At the end of the day, we want to achieve our enrollment goals to become sustainable,” Marchand says.

He anticipates that the exchange will select assistors April through June 2013 and complete training and certification by July. He says that while the state will follow loosely set recommendations from HHS on training, the exchange will develop a curriculum consistent with state regulations that reflects diverse population needs.

Marchand says the exchange is looking primarily for in-person assistors and navigators that have an understanding of diverse populations. Candidates must present a solid business plan and be prepared to respond to a possible audit seamlessly and transparently.

“There will be a high degree of scrutiny for the exchange related to the navigator program,” he says, “and the navigators will be a reflection of the state.”

Connecticut
Although the PPACA mandate requires partnerships with at least two navigator organizations, the Connecticut Health Insurance Exchange plans to issue as many as 300 annual grants for $5,000 to $10,000 each.

The grants will target community-based organizations that want to serve the role, many of which already have similar experience and the ability to establish relationships with employers, employees and consumers, says Jason Madrak, chief marketing officer for the exchange.

The Connecticut exchange, which received conditional approval in early December, will address the needs of the uninsured, those eligible for subsidies and small businesses. Madrak estimates that 350,000 uninsured will enter the state exchange marketplace. At least nine insurers have indicated their intent to participate so far.

He expects that most of the grants will be awarded during July and August, based on a competitive proposal process, while the remainder will be granted during the first quarter of 2014. He says navigator activities will subside appreciably after the 2013 enrollment period and gear up the following year.

Accenture’s Poley believes the navigator role will not phase out as exchanges become fully operational-especially if each navigator is responsible for ongoing management of a specific caseload.

He says changes in income status will affect subsidies throughout the process and changes such as pregnancy would necessitate a need for added assistance in the middle of a benefit cycle.

Madrak agrees that forming close ties between navigators and consumers will drive enrollment.

“We want to ensure that consumers using the exchange will be able to talk to someone local, which is the spirit of the navigator program,” he says.
To overcome the conundrum created by not being able to use establishment grants to fund the navigator program, the Connecticut exchange aims to partner with large philanthropic and non-profit organizations.

The in-person assistors, whose role and responsibilities will be based on the exchange’s needs, will complement and extend the navigator program. Connecticut anticipates that many of the assistors will be drawn from public programs and existing state agencies.

The Connecticut exchange plans to monitor navigator performance by polling exchange participants about how well they understand exchange operations, the enrollment process and qualified health plan and Medicaid benefits; use of services; and responses to outreach activities such as education and enrollment events.

Navigators will be paid from grants out of non-federal exchange operating funds rather than through commission.

Poley says that navigator compensation models will vary from state to state-most likely tied to enrollment; however, he believes they will not be well aligned with incentives.

He is concerned that compensation will be based on enrollment of those consumers who already intend to participate rather than on those who intentionally avoid buying coverage, such as the “young invincibles” over 26 who are not eligible for their parents’ benefits.

“Exchanges will need to create a risk pool by enrolling as many people as possible through different modalities with an emphasis on market segments,” Poley says.

He favors compensation based on leads rather than enrollment-on activities instead of sales-making efforts as valuable as actually enrolling someone. 

Mari Edlin is a freelance writer based in
Sonoma, Calif.