Facilitating the Enrollment of Newly Eligible Families into the Exchanges

Beginning on October 1, 2013, individuals and small businesses will be able to purchase private health insurance through state-based competitive marketplaces called Affordable Insurance Exchanges (Exchanges), also known as the Health Insurance Marketplaces. Between the expansion of Medicaid and the subsidies that will become available to assist low-income families to purchase other types of insurance, these Exchanges are estimated to expand insurance coverage by the tens of millions. Health insurance is important for multiple reasons – and dramatically impacts outcomes for low-income families.  A study by the National Bureau of Economic Research found that having Medicaid corresponds with increases in hospital, outpatient, and drug utilization, increases in compliance with recommended preventive care, and declines in exposure to substantial out-of-pocket medical expenses and medical debts. There is also evidence of improvement in self-reported mental and physical health measures, perceived access to and quality of care, and overall wellbeing.

Affordable Insurance Exchanges will have a large impact on currently uninsured populations, especially young adults aged 18-34, who are the most likely to be uninsured. However, enrolling in health coverage is a significant obstacle for many Americans and their families. Many face challenges such as limited access to technology, low literacy skills, and language or cultural barriers. While the Affordable Care Act (ACA) simplifies the enrollment process and makes it much more consumer-friendly, many will need the assistance of trained and compassionate advisors in order to understand their coverage options and enroll in the most appropriate public program and/or health plan.

The Affordable Care Act (ACA) addressed the importance of in-person assistance by requiring all Exchanges to provide Navigator grants to entities for conducting public education activities to raise awareness about the new coverage options, helping people apply for, and enroll in, plans offered through the Exchanges, as well as providing referrals. It is the responsibility of Navigators to provide fair and impartial information to consumers about health insurance, the Exchange, Qualified Health Plans, and insurance affordability programs including premium tax credits, Medicaid and the Children’s Health Insurance Program (CHIP). Navigators will also provide referrals to consumer assistance programs and health insurance ombudsmen for enrollees with grievances, complaints, or questions about their health plan or coverage. Furthermore, Navigators are directed to provide information in a culturally and linguistically appropriate manner, including to persons with limited English proficiency; and to ensure accessibility and usability of Navigator tools and functions for persons with disabilities.

The U.S. Department of Health and Human Services submitted a related proposed rule for the Navigator Program on April 5^th and closed the comments period in May, with a final rule expected within the next few months. This proposed rule would establish conflict-of-interest and training standards, including standards for certification and recertification, for Navigators. States have the option of creating their own standards, as long as they meet the minimum requirements of the forthcoming final federal regulations.

As state policymakers design their Navigator Programs, important lessons from other consumer enrollment programs should be considered. According to an issue brief from the Georgetown Center for Children and Families, there are several components a Navigator Program should include in order to be responsive to people with low-income.

Target navigator resources to the most vulnerable. Research indicates that the lowest income and rural consumers prefer the kind of high-touch in-person services offered by community-based organizations while more moderate-income individuals may be comfortable with using a website or applying over the telephone with assistance from the Exchange’s call center. Given that resources are limited, it will be strategic to target navigator services through community-based groups that are best able to reach the most vulnerable, uninsured populations, focusing on those who are less likely to maneuver the eligibility and enrollment process on a self-service basis.

Integrate assistance for all insurance affordability programs. Two key factors drive the need for integrated navigator programs. First, many families will be covered through multiple programs (i.e. 75% of parents in the Exchange will have children in Medicaid or CHIP) and a significant number of people with fluctuating incomes will transition back and forth between Medicaid and the Exchange. Second, the ACA’s “no wrong door” approach requires that states provide access to all coverage options regardless of how and where consumers apply. Thus, consumers will best be served if navigators are highly trained and can provide assistance for all insurance affordability programs, while states will benefit from efficiency gains and economies of scale in consolidating navigator-type services.

Several enrollment strategies employed by Massachusetts were instrumental in the state’s success in reducing the uninsured population. Massachusetts’ enrollment gains under state health reform have been attributed to four key features of their implementation plan. These enrollment strategies help to explain why 97% of Massachusetts’ population is insured.

1. Massachusetts utilized data-driven eligibility and enrollment.
2. The state created a single, integrated eligibility system that offered information about various health coverage programs.
3. The state provided grants to community-based organizations for public education and enrollment support.
4. Massachusetts coordinated a strong public education campaign to inform consumers about coverage options and the individual mandate.

 In-person assistance will be critical to informing people that health coverage is available, to providing education about new coverage options, and to help with benefit utilization. Previous experiences with the creation of CHIP, and health insurance expansions in Oregon and Massachusetts show that an aggressive outreach and marketing campaign will achieve the result of markedly reducing the number of uninsured families - leading both to better health and economic security outcomes.

CSSP Resources for Health Reform Implementation

• Health Reform Implementation Opportunities for Place-Based Initiatives: Going Beyond Coverage to Improve Community Health - Issue Brief 1
• Health Reform Implementation Opportunities for Place-Based Initiatives: Consumer Protection and Patient's Bill of Rights - Issue Brief 2
• Health Reform Implementation Opportunities for Place-Based Initiatives: Community Roles in Assuring Coverage and Benefits - Issue Brief 3

For results-focused public policy strategies to ensure that children and families are healthy, visit Policyforresults.org.