Reflections on the Basics of Delegation Oversight

Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to understand complex language and reading concepts without the foundation or basics. It would be quite an overwhelming few months for anyone.

With any course of study, it is important to start from the beginning. Furthermore, if you want to master that course, teamwork and collaboration allows for practice and improvement towards fluency.

As we start wrapping up 2016 (and wrapping up holiday presents), it’s a good time to reflect on the basics. What does this have to do with delegation oversight? The basic premise of delegation is that you are entrusting someone to perform an activity on your behalf. If you are looking to delegate for success, we recommend the following key steps to take place at the very beginning:

  • Get to know your delegate partner via pre-delegation discussions, site visit, and audit.
  • Understand how your delegate will demonstrate effective, compliant activities on your behalf.
  • Agree upon monitoring and auditing activities ahead of time, leaving room for augmentation.

We have seen many examples of delegation oversight programs and activities over the course of the year, and some Compliance Officers and Operations leaders find themselves in the delegation oversight equivalent of enrolling in Advanced French. That is, they were not involved in pre-delegation activities and, therefore, did not have a chance to advocate for the sponsor's obligations towards an effective compliance program. Without the basic foundation, they find themselves in an uphill battle when they try to get data or ask for changes to monitoring frequency.

“Oversight of delegated entities can be an overwhelming task,” says Beth Matel, Senior Director of Compliance Solutions. “To help ensure a sponsor has the cooperation of the entity to which they have delegated responsibilities, they must start by including the pertinent contractual provisions outlined in Medicare Managed Care Manual, Chapter 11, Section 100.4 - Provider and Supplier Contract Requirements and 100.5 - Administrative Contracting Requirements.” Sponsors delegating Part D administrative or health care service functions will need to ensure the appropriate subcontractor contractual language is in place as well.

Our Compliance Solutions team is grateful for all the opportunities we have had this year to support our client partners and share best practices, from the basics to the advanced. As you reflect on your delegation oversight programs, give yourself a present if you:

  1. Have strategies in place to ensure shared data is sent and received correctly each time (especially membership data!).
  2. Conduct immediate root causes analysis in response to inquiries or grievances regarding something potentially amiss.
  3. Complete robust testing prior to new benefit implementation.
  4. Partner as a team (Compliance and Operations) to ensure success together.
  5. Maintain a dedicated unit focused on delegation oversight.
  6. Stay up to date on the Centers for Medicare & Medicaid Services requirements and changes as they affect your delegates and communicate them timely.

Bonne chance!

 

Resources

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Sales Oversight — Essential Guidelines

All agents are expected to comply with the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines, federal and state laws, and health plan rules, policies, and procedures.  But what does that mean, and how can health plans enable their employed sales staff and contracted agents to stay compliant while achieving target goals and growth?

Some organizations may have sales management monitoring tools and processes to review the agent's compliance, quality, and performance thresholds. In most cases, sales management personnel are required to provide ongoing monitoring of agent sales activities and performance.

Below are a few key components to Medicare sales force and distribution channel management:

  • Ensure all agents selling Medicare products complete and pass all required training
  • Communicate all product and regulatory information
  • Ensure agents participate in any required remedial training
  • Communicate the results of all ride-along evaluations
  • Document any complaints or corrective action plans in the agent's file, which should be held for a minimum of two years
  • Ensure any corrective action plan is completed and reported back to the health plan
  • Report terminations of any agents/brokers to the state and the reason(s) for the termination

Gorman Health Group (GHG) suggests implementing a variety of compliance monitoring programs to ensure all agents are conducting sales, marketing, and enrollment activities in accordance with federal, state, and health plan regulations, rules, and guidelines. With the Annual Election Period (AEP) just several weeks away, health plans should be finalizing their sales oversight and agent performance standards. Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, says: "We know it's not easy. These activities take a village. A solid partnership between the creative minds in Sales and the rules-minded Compliance staff is critical to success. A sponsor with a well-planned roadmap for AEP will be one step ahead of competitors that have not executed as well."

To promote compliant behavior, health plans, sales management, agency owners, and agents should take an active approach to compliant behavior — attend additional training, understand and follow the rules and regulations outlined in the Medicare Marketing Guidelines, and always lead by example.

For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.

 

Resources

Sentinel Elite™ is a flexible, module-based software solution, built from the ground up, and designed to assist government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Request a demo today >>

The Medicare Advantage marketplace is evolving — are you prepared? Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. Visit our website to learn more about how we can help you >>

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Why Do We Make Simple Things So Difficult?

Time and time again, we encounter "the coolest workarounds" ever invented within the government programs space. Said a different way, we encounter staff who are stuck inventing ways to accomplish the regulatory burden upon their shoulders when they don't have the right processes and tools to efficiently do their job. The manual effort and workarounds almost get the job done but ultimately leave the plan short of their end goal. This phenomenon is not just seen in one operational area but is commonly experienced across multiple disciplines within the health plan.

In some cases, we are stuck with the workarounds forever. There is no good system, and there will never be one that eliminates some of these workarounds. The regulatory web is too tangled for good processes and tools to solve for it.

However, in other areas, we have solutions that will eliminate these workarounds and hundreds of hours of wasted manual effort to do some of the simplest things. One example of this is seen with some of the Part C & D Reporting requirements. We have heard horror stories of multiple team members working multiple weeks on nothing but agent/broker reporting requirements. Why? It's not because they want to but because they don't have the right solutions to eliminate the wasted effort. Without the right solution, the process of assembling these requirements in Quarter 1 of each year involves multiple files from multiple systems, which is never an easy task regardless of the department and data.

The Annual Election Period (AEP) is coming, and plans are making their decisions now in preparing agents for AEP. Have you considered the following questions?

• Is your Part C & D reporting for agents/brokers automated?
• Do you have a system that tells you when your agents are ready to sell?
• Are you using automated processes and tools to onboard your agents, or are you using spreadsheets and man-hours?
• How do you verify whether your Marketplace agents have met training and license requirements?

If you answered "no" or currently can not provide an answer to the above questions, Sentinel is the right solution for your organization.

Our clients who utilize the Onboarding and Oversight modules within Sentinel tend to take a vacation while other plans are doing their annual workarounds. Sentinel combines the ready-to-sell program steps, agent oversight allegation tracking, and enrollment information to produce Part C & D reporting requirements that are ready with a few simple clicks.

Workarounds versus vacation—you choose.

 

Resources:

Sales Sentinel™ is a flexible, module-based software solution with the ability to onboard agents, provide training, manage ongoing oversight activities and pay commissions. Read more >>

Join us on Thursday, May 26, from 1-2 pm ET, for an in-depth webinar analysis of the key changes finalized in the new Medicaid regulation, how these changes will affect states and managed care plans, as well as how to adapt. Register Now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

 


Agent Commission: Don't find yourself on the wrong end of the tipping point

Agent compensation for Medicare Advantage has changed drastically since the implementation of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. MIPPA included regulations, for the first time, around Agent/Broker Commission - among many other things. The goal of implementing commission requirements was to ensure there was a level playing field between plans by implementing the Fair Market Value (FMV) limits, thereby removing the incentive for agents/brokers to enroll a beneficiary into the top-paying plan or to churn beneficiaries from one plan to another. Rather, the goal was to ensure the beneficiary was enrolled in the plan that best fit his/her needs.

So, how did it work? Well, for the most part, we have seen the requirements implemented and The Centers for Medicare & Medicaid Services (CMS) prescribed processes followed. However, we've also seen an increasing amount of instances in which plans are trying to get around CMS requirements. For example, by paying exorbitant "override fees" to the Third-Party Marketing Organization (TMO) for little to no actual services in exchange or by not pro-rating commissions per CMS instructions, an issue which we saw addressed twice by CMS via Health Plan Management System (HPMS) memo this Annual Election Period (AEP). See HPMS memos titled, "Agent/Broker Compensation," released on October 30, 2015 and November 20, 2015.

The reality is that CMS has been focusing their Program Audits in recent years on those issues which have direct impact on beneficiary access to care and has not routinely audited agent commission requirements for several years. Have plans taken advantage of the fact CMS has been focusing efforts elsewhere? Yes, we believe so. However, it appears CMS is becoming aware of the non-compliance around agent commission that is pervasive and even standard in the industry, evidenced by the multiple HPMS memos released this AEP addressing issues of non-compliance.

We know that in the past several years, CMS has exercised its authority by handing down Enrollment Sanctions and Civil Money Penalties (CMPs) for non-compliance. In fact, we see the current year-to-date total CMP amount at $4,719,220 — up from $1,131,505 in 2013.

So, the question is not if CMS will take action to address non-compliance around agent commission, the question is when. More importantly, when CMS does take action, on which side of the tipping point will your Organization land?

If you're not sure where to start, here are some recommendations:

  • Review your agent/broker and TMO contracts to ensure the contract language is in compliance with CMS requirements — pay particular attention to the "admin fees" being paid to the TMO.
  • Review actual payments made to agents/brokers to ensure the payment system is calculating the accurate amount based on current compensation schedules on file with CMS.
  • Review actual payments made to agents/brokers when the amount should have been pro-rated to ensure the payment system is calculating the amount accurately.

If you have questions or need clarification regarding any of the information listed above, contact us here and a team member will be in touch with you shortly.

Resources

Gorman Health Group's Sales Sentinel™ Commissions Module provides a quick and easy solution for organizations to generate commissions payments. Contact us today to learn more >>

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and February 14 to receive the $1095 price. Come February 15, the price increases to $1,295.Register today >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>


The Impact of CMS Changes on MA & FFM 2016 Agent Readiness

Preparing for the 2016 selling season means implementing a strategy that mitigates compliance risks for your organization and empowers your sales force to meet your enrollment targets. In our recent webinar regarding the impact of the Centers for Medicare & Medicaid Services (CMS) changes on Medicare Advantage (MA) and Federally-Facilitated Marketplace (FFM) 2016 Agent Readiness, I outlined key takeaways your organization needs to enforce in order to protect your health plan from compliance risks while also positioning it for sales success in 2016 and beyond.

1. MA/Part D Compliance and FWA Training for FDRs:

Beginning on January 1, 2016, every organization will need to ensure Compliance and Fraud, Waste, and Abuse (FWA) training requirements for first-tier, downstream, and related entities (FDRs) are fulfilled ONLY through CMS courses found on the Medicare Learning Network (MLN). This includes contracted Field Marketing Organizations (FMOs) and agents/brokers. This means the organization may now require these individuals to take custom training and must have mechanisms in place to accept completion of the CMS training. CMS also explicitly states plans will need to provide accurate reporting of this information.

Ways to fulfill requirement:

Note this requirement does not exempt organizations from ensuring all employees and FDRs are informed on how to report instances of fraud, waste, or abuse and other relevant information as described in Compliance Program requirements.

2. New Features for Health Insurance Marketplace Training

CMS is implementing changes to its process where vendors will be offering training. CMS has approved three vendors as "conditionally approved" (not approved until go-live in late summer 2015). GHG is a conditionally-approved vendor for Health Insurance Marketplace training. The number one takeaway from this is agents still begin and end on the CMS website. They cannot come to any vendor website to take their training; they must go directly to CMS and choose the party they would like to utilize.

Important to note:

  • Vendors may use CMS' training or vendor-developed training approved by CMS.
  • New! Vendor pricing varies: GHG's pricing is $29 for Individual and/or Small Business Health Options Program (SHOP), while AHIP is $125 for Individual or SHOP and $150 for both.
  • Vendors offer Continuing Education (CE) units in 5 or more states (pricing varies by vendor).

For information on the requirements and process for completing Health Insurance Marketplace agent and broker registration and training for plan year 2016, please visit here.

Learn more about GHG Health Insurance Marketplace training at exchangebrokertraining.com.

3. Plan Benefit Training Is Important (but doesn't have to be long!)

The point of plan benefit training is not to communicate every detail of your benefits but to provide key information, such as:

  • basic company information,
  • plan types,
  • service areas,
  • premiums and deductibles,
  • any changes from benefits last year,
  • network restrictions and/or changes,
  • highlights of drug benefits,
  • description of value-added benefits,
  • anything that makes you stand out from competitors, and
  • most importantly, how and where to get more detailed information

Remember, every interaction your sales agents have with prospective enrollees should be viewed as a golden opportunity to educate the public about your organization. Ensure your staff is effectively trained to make every member touch count.

4. Licensure

CMS does not specify how or how often the organization checks licensure − just that they ensure the agent is licensed. GHG recommends the organization use primary-source verification through the state Department of Insurance (DOI) or National Insurance Producer Registry (NIPR). At a minimum, the organization should check annually and upon any expiration date. Quarterly checks are slightly more robust, and monthly checks the most rigorous.

5. OIG/GSA (Exclusion) Checks

Like compliance and FWA training, this is a compliance requirement that applies to all delegates (and employees) — not just agents. Every agent representing your plan needs to be checked against the federal exclusion lists every month. Plans need to work with their Compliance Department to ensure this requirement is met.

Whether you operate strictly in the MA market or are participating in the Health Insurance Marketplace, thorough and streamlined agent/broker training positions your plan to make the most of every opportunity and minimize compliance risks. Focus on better agents, not just more agents, to best serve your plan and your beneficiaries.

Need help? GHG's fully-automated Sales Sentinel™ can take your agents from zero to ready-to-sell in as little as one week, ensuring agents are not only trained but contracted, licensed, and appointed per CMS requirements. Sales Sentinel™ can also assist your organization with administrative onboarding functions such as form collection and writing code assignment.

If you have questions, please contact me directly at afleming@ghgadvisors.com.


Resources

Gorman Health Group is one of three conditionally approved for exchange marketplace training, is accepted by all carriers in federal exchange states and provides CE credits available in most states. To learn more visit exchangebrokertraining.com >>

Stay connected. Subscribe to Gorman Health Group news and updates via our weekly newsletter.

 


AEP Begins in 120 Days. Are your agents ready?

It's so much more than training. GHG's fully-automated Sales Sentinel™ can take your agents from zero to ready-to-sell in as little as one week, ensuring agents are not only trained, but contracted, licensed, and appointed per CMS requirements. Sentinel can also assist the organization with administrative onboarding functions such as form collection and writing code assignment.

See full capabilities below:

 

No matter what you need — we can help.  Contact us for more information.

 

Resources

Gorman Health Group's Sales Sentinel™ is specifically designed to make agent onboarding easier for health plans. The web-based, modular solution manages every step of getting your agents ready to sell: contracting, license verification, background check, training, and appointment. Let's get started.

 

 

 

 

                     

 

 

 

 


The Risk in DIY: CMS Mandated Material

"Do It Yourself", or DIY, has been the rave for years now.  From social media sites like Pinterest to television networks like HGTV, Americans have become fond of this philosophy.  Now, I am a big believer in being self-sufficient and must say that I have been sucked into marathon viewings of DIY shows often (Nicole Curtis of Rehab Addict is no joke!).  And, while I have seen my share of success stories, more often than not, I see DIY projects result in complete frustration from those attempting to DIY and very costly mistakes.

A prime example of this within the MA industry is the DIY approach to creating CMS mandated material.  Year after year, I see organizations attempt to produce upcoming plan year material in-house with the intention of saving budget dollars, but ending up with a costly mess due to lack of subject matter expertise and lack of adequate resources.  When you think about the overall importance that is placed on CMS mandated material and the level at which these materials are scrutinized by CMS, it begs the question, "Is the risk in DIY really worth it?"

Picture this: your organization decides to use existing staff to prepare mandated material for the upcoming plan year.  Initially, the approach seems feasible and the cost savings looks attractive.  Although the process is very time intensive, your organization completes the undertaking, or so you think.  It turns out that the amount of time it took to review materials before HPMS submission could not be supported by your Medicare Compliance Department due to lack of resources.  That results in functional areas being made accountable for not only the development of respective mandated material, but also the compliance review.  With business-as-usual responsibilities not changing, the Enrollment department, which was tasked with creating ANOC/EOCs did not factor in a review for accuracy of information and compliance.  Although your organization met the CMS distribution deadline, it is discovered that many of ANOC/EOCs contain cost-sharing errors and do not follow the CMS model templates and allowances.  This discovery impacts about half of your membership and must be reported to CMS.  CMS initially requires your organization to create errata for these documents, but when it is identified that the errors are so significant and high in volume, CMS requires your organization to recreate the affected ANOC/EOCs in their entirety and slaps on a civil monetary penalty.  With a clear understanding of what led to inaccuracies in the first place, your organization seeks outside help from subject matter experts to limit the risk of non-compliance errors.  It is later identified that an original version of an ANOC/EOC is still being sent to members upon request for a particular plan benefit package because a process for document version control was non-existent.  In the end, this is a DIY project gone horribly wrong.  The intention to save money by DIY resulted in something exponentially more expensive between CMPs and the exorbitant cost to reproduce materials.  Most important of all, your beneficiaries were impacted by these inaccuracies.

I know we would all like to think that DIY is always a contending option, which it is, when you have the necessary resources and expertise to do so.  But just as I will never claim to be an expert in building houses just because I've performed some wall patchwork here and there, organizations need to face the reality of the risks in DIY.  Take the time to seriously consider how well-equipped your organization is to handle the development of CMS mandated materials as the season rapidly approaches.  Is it time to bring in the experts?

Resources

For questions regarding consulting services for CMS mandated materials, contact me directly at rpennypacker@ghgadvisors.com

The Gorman Health Group 2015 Forum is April-7-9! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for the Gorman Health Group 2015 Forum today!


In 2015 a Slap on the Wrist Can Be the Kiss of Death

It is truth that in the second term of Democratic administrations, scores get settled between Washington regulators and business partners of the Federal government.  2015 will be no different for our favorite agency, the Centers for Medicare & Medicaid Services (CMS).  It's already on a pace for 2015 to be the toughest year ever in enforcement actions against Medicare Advantage plans.  And generally speaking, the regulatory bar is rising faster than anyone imagined.  Consider:

  • So far in 2015 CMS has issued significant new Medicare Advantage and Part D regulations, and this year's Advance Notice for 2016 rates and rules for Medicare and Part D health plans is the most anticipated I can remember in more than 20 years.
  • 2015 is the toughest year in benchmark payment rates thanks to the approximately $200 billion in cuts from the Affordable Care Act.
  • 2015's technical corrections for Star Ratings are almost bewildering in their complexity in raising the clinical bar. Indeed, in 2014, an election year, CMS famously told Medicare Advantage plans below 3 Stars for 3 consecutive years that a stay of execution was granted. In the fall, many of those low performers were quietly shown the door and were non-renewed. In 2015, however, the agency is handing out live ammunition to its firing squad.  Now an intermediate sanction freezing marketing and enrollment automatically knocks the plan down to 2.5 Stars, often meaning loss of millions in bonus payments and rebate dollars. In competitive markets now, the first plan sanctioned is the first hunk of roadkill.
  • The HHS Office of Inspector General, the guys with the badges and guns in Medicare, have made data validation audits for Medicare Advantage risk adjustment one of its top priorities in its 2015 workplan.   And the President's budget includes over a half-billion dollars in recoveries from these RADV audits.
  • But nowhere is there better evidence that the paper tiger is growing its claws back than in CMS' track record in enforcement actions against MA plans.  In January, the agency levied the highest monthly toll of civil monetary penalties ever -- and if it keeps up the pace, 2015 will be nastiest enforcement environment in Medicare history.

*January 2015

Granted, CMPs don't typically amount to much, usually no more than a couple hundred grand, rarely 7 figures plus.  But the damage is actually far greater, when considering damage in the local and national press; the chatter factor among beneficiaries; lost membership, and damage to the Star Rating and the relationship with CMS, which for many plans is or is becoming its biggest customer.  A slap on the wrist is now the kiss of death in this environment.

Last week, my colleague conducted a webinar on the "Top 10 Things Killing Your MA Plan." CMS' top infractions, in order, are coverage determinations and grievances, and formulary administration, or performance of your pharmacy benefits management vendor.  Those findings are driven by these 10 root causes:

1.Documentation
2.Timeliness
5.Member letter content
6.Clinical decision-making

Now is the time to ensure your compliance function and Medicare operations have the right tools, processes and people to be successful in the toughest environment we've ever seen in government health programs. In 2015, Gorman Health Group launched its latest product, CaseIQ™ , providing a new way to ensure your Appeals & Grievance cases come to a timely and compliant resolution. The tool not only captures all the data points needed to categorize, work and report coverage disputes and complaints; it also guides users through the appropriate processing of each case, minimizing the risk of non-compliance due to user error.  Built and governed by GHG Medicare compliance subject matter experts, CaseIQ™  aims to keep our clients out of CMS' audit crosshairs. Learn more in our recent press release.

In addition, in the Common Conditions, Improvement Strategies, and Best Practices memo based on 2013 program audit results, CMS outlined areas where plans have been consistently non-compliant and described best practices to address failings. Ongoing monitoring is at the heart of non-compliance. Our solution, the Online Monitoring Tool(OMT™), is a highly flexible oversight tool and dash boarding software that brings together key metrics, documents, and tasks for ongoing monitoring and auditing, which results in the Organization being audit ready. This integrated solution also streamlines vital compliance activities, such as the implementation of new requirements and corrective actions. Read our recent White paper to learn more.

Resources

CaseIQ™, GHG's latest solution, offers built-in reports that allow for tracking of past performance, current backlog as well as trends, and is designed to assist the caseworker to a complete and compliant resolution in Part C (MA) appeals, Part D appeals, and Part C and Part D grievances. Learn more >>

Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!


Sales Allegations — What is the best practice?

It's just about that time of year again. Yes, you've got it — Sales Allegation time. During AEP, Organizations receive an influx of complaints of alleged sales misconduct "Sales Allegations". And, every year we receive some of the same questions around how these allegations "should" be investigated and closed. The rub is, CMS is all but silent on the specific requirements around investigation and closure of Sales Allegations. So, here are a few critical pieces to keep in mind:

  • All Sales Allegations must be thoroughly investigated, even if it seems like a straight forward case.
  • All documentation such as a member interview and agent statement must be maintained by the Organization.
  • All cases must have a determination (e.g. Founded, Unfounded, Undetermined, Withdrawn).
  • The disciplinary action process must be different depending on the offence. For example, an issue of Fraud would not receive the same action as a less than comprehensive explanation of the fitness benefit.
  • All outcomes should be tracked and trended in order to identify issues with individual agents, as well as knowledge gaps throughout the entire Sales force.

Remember, you can't prevent Sales Misconduct or Sales Allegations. But, ensuring that complaints are investigated and closed properly will reduce your Compliance risk and will impact the beneficiary's experience in a positive way.

 

Resources

Now is the time to ensure your Plan - and your agents - are ready to sell while remaining compliant.  We invite you to learn how the Sales Sentinel™ suite of agent oversight tools can help demonstrate your organization's commitment to compliance.

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>

On September 10, join us for an exploration of why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Register now >>


Navigators, In-Person Assisters and Brokers

The Alliance for Health Reform held a briefing on August 5, 2014 on "Navigating the Health Insurance Landscape:  What's Next for Navigators, In-Person Assisters and Brokers?"

Consumer enrollment in Qualified Health Plans (QHPs) offered in the Exchange Marketplaces for 2014 was greatly assisted by Navigators, In-Person Assisters (including Certified Application Counselors) and Brokers. 28,000 navigators and assisters helped 10.6 million consumers during the first ACA open enrollment period.  The Kaiser Family Foundation just completed a survey and issued a report entitled "Survey of Health Insurance Marketplace Assister Programs: A First Look under the Affordable Care Act". The survey did not include agents and brokers.  The survey reported that there were 4,400 assister programs nationwide.   Certified Application Counsellor Programs account for 45 percent of the assister programs, in-person assistance programs were 26 percent, the FQHC share was 26 percent, Navigator programs represented only 2 percent and the Federal Enrollment Assistance program provided only 1 percent.

According to the Kaiser study, the federal government spent over $400 million on these assistance programs during the first year. $100 million came from Exchange establishment grants, $208 million from grants to FQHCs, and $105 million from CMS ACA implementation funds. In addition, there was substantial additional funding from private sources including non-profit community programs, hospitals and health care providers, state and local governments.  Funding for assister programs in the state-based marketplaces and federal-state partnership markets was substantially higher than funding in the federal marketplaces.  The uneven funding distribution meant that the number of assister staff per 10,000 uninsured was about half in the federal marketplaces.

Assistance was time intensive involving on average one to two hours for each client.  The top three reasons consumers sought assistance included their limited understanding of the ACA and the need to understand plan choices and their lack of confidence in applying on their own.   Information from QHP websites was inadequate and plans did not have dedicated phone lines for assisters.  Assisters faced a number of challenges including lack of health insurance literacy, transportation issues in rural areas and lack of trust in certain hard to reach communities. States had only 10-12 weeks to hire and train most assisters. 92 percent of assisters wanted additional training especially in the areas of subsidies, tax penalties, and immigration issues.  Successful techniques in reaching the target uninsured populations included partnership with community agencies, building on Medicaid and CHIP networks, use of mobile navigators and media outreach efforts.  Back-end access to Exchange portals in some states, e.g. Maryland and New York greatly helped the assisters with their jobs. States with larger funding were able to conduct more outreach and education events and schedule one on one appointments.

There is no data on the number of agents and brokers that participated in the 2014 open enrollment period.  The National Association of Health Underwriters (NAHU) reported high broker interest and their 2013 survey found that almost 75 percent were obtaining marketplace certification.  HHS reported that 70,000 agents were certified by the federal marketplaces.  State exchange data shows 30,000 additional agents and brokers were certified. The NAHU reported that agent and broker services had an 89 percent customer satisfaction rate. In general, state based exchanges were designed with better broker participation mechanisms than the federal marketplace, although all exchanges experienced technological issues.  The level of collaboration between brokers and assisters varied across states.  Some assisters were wary of brokers, largely because they received commissions from the plans.  Others valued the expertise of the brokers.

90 percent of assister programs reported post-enrollment problems after the ACA open enrollment ended in April.  The top problems identified included not receiving an insurance card, Medicaid eligibility determination problems, and failure to receive a premium invoice. Three fourths of the consumers lacked understanding of the basic insurance concepts. About one-third of the enrollees picked the wrong plan, for example because they didn't understand high deductible plans or innovative benefit designs that covered some benefits but not others.

76 percent of the assister programs plan to continue during the second open enrollment.  This open enrollment is 50 percent shorter than the first enrollment period and overlaps with tax season.  The assisters will also be facing the QHP renewal process as well as uncertainly on the functionality of the online portals.  New QHPs will be entering the marketplace. Federal Navigator funding will be $8 million less.  States can continue to use their grants for the 2015 enrollment period, but they must be self-supporting in 2016.  Additional education will be needed on tax penalties which will be three times larger if consumers don't sign up in 2015.

NAHU expects broker participation in the 2015 open enrollment period to be high, although slightly lower than 2014.  A June survey found that 69 percent of brokers plan to sell on the individual exchange in 2015. Brokers see opportunities with new plans entering the marketplace and the availability of the SHOP exchanges. Brokers and agents experienced a number of challenges in 2014 including payment and liability issues resulting from the failure of applications to record multiple assisters.    NAHU recommends broker portals, additional fields to record multiple assister numbers on applications, ability to edit enrollment records to add NPNs and addition of a complete list of brokers on HHS.gov.

Resources

Gorman Health Group's Sales Sentinel has been providing training and certification services to the healthcare industry for 8 years. Every value is reportable, and Sales Sentinel currently reports on over 120 data points. Learn how Sales Sentinel can help you certify your agents and brokers today >>

GHG currently offers guidance and support in every strategic and operational area in Government sponsored health programs. Visit our website to learn more >>

Join John Gorman, GHG's Founder and Executive Chairman for an exploration of why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Register now >>