Em El AR Passive Statistic or Call to Action?

For many, the medical loss ratio (MLR) is the ratio of the health plan's incurred medical claims to the total premiums earned. However under the Affordable Care Act and for government health programs, the MLR is the ratio of medical claims plus quality improvement costs divided by earned premiums minus federal and state taxes and fees and payments in lieu of taxes.

This is not the time or place to get into a discussion about the rules for what is included in the calculation of the Medicare Advantage MLR, but rather focus on what are some of the drivers of the medical spend which makes up the greatest proportion of the MLR and what health plans should be focused on to control that medical spend without sacrificing the quality of services provided or the expected outcomes.

Most payers and provider sponsored health plans collect data based on provider submitted claims, and in most cases translate the data into an annual statistic referred to as the MLR. That is where the common ground begins to turn into quicksand. Why? Because not every health plan has either the capability or knows what to do next with the data that is being collected. Some plans will ask the questions related to what are the drivers behind the MLR, such as: what are the medical utilization outliers; are the providers coding inaccurately; are the referrals and referral patterns from PCP to Specialist or from Specialist to inpatient settings appropriate? What about the use of the ER, or the use of pharmaceuticals? Is the claims configuration process and adjudication process supportive of the provider contracts that have been negotiated? And so it goes.

The point is that even the more sophisticated Plans at times, are at a loss to identify all the drivers that impact the MLR, and therefore Plans are not able to address completely all the existing outliers that drive the MLR. Without that information, a Plan's success in developing short, intermediate and long term strategies and initiatives focused on population management, medical management and financial planning is not fully realized.

A comprehensive understanding of the various elements that drive medical expenses and hence the MLR will enable Plans to develop forward looking assumptions regarding premiums for lines of business, projections on utilization of clinical services, and provider contracting budgets, just to name a few. Recognizing specific drivers of medical expense can assist health plans in transitioning from fee for service (FFS) driven contracted networks to "value based" networks as well as working proactively to lead a transformation of population management .

Such understanding can lead to health service initiatives around how to best impact provider practice patterns regarding member access, coordinated treatment planning, appropriate referral patterns and improved coordination of care via elimination of duplicative or unnecessary procedures.

Ultimately, the goal should be the development by the Plan of a medical expense management plan that is characterized by a forward looking and dynamic approach to proactive medical management and includes provider initiatives supported by performance based measures.

The bottom line is that for many of the health plans,  the issue is not lack of data but how to ask the right questions of the data in order to create actionable efforts that lead to improved performance by the plan and provider and results in improved outcomes to the member.

And sometimes it takes an outside objective partner with a fresh approach to data analysis and understanding of industry best practice to interpret what the data implies. That is where we at the Gorman Health Group  can help. Contact us today. You will be glad you did.

 

Resources

On September 26, Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register today >>

On Tuesday, August 19, GHG's Senior Vice President, Bill MacBain and Senior Vice President of Healthcare Innovations, John Nimsky, explored the drivers and trends in cost and revenue which affect your MLR. Access the webinar recording by becoming a member of the Point >>

In addition to our continued work launching new entrants into the MA market, we are helping many experienced plans develop smart networks: accountable care, shadow capitation, and payment bundling within their current service areas and networks. Contact us today to learn how we can help you >>

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 >>


PA's Corbett is Latest GOP Governor to Take Medicaid Expansion. Will Others?

Last week the Center for Medicare and Medicaid Services (CMS) announced the approval of Pennsylvania's Healthy Pennsylvania plan to expand Medicaid coverage to more than half a million low-income people, becoming the 27th state to do so under the Affordable Care Act (ACA) and the 9th Republican governor.

It's a big step for Governor Corbett, who joins GOP governors in Arizona, Iowa, Michigan, Nevada, New Jersey, New Mexico, North Dakota, and Ohio in breaking party lines and taking the expansion.  The plan would require certain Medicaid-eligible people to pay directly for a portion of their care, utilizing ACA funds to purchase their benefits on the private market. A huge factor in Corbett's decision: hospitals, which carry huge leverage in PA, both academic and for-profit.  Politically speaking, Corbett had little choice.  Economically speaking, he's the latest RedGov to awaken to the fact that it makes no sense for states to pass up on the ACA's huge Federal matching funds.

Does this mean more GOP governors will see the light and stop the obstruction on Medicaid expansion, enabled by last year's infamous Supreme Court ruling? Yes -- but not all.

As I wrote back in June, there are still 23 holdout Red states, whose governors like Rick Perry (TX) and Bobby Jindal (LA) continue to be hell-bent on throwing a middle finger at the White House while thousands of their constituents literally die because of inaction.  Speculation is that a growing number of Red states will fold and take the Medicaid expansion money — but not until after the midterm elections.  Here's why:

  • Funding:  the Feds are funding 100% of Medicaid expansion through 2016, scaling down to 90% in 2020+. While the initial ACA backlash may have provided cover for states not to expand, it will be increasingly difficult to continue to defend not taking the federal money to insure a significant population group.  Remember, Red states have the highest rates of uninsurance per capita, largely due to their historically stingy Medicaid programs.  Texas, for instance, has more uninsured people than Colorado has people.
  • Access: most states that choose not to expand created a significant coverage gap. This happens because subsidies on the exchange are available from 100%-400% of the Federal poverty limit, but not below that, leaving a low-income population paying significantly more for healthcare coverage.
  • "You're Still Paying for It": The ACA funds Medicaid expansion largely from tax revenue. States like Texas and Florida are among the highest contributors to general tax revenue and have the highest number of uninsured population.  They are helping to fund Medicaid expansion for other states via higher income taxes, yet not receiving any of the benefits for their own population.  Medicaid accounted for about two-thirds of all federal funding to states in 2014, up from 43 percent two years ago.
  • Hospitals: hospitals traded in insufficient DSH funding and bad debt for Medicaid or exchange coverage in the ACA.  Hospitals in Red states that didn't expand Medicaid are now reporting they can't even issue bonds for capital projects, and are dying on the vine as the DSH funds are taken away without a substitute.  Considering hospitals are often the largest employers in their communities, and especially in rural Red states, their lobbying might is expected to break anti-ObamaCare partisanship after the elections are over.  They were a huge factor in Pennsylvania.

I'm not as optimistic as some on Wall Street that all RedGovs will fold in the face of these arguments, but suspect that several more will as we head into 2015. Immediately after the PA waiver approval, Tennessee's governor said he may submit a similar proposal to CMS to help provide coverage for approximately 180,000 individuals.  The driver there?  Once again, hospitals:  Community Health Systems, HCA, and LifePoint all have a significant presence in TN, including the headquarters of several.  And given the central and growing role Medicaid plays in healthcare financing -- it is the largest health insurer on earth now -- health plans are awakening to the fact that if they're not in it, they won't be around long.

Resources

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 >>

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 >>


So, what does “Unreasonable Delay" really mean in Federally Facilitated Marketplaces?

As expected, CMS has been sending correction notices to health plans about their networks. Also, as expected, some plans have received a second rejection of their response to the first rejection. Now, time is limited since final corrections are due by September 4. Health plans are asking CMS to give them some idea about how to meet CMS expectations.

Plans are asking—

  • What standards does CMS use that makes for a rejection?
  • What do we need to do?
  • What exactly is deficient?

Given the short timeline, most of these plans are asking "how can we know when we jumped high enough?"

Currently, there are no reasonable standards that CMS or plans can look to. CMS responses to these questions remain vague and unspecific as plans complain that the rejection notices give no direction on what is really wrong. Instead, CMS wants plans to respond with another narrative that explains the pattern of care, any extenuating circumstances, or even a confession of network complaints. Health plans aren't feeling too comfortable with CMS' responses. They are still not sure they will get a "pass" with the next and final submission. Given that multiple CMS reviewers can result in varying opinions on what is sufficient, health plans are worried about the final CMS judgments.

At the same time, CMS assumed responsibility for assuring network adequacy when they initiated these reviews for 2015. So, the focus on narrow networks has placed CMS in the cross-hairs again if network complaints re-surface.

While CMS acknowledged that there might be another window after September 4th, at this point, plans should use metrics using technology support to make their case to support the narrative. Numbers and metrics plus persistence may count.
Resources

Gorman Health Group's network evaluation service deploys an automated software solution that uses metrics based on population, provider ratios and time/distance standard. Learn more >>

Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register now >>

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 >>


The Medicare ACO Demos Are a Mess. Here's What it Means for Health Plans.

This week, another Medicare Pioneer Accountable Care Organization Demonstration site, longtime GHG client Sharp Healthcare in San Diego announced it was dropping out.  It was the tenth Pioneer to quit the trail, and not for lack of trying.  Many of the Pioneers did great on improving quality and reducing costs -- the issue is not the performance of Pioneers.  It's CMS' methodology, with its requirement for Pioneers to bear risk in the third year, and benchmarks calculated to make any gainsharing impossible.

The deck was stacked against them from the beginning, including inability to control beneficiary out-migration, inability to generate meaningful savings if the network was already highly efficient, and the beneficiary at-will opt-out. It's left dozens of Medicare ACOs in both Pioneer and the more than 330 in the Medicare Shared Savings Program (MSSP) scratching their heads and wondering how to monetize the millions they've invested in population health and complex case management -- the "hard part" of Medicare managed care.

I think many will conclude it's time to move up the food chain and become Medicare Advantage plans, and we'll start seeing them next year, with a mini-surge to follow in 2016 and 2017.  Look at it this way: Even if only 10% of all Medicare ACOs decide to jump into the elder insurance game, we could be talking as many as 40 new Medicare Advantage plans entering the program over the next three years.  All of them local and/or regional powerhouses with loyal followings to command those thousands of "assigned" beneficiaries.  At a minimum, a Medicare Advantage contract of their own would command big leverage in negotiations with competing plans they may already be in business with.

To participate in Pioneer or MSSP, health systems needed to develop sophisticated reporting structures to meet CMS demands, as well as the significant investments needed to better manage their elderly frequent flyers.  They assembled more integrated, coordinated providers and held them to tough quality standards, and for the most part, they delivered.  But for all the hard work of evolving their delivery systems, most -- we estimate as many as three-quarters -- won't see a penny from either demonstration.

Many of these ACOs will look at the health plans they contract with in Medicare Advantage, flip the model on its head, engage the plan or a vendor like TMG Health to operate "back office" insurance functions like enrollment, and enter the market in 2016 or 2017 as private-label senior plans.

They'll have a great story to tell, loyal followings, brand recognition, and -- hugely -- will enter Medicare Advantage with the newbie default 3.5 Star Rating, including the 3.5% bonus.  And let's not forget 2016 and 2017 are when the worst is over in the Medicare Advantage rate cuts from the Affordable Care Act, with MA benchmarks being pegged at the traditional Medicare growth rate.  These two factors, not to mention a health system's inherent advantage in collecting risk adjustment diagnostic codes, should provide a substantial tailwind to these new entrants.  Disappointed Medicare ACOs will reinvent themselves as MA plans making an entrance in 2016-2017 like Beyoncé at the Video Music Awards.

This mini-surge of provider-sponsored MA plans should be considered by many sectors of our industry, from provider relations execs and health plan strategists, to pharmacy benefit managers and other vendors hunting new prospects. Disruptive events like the Affordable Care Act have ripple effects, and one will be the evolution of ACOs into full-risk insurers seeking to control their own destiny.  And we need to look no further than members of the Health Plan Alliance, systems like Geisinger Health Plan, or UPMC, or Security Health Plan to see the impact they can make.

If you're a Medicare Advantage Plan with a Medicare ACO in your neighborhood, or worse in your network, start sleeping with one eye open. It's now time to keep your friends close and your enemies closer.

Resources

Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. Learn more about how GHG can help >>

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 >>

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 >>


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 >>


The Clock is Ticking...

If you are a veteran of Medicare Risk Adjustment reporting, you are probably in high gear planning or implementing year end programs to optimize 2014 and 2015 revenue. But is the same old approach you used last year the right approach for this year? Or maybe you are new to Medicare Risk Adjustment or Commercial Risk Adjustment reporting and not quite sure of what programs you should be doing this time of year.

GHG has experienced Risk Adjustment analysts and consultants that can help you meet and exceed your yearend goals. Below is our checklist of processes you should be doing now to help ensure complete and accurate Risk Adjustment data reporting for yearend:

  • Implement analytics that appropriately consider the new Medicare blended HCC model.
  • Suspect targeting for Medicare and Commercial chart reviews — Employ a targeted approach to cast a wide net, but optimize program results.
  • Suspect targeting for 2014 Medicare and Commercial member outreach — Member calls, in-home assessments, provider interventions — one approach alone won't get you there.
  • Chart review execution — Know what your vendors are coding (do they include Rx HCCs?). Could computer aided coding reduce costs and improve ROI? What is the quality of the vendor reviews...would they hold up in an audit? Are they also looking to delete codes?
  • Commercial Risk Adjustment — Select an independent vendor to perform your required audits.
  • Audit Readiness — Execute the appropriate data quality audits now to minimize audit risk next year.
  • ICD — 10 — Revisit or develop an implementation plan…ready or not here it comes!

Plans need to be proactive in their data capture to submit data before the January 31, 2015 deadline for Medicare and April 30, 2015 deadline for Commercial. Data accuracy also needs to be a priority with both programs to minimize audit risk and government take-backs.

Our team of experts can show you the way. Please contact us today.

 

Resources

Gorman Health Group can help ensure that your procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete. Visit our website to find out how GHG can help ensure you are ready for that RADV audit when CMS calls >>

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 >>

Join us on September 19 for an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy." Register today >>


Hospice Guidance Turns 180 Degrees

After 70 Senators signed a protest bill and the hue and cry from hospice providers, patients and prescribers got too loud, CMS rescinded its' previous regs for hospice patients and published new guidance on 7-18-14. Previous guidance required health plans to place prior authorization edits on all medications after a member was identified as being a hospice patient. So, all the medications that the member was previously receiving under their Part D benefit were denied at point of sale. This caused a significant hardship to hospice providers who many times had to pay for the hospice member's medications. The philosophical and medical issue continues to be what medications should be continued and which medications should be discontinued when members are in their hospice benefit. Should antihypertensive, antihyperlipidemic, diabetes and other chronic medications be continued for hospice patients? Rational and substantive arguments exist for the continuation of some chemotherapy medications which keep tumor growth in check and are considered to be palliative for some patients.

The new guidelines require plan sponsors to place beneficiary level prior authorization requirements on four categories of prescription drugs:

  • Analgesics
  • Antinauseants (antiemetics)
  • Laxatives
  • Antianxiety drugs (anxiolytics)

These categories are assumed to be "related to the terminal illness and/or related conditions". Hospice providers will provide these medications. Plan sponsors are expected to continue to provide other medications which may have CMS approved utilization management edits including quantity limits, step therapy and prior authorization. Retrospective review is expected to determine whether other medications were "unrelated to the hospice beneficiary's terminal illness".

 

Resources

We can help your MA-PD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Visit our website to learn more >>

The Online Monitoring Tool™ (OMT™) is a complete compliance toolkit designed to help organizations track the compliance of their operations. Modules developed specifically for MA and Part D sponsors address distinct operational and compliance needs. Learn more about OMT™ here >>

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 >>


The Model of Care's Interdisciplinary Care Team

The Centers for Medicare & Medicaid Services (CMS) has outlined expectations for Model of Care (MOC) for Medicare managed care programs. One of the critical elements of the MOC is the Interdisciplinary Care Team (ICT). CMS has placed greater emphasis on outcomes measures and a well-designed ICT can be a success factor in improving the quality of care and service afforded to beneficiaries.

The health plan case manager after initial member assessment is responsible for developing goals / objectives and barriers to improving member health. The case manager is charged with identifying relevant personnel for the ICT that holds accountability for developing a comprehensive Individualized Care Plan (ICP) addressing the beneficiary's particular needs.

The ICT's duty is to review multiple sources of information: health risk assessments (HRA), medical and pharmacy claims, risk profiles, patient goals / objectives and barriers in order to create a robust ICP; in addition to managing the beneficiary's clinical and psychosocial needs and working with the case manager to coordinate the delivery of required services and benefits.

Each ICT is required to update the ICP and define the appropriate frequency of ICP reviews and revisions. It is also responsible for notifying beneficiaries / designees, primary care providers, and relevant specialist(s) of meeting dates. Depending on case volume ICT meetings can vary from weekly, bi-weekly or monthly whichever is relevant to the identified goals and objectives. Each meeting should have a prepared agenda and case summary that's shared with the beneficiary, providers and specialists in advance. Attempts to schedule meeting times that maximize beneficiary and provider participation are beneficial.

Numerous health plans struggle with the formation of an Interdisciplinary Care Team. If you are uncertain or concerned that your plan does not have a solid ICT process or design, GHG can assist you in evaluation and identification to adhere to best practices.

 

Resources

Join John Gorman, GHG's Executive Chairman together with colleagues, Glenn Ellerbe, Executive Vice President, Dr. Paul Alexander, Senior Clinical Consultant, and Mae Regalado, Senior Director, for an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy. Register now >>

Gorman Health Group can Translate your business strategies into practical, efficient and rigorous work processes. Visit our website to learn more today >>


Health Plan Strategists: Fish Where the Fishes Is -- in LTSS

One of the best pieces of advice I ever got in business was to "fish where the fishes is", and for health plan strategists it holds up.  In this Golden Age of Government-sponsored Health Programs, one of the biggest fishing holes is Long-Term Services and Supports, and a new primer from KFF lays out the opportunity beautifully.  And the hazards: patients who require LTSS are of course the most vulnerable and complex patients in the entire US health system, literally the final frontier for health plans and coordinated care.  Huge risk, huge rewards.

LTSS -- often totally unfamiliar to both Medicare and Medicaid plans, and requiring new types of providers in-network -- help the elderly and disabled with activities of daily living, and include nursing home care, adult day care, transportation, and caregiver supports.  As a nation in 2012 we spent $368 billion on LTSS, 40% of that from Medicaid, and 20% from Medicare, and likely to be around $400 billion today. That's way more than what we're spending on ObamaCare's exchanges and subsidies on an annual basis.  It's unsustainable already, and is now a top-2 item in most state budgets. And with seniors 85+ now the fastest-growing segment of the US population, and their needing LTSS at four times the rate of their younger cohorts, the urgency to convert these vulnerable patients to a coordinated care environment has never been greater, and it's happening fast.

Most LTSS reforms occurring at the state level involve transitioning frail elders and the disabled from the human warehouses of nursing homes and rehab hospitals to home and community-based settings, often under a capitated financial arrangement.  With a year of nursing home care costing $90,000+ but a home health aide or adult day care running about $20,000, it's not hard to see why 45 cash-strapped states are pushing this transition.

The catch is that with the complexity of these populations, and the growing resistance of beneficiary advocates, especially for the developmentally disabled, this transition will involve an unprecedented degree of transparency and accountability from health plans.  If you think Medicare Advantage Star Ratings measures are tough, you ain't seen nothin' yet.  Many quality standards for the frail and disabled, like provider visit timeliness and drug adherence, haven't even gotten off the drawing board yet, and they often vary by state.  What's clear is that service and coordination expectations of regulators will be far more robust for very old and disabled beneficiaries.  That means more emphasis on data-driven case management and coordination, in-home and in-community interventions, robust reporting for regulators and actionable clinical intelligence for providers.

So strategists should "fish where the fishes is" and plan to participate in these groundbreaking programs -- but come equipped.

Resources

Gorman Health Group can provide guidance and support in every strategic and operational area in Government sponsored health programs. Contact us 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 >>

Join us on Friday, Sept, 12, for GHG's perspective on trends relating to CMPs, the CMS audit findings and oversight activities that have taken place in the last six to 12 months, as well as tips on how to avoid and remediate CMS findings. Click here to register >>


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 >>