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 >>
Regulatory Oversight of Narrow Network Plans
The Alliance for Health Reform held a meeting that focused on "Network Adequacy: Balancing Cost, Access and Quality" on July 21. The meeting was very well attended for mid-summer, indicating substantial interest in the trend towards smaller networks particularly in qualified health plans offered through the ACA Exchange marketplaces. Several of the panelists mentioned a recent McKinsey study that found that 92 percent of consumers using ACA plans have access to narrow network plans while 90 percent of ACA plans offer broader networks.
The panel participants emphasized the value that smaller networks bring to consumers in offering substantially lower premiums. For example, a recent Milliman report for AHIP found that high value networks can reduce premiums by 5 — 20 percent. However, it is important that plans select the providers based on quality and performance and not just on price. Paul Ginsberg pointed out that smaller networks also can support integration of care and that these plans are moving in the same direction as payment reform e.g. making payment based on episodes of care or bundled payment. Katherine Arbuckle from Ascension Health noted that providers in smaller network plans can benefit from being connected to the same electronic health record system which further benefits clinically integrated care.
All of the panelists agreed that there needs to be adequate regulatory oversight of network access. Currently the NAIC is in the process of updating their Model Network Adequacy Act which has not been modified since 1996. The goal is to have an updated model by the end of the year. NAIC is focusing on new provisions on essential community providers, tiered networks, formularies, provider directories and updates, continuity of care and consumer protection from unanticipated bills and broadening the act to all types of managed care plans. NAIC wants to retain state flexibility to deal with local conditions, for example, provider access standards should be very different in Wyoming than Los Angeles. Paul Ginsburg noted that passing any willing provider laws is an overreach and will offset the advantages that smaller networks, carefully chosen, can bring to the marketplace.
NAIC does not have regulatory jurisdiction over Medicare Advantage plans. CMS is considering making changes to MA access standards to deal with mid-year network changes beginning in 2015, for example by allowing enrollees to switch plans if their doctor leaves the network mid-year without cause. Senator Sherrod Brown and Rep. Rosa DeLauro have introduced legislation to prohibit MA plans from dropping physicians mid-year without cause.
Resources
Find out what provisions in the final marketing guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes in a webinar next Wednesday, July 23.
It's silly season again, so let's sue the President
The Speaker of the United States House of Representatives, one of the most senior elected officials in the US government, has announced that the House is going to sue the President because he has delayed enforcement of a provision of the 2010 health care law; a provision that a majority of that same House has vociferously criticized as unfair to business and a "job killer." In 2014 Washington, this makes perfect sense.
President Obama has delayed enforcement of the mandate that requires most employers to offer health insurance to their employees, starting in 2014. The President has delayed enforcement until 2015 or 2016 (depending on the size of the employer). The Administration argues that the Internal Revenue Code allows for transitional relief in the implementation of new legislation (the mandate's fee would be collected by the IRS, and so this ostensibly falls under the authority of the Internal Revenue Code). The Speaker says not so much.
So here's the scenario. The employer mandate is set to take full effect by 2016, less than 18 months from now. The House's lawsuit will make its way through the federal court system, with appeals ultimately taking it to the Supreme Court. By then, the mandate will be in full effect, and the Supremes could decide that the case is moot and reject it. Or, even if they decide in favor of the House, there will be no immediate impact since the mandate will already be in effect.
So what's the point? My guess is that the Speaker is hoping to suck some energy from his back benchers who want to impeach the President. Impeachment would fill the newscasts with images of issue conservatives and libertarians competing to load up the articles of impeachment with every criticism of Mr. Obama that has been rendered from the Right since 2009. Having this public spectacle just as voters are going to the polls this November must be one of the Speaker's worst nightmares. So sue the guy. Anyway, it's one of the few things that the GOP majority in the House can accomplish without help from Democrats or concurrence of the Senate.
There is risk for the Speaker in this. He only has a 35 vote majority at present (with 2 vacancies). If half of them vote against the lawsuit, on the grounds it's too wimpy and only impeachment will do, he's going to suffer a major political embarrassment. That's a margin of 18 votes, and 15 members have already voiced support for impeachment.
Even with the Nats in first place in their division, Congress is still the best spectator sport in DC. So pull up your lawn chair, grab a brew, and try to forget for a while that these are the people to whom we have entrusted the governance of our homeland.
Resources
Find out what provisions in the final marketing guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes in a webinar next Wednesday, July 23. Register now >>
High Performance Health Plan Networks
A Milliman report commissioned by AHIP finds that narrower, high value provider networks can help reduce premiums from 5 to 20 percent when compared to broad network plans. A high value network is one selected on the basis of not only fee schedules, but also overall efficiency and quality metrics. Health plans can make these judgments in ways individual consumers cannot.
It is ironic that ObamaCare has created the structure and incentives for a truly competitive health care market, something long sought by Republicans as an alternative to government regulation of prices and medical practice.
The Exchanges offer consumers an opportunity to compare plans on cost and (when the data are accurate and up to date) on networks. Now that insurance companies cannot manage costs by waiting periods and exclusions, they have more incentive to high performance networks as their main competitive advantage. This leaves excluded providers with the option to improve, and qualify for high performance networks, or lose business. Maybe, just maybe, we'll see some improvement in the mismatch between what we pay for health care and what we get.
Resources
On Wednesday, July 23, join GHG to discuss the 2015 Medicare Advantage Marketing guidelines and how to plan for the upcoming changes. Register now >>
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott, Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
Hobby Lobby and Corporate Person-hood
The Supreme Court ruled on Monday, in the Hobby Lobby case, that requiring family-owned corporations to pay for insurance coverage for contraception under the ACA violated a federal law protecting religious freedom. This essentially means that some corporations now have religious rights. Although the majority tried to make this ruling as narrow as possible, it does open the door to future suits claiming exemption from other laws that are deemed by the owners of closely held corporations to infringe on the free exercise of their religion. An initial concern for insurance issuers is whether religious exceptions will proliferate, requiring an increase in benefit design variation. More benefit options means increased operating costs, and more difficult premium calculations.
Beyond this, the logic that a family-owned corporation is indistinguishable from its owners when it comes to religious rights may poke holes in the corporate veil in other ways. Corporations are created by state governments to protect their owners from personal liability. They are fictitious persons, endowed by their creator (the state) with certain specific rights and privileges. The tendency of this Supreme Court to see corporations as extensions of their owners, or of their donors in the Citizens United case, seems to violate this notion of limited rights as well as limited liability, all as determined by state incorporation law. If corporations enjoy freedom of speech and protecting under the federal Religious Freedom Restoration Act, are they also people for purposes of voting and holding public office? Isn't this train of thought leading into some weird and nonsensical places?
Resources
On Wednesday, July 23, join GHG to discuss the 2015 Medicare Advantage Marketing guidelines and how to plan for the upcoming changes. Register now >>
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott, Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
The Impact of Tax Subsidies in the Federally Facilitated Marketplaces (FFM)
A recent report released by the Department of Health and Human Services (HHS) found that four out of five persons who qualified for tax credits in the Federally-facilitated Marketplaces paid an average of $82 a month in premiums after tax subsidies for their health coverage.
69 percent of individuals selecting plans with tax credits in the FFM have premiums of $100 or less while nearly half had premiums of $50 or less. The tax subsidies averaged $264 per month and reduced enrollee premiums an average of 76 percent.However, the analysis shows wide variations among states in the premiums that people are paying for their new insurance, the amount the government is picking up and the proportion who qualify for the subsidies. For example, enrollees in Mississippi paid an average of $23 in monthly premiums after subsidies while enrollees in New Jersey had the highest post-subsidy premiums averaging $148. Cost sharing expenses, such as deductibles and coinsurance, are additional beneficiary costs and were not included in the report. In addition, the report did not analyze premiums in State-based Exchanges, such as California, which had by far the most people sign up.
On average, the federal exchanges provided a choice of 47 health plans offered by an average of five insurers. New York had the highest number of issuers with 16. Florida and Wisconsin had the largest choice as measured by number of plans. However one in five enrollees had a choice of two or fewer insurers, for example there was only one issuer in New Hampshire and West Virginia. New issuers, including CO-OPs, represented almost 26 percent of all state issuers. The majority of new issuers had Medicaid experience. On average, an increase of one issuer in a rating area reduced the second lowest cost silver plan premium by four percent.
Nearly half of enrollees chose the lowest cost silver plan and two-thirds chose one of the two lowest cost silver plans. The HHS report provides analysis of enrollee selection of plans at all metal levels and analyzes premiums by age group in FFMs as compared to State-based marketplaces and Medicaid expansion states.
What does this mean for you if you are participating in the FFM?
- According to the analysis above, the Americans who qualify for tax credits through the new federal insurance exchange are paying an average of $82 a month in premiums for their coverage — about one-fourth the bill they would have faced without the government's help.
- The government has previously reported that 87 percent of the 5.4 million Americans who chose a health plan through the federal health exchange qualified for some financial help.
- Be careful: As of June 1, the government will need to verify eligibility of subsidies by additional documents to verify their income, citizenship, immigration status and Social Security numbers, as well as any health coverage that they may have from employers. People who do not provide the information risk losing their subsidized coverage and may have to repay subsidies next April.
Resources
The launch of the Health Insurance Exchanges is the most challenging implementation in our industry's history with a patchwork of eligibility, new systems and numerous regulations. GHG can help, find out how >>
Integration of MMP Requirements
MA-PD plans have plenty to worry about with CMS requirements, regulator's issue of the day, or Central Office determining what issue to hang their hat on today, seemingly changing with the shift of the wind. It is a challenge to keep track of it all, but it's a necessity we promote and support.
Running like a drippy faucet is the constant stream of sub-regulatory guidance being issued on CMS' Medicare-Medicaid Integration office web page on the Financial Alignment Initiative. We already know that this population is high-touch, with just about every service requiring preauthorization. Operational areas have to keep up with this guidance and also ensure that they are meeting state and Federal requirements for the care of their membership. Generally, they are getting that guidance from the organization's regulatory knowledge center: Compliance.
Imagine you are a large, multi-state plan jumping off the springboard into this pool of Medicare-Medicaid Plans, and you need to ensure you are speaking the right language (i.e. Fully Integrated Duals Advantage, One Care, Healthy Connections Prime, Integrated Care Organization, Integrated Care Demonstration Project, and so forth). The fact that the states are on different timelines in terms of implementation doesn't make it any easier. In this first half of June, for example, the Texas Memorandum of Understanding was posted; one Spanish-language chapter of the Ohio MMP Member Handbook was posted; three separate chapters of the NY MMP Member Handbook were posted, and the reporting requirement templates for Ohio were posted.
I've seen plenty of ways that Compliance tracks new rules, memoranda and plan-specific notices, from extremely effective to non-existent. Sometimes the right tool exists but not the right players — sometimes the right staff is in place but with no effective tool. Whatever the state of affairs, this new guidance has to be reviewed, addressed, and if it pertains to reporting or pulling universes, practiced. I can't stress that enough. CMS gives you the tools and templates; they expect you to be well-versed in how to use them when they come calling.
We are keeping our eyes open in terms of Medicare-Medicaid coordination, in addition to the regularly expected updates from CMS. It should be an interesting next six months as organizations move further ahead in their MMP initiatives, and chances are good that this program won't look the same a couple years down the road.
Resources
Many plans have not yet adapted the way they monitor their business to minimize compliance risk. The Online Monitoring ToolTM (OMTTM) is a complete compliance toolkit designed to help organizations track the compliance of their operations. Learn more about how OMTTM can help bring transparency to performance monitoring, including the required oversight of the delegated entities >>
What's Gained and Lost with an HHS Secretary Burwell
My old Clinton Administration colleague Sylvia Mathews Burwell sailed through a confirmation hearing last week. What was expected to result in serious anti-ObamaCare fireworks and soundbite fodder for midterm campaigns ended with a whimper. Her second confirmation hearing was yesterday, and it's a "Washington dog isn't barking" story. It's now looking like she'll cruise through and we'll have an unexpectedly rapid successor to the embattled Kathleen Sebelius.
Mathews is unquestionably qualified for the job, but there are both positives and negatives of her succeeding the former Governor and Insurance Commissioner of Kansas as Secretary of Health and Human Services at the most critical juncture since Medicare and Medicaid were launched in the 60's.
Here's what's gained: bipartisan support. Sebelius had become the face of last fall's ObamaCare meltdown and needed her own parking spot on the Hill for all the oversight hearings she had to endure. The GOP majority in the House had especially come to revile her, but Mathews is known on the Hill as a skilled technocrat with none of Sebelius' baggage, quiet, non-ideological, and effective. It also helps that with the 7 million enrollee target easily met in the first ObamaCare open enrollment period and at a lower cost than expected, Republicans are turning away from their "repeal and replace" mantra of the last 4 years.
Mathews' proven management skills are also critically important as ObamaCare sails into Year 2. The initative's turnaround this winter was nothing short of incredible, but there's still ample opportunity for health insurers to cause a crackup with the less-visible "back end" problems that persist. Details matter now more than ever. Remember Mark McClellan's impact on Medicare Part D. A massive implementation of government-sponsored insurance needs an operator to see it through.
But here's what's lost: Burwell, locked in the bowels of the Office of Management and Budget for much of her career, enjoys none of the relationships with governors, state Medicaid directors, insurance commissioners or insurance executives Sebelius does, especially those in hostile red states where coverage expansion is needed most. And that could hurt post-midterm chances of getting RedGovs to roll over on the Affordable Care Act's Medicaid expansion and hostile insurance commissioners like Georgia's to back off. She will need to build trust as the face of ObamaCare with politicians in the deep south and west. She will also need a "meet-and-greet" tour of insurance executives, and must demonstrate her ability to hear their concerns and implement fixes quickly in CMS in the runup to open enrollment Round Two.
This isn't to say Burwell will completely avoid controversy and that the Health Secretary's impossible job got much easier. She should continue to pull on her asbestos Spanx every time she sets foot outside her new office in this political environment. But it will give her some breathing room to hit the job hard, get some wins early, and build the trust that's necessary to see ObamaCare through from partisan lightning-rod to established and popular entitlement program.
Pass through payment cuts to providers?
The Medicare Physician Quality Reporting System (PQRS) has teeth. Says CMS: "Eligible professionals who do not satisfactorily report data on quality measures for covered professional services will be subject to a payment adjustment under PQRS beginning in 2015...Accordingly, eligible professionals receiving a payment adjustment in 2015 will be paid 1.5% less than the MPFS [Medicare Professional Fee Schedule] amount for that service. For 2016 and subsequent years, the payment adjustment is 2.0%."
The question for health plans is how to react to this? Do their provider contracts allow them to pass along this cut to physicians? Or do they becomes a sanctuary from the PQRS penalty? WE can expect that the benchmarks will eventually reflect the impact of this penalty, so it's reasonable for plans to determine how they want to react.
A related question is whether plans want to work with participating professionals to help them comply with PQRS and avoid the penalty. This might make particularly good sense if a plan is also passing through the payment reduction.
And, since PQRS also has reward payments, do plans want to include these in payments to physicians who qualify?
As with sequestration, this cut applies only to the Medicare part of the physician's payment. The patient will still pay cost sharing based on Medicare allowable amounts, gross of the PQRS reduction. So docs will still get $20 from patients for a $100 service. But the $80 form Medicare will be cut by 1.5%, or 2%. This comes on top of the 2% sequestration. Payments from Medicare plans that seek to mirror CMS, will need to limit their cuts to the Medicare portion of their payment (the $80 amount in my example).
This raises the larger question of how should plans word their provider contracts. Should they pay a percent of "Medicare allowable," or a percent of what Medicare would pay. In other words, should provider contracts be worded to clearly allow plans to pass cuts like sequestration and the PQRS penalty along to providers?
Resources
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Let's get started. Contact us today >>
Are ACOs fulfilling expectations?
Many of the Medicare Shared Savings program ACOs are now in their second year of operation and some of the Pioneer ACOs are approaching year three. As a result, we are beginning to see published data on which of those ACOs are achieving shared savings. For those ACOs that began operating in 2012, (only ones for which any credible data is available), we know that of the 32 Pioneer ACOs only 23 continue to operate. We know that of those 23 operational Pioneers less than half generated shared savings. We also know that of the MSSP ACOs launched in 2012, about 25% shared in interim savings.
Based on those preliminary results, it is too early to pronounce the ACO program either a success or a failure. Additionally, success or failure should not be measured only in financial terms. Improved financial efficiency was only one of several objectives behind the ACO program. Others included better coordination of care, improved approach to the diagnosis of beneficiary medical problems and improved beneficiary access to care. ACOs that were able to impact practice and service delivery behavior patterns which led to improvement in coordination of care and patient access, I would argue had a successful year.
In debating the feasibility and sustainability of ACOs it is important to recognize that not all ACOs are alike, in fact, most are not. For example the Pioneer ACOs were selected by CMMI on the basis of their past experience in managing the financial risk for a defined patient population, either thorough capitation or percentage of premium contracts.
It is also important to note that for both the Pioneer and the MSSP program ACOs, participating members are not incentivized or obligated to seek medical care within the ACO. Thus the government sponsored ACOs are unable to manage the medical spend for each participating member thus impacting the ACOs ability to generate savings. Private ACOs can and do require participating members to seek care within the ACO or be subject to "out of network" restrictions.
ACOs may or may not survive long term as a discrete healthcare delivery structure. Irrespective, the long term contribution may be that the ACO program accelerated the recognition by providers and health plans that tools exist which, if implemented wisely, can positively impact patient outcomes while controlling costs. Doesn't that seem worthwhile regardless of nomenclature?
Finally those organizations that were already doing a great job of controlling the medical spend prior to organizing as an ACO are having a more difficult time generating additional savings.
Resources
Join us on 4/11 for a FREE webinar as Gorman Health Group founder and executive chairman, John Gorman, financial expert and former health plan CFO, Bill MacBain, and former regulator and industry-renowned policy expert Jean LeMasurier offer insight on the Final Rate Announcement from CMS. Register today >>
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 >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Find out how >>
Join Gorman Health Group May 1 - 2 at the Red Rock Casino and Resort in Las Vegas for the 2014 GHG Forum. This two-day event builds on the success of past GHG Forums and is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population. Register now >>