2015 Survey of Health Insurance Marketplace Assister Programs and Brokers
Now in second year, a new infrastructure of consumer assistance in health insurance continues to develop. The Affordable Care Act (ACA) provided for new publicly funded consumer assistance entities to help people on an ongoing basis as they apply for health coverage and subsidies and resolve questions and problems with their insurance once covered. Nearly all Marketplace Assistance Programs established for the first year returned this year to continue helping consumers. These assistance professionals have unique insights into how ACA implementation is progressing, what is changing and what challenges remain. How Assister Programs develop in their own right will also likely impact whether consumers can continue to get the help they need.
This report is based on findings from the 2015 Kaiser Family Foundation survey of Health Insurance Marketplace Assister Programs and Brokers. The online survey was conducted from March 31 to May 3, 2015 as the second Open Enrollment period concluded. As was the case last year, Federal and state-operated Marketplaces provided contact information for directors of their Assister Programs, all of whom were invited to participate. Two years of data enable comparison of Assister Programs capacity and experiences from one year to next. This year’s survey also included brokers for the first time. Brokers have traditionally helped consumers enroll in private health insurance coverage. In 2014, many brokers registered to sell coverage through the Marketplace, and nearly all of them returned this year, as well. Returning brokers also offered some observations about how this year compared to the first year, and how it compared to their experience selling non-group coverage prior to ACA.
Ninety-one percent of Assister Programs and 86% of brokers this year had also helped Marketplace consumers last year, and most (82% of Assister Programs and 79% of brokers) who returned said the second open enrollment period went better than the first. In particular, Marketplace websites worked better this year. In 2014, 65% of Assister Programs said most or nearly all consumers sought help, in part, because of technical difficulties with the Marketplace website. This year, 38% of Programs said this was the case. In 2015, more Assister Programs reported they could complete the enrollment process with consumers and see their plan choice (71% vs. 61%) Returning Assister Programs had also gained a year of experience. By comparison, when the first Open Enrollment period began, only 16% of Assister Programs had previously helped consumers enroll in private health insurance.
More than 4,600 Assister Programs served Marketplace consumers in the second year of health reform, collectively employing 30,400 full time equivalent staff and volunteers. The overall number of Assister Programs and staff increased slightly in the second year. Similar to last year, 15% of Assister Programs were Navigators, funded directly by the Marketplace, while Assister Programs in Federally Qualified Health Centers (FQHCs), supported by grants from the Health Resources Services Administration (HRSA), comprised another 25% of total Programs. Certified Application Counselor (CAC) Programs, which are mostly supported by their sponsoring non-profit organizations or foundations and do not typically receive direct government support for assistance activities, comprised 60% of total Programs, and more than 50% of FTE staff. In terms of consumers helped, Navigators and FQHCs provided assistance to the majority of consumers reached during the second open enrollment period. Together, Navigators and FQHCs served 70% of all consumers who received help this year (30% and 40%, respectively), while CACs provided assistance to only 30% of consumers helped.
Assister Programs helped an estimated 5.9 million consumers this year. Returning Programs helped 5.8 million of those, or about 19% fewer than last year. This decline was driven by a large drop in the number of people helped by returning CACs. Collectively, returning Navigator and FQHC Assister Programs this year helped about the same number of consumers they reported helping last year (4 million vs. 4.1 million), while returning CAC Programs helped 1.8 million individuals, 60% of the number they helped last year. These differences suggest that Assister Programs supported by outside grant funding may be in a better position than voluntary Programs to help more consumers and to sustain their capacity over time.
The need for in-person consumer assistance remains substantial. Website improvements notwithstanding, millions of consumers continue to need personalized help to apply for health coverage and subsidies. Seventy-nine percent of Assister Programs this year (and 80% last year) said most or nearly all consumers sought help because they lacked confidence to apply on their own; 82% of Programs this year (83% last year) said most or nearly all consumers needed help understanding their plan choices; 74% of Assister Programs (this year and last year) said most or nearly all consumers needed help understanding basic insurance terms, such as “deductible.” In addition, this year, like last year, most Assister Programs said it took one to two hours, on average, to help each consumer who was new to the Marketplace. Programs said it took somewhat less time, about an hour on average, to help consumers who were returning to renew Marketplace coverage and subsidies.
Consumer demand for help exceeded what some Programs could provide this year, though not by as much as last year. About one-in-five Assister Programs reported having to turn away at least some consumers this year. For the Open Enrollment period overall, 19% of Programs said they could not help all who sought assistance; during the final two weeks, 22% said they had to turn at least some consumers away. This contrasts with the first year, when 37% of Programs were stretched beyond capacity during Open Enrollment overall, and nearly half had to turn away at least some consumers during the final two weeks. It appears the availability of Marketplace consumer assistance is aligning with demand; however, additional capacity may still be needed.
In between Open Enrollment periods, returning Assister Programs helped an estimated 630,000 consumers apply for coverage through special enrollment periods, 290,000 consumers report mid-year changes to the Marketplace, and nearly 800,000 consumers resolve post-enrollment problems. The need for consumer assistance is year-round. Changes in work or family status or income during the year mean some people must enroll in coverage outside of Open Enrollment or apply for new or revised subsidies mid-year. Marketplace Assister Programs are tasked with helping consumers at these times as well. In addition, consumers need help once enrolled, including with questions about how to use their new health insurance, or what to do if their provider is not in network, or if a claim is denied. Under the ACA, state ombudsman or Consumer Assistance Programs (CAPs) were established to provide post-enrollment assistance, though CAP funding has not been appropriated since 2010. Most Assister Programs, therefore, try to help Marketplace consumers with their post-enrollment problems, and 69% said they could successfully resolve problems most of the time.
Assister Programs report further improvements are still needed in Marketplace websites and Call Centers, and other technical assistance could be strengthened. Most Marketplace online eligibility systems, especially in FFM states, are not yet integrated with Medicaid, so the single, streamlined application for financial assistance envisioned under the ACA is not yet a reality. As a result, when Marketplaces determine a consumer is likely eligible for Medicaid or CHIP, a new separate application is often required. Sixty-nine percent of Assister Programs will help consumers complete a separate Medicaid application. Most say this can be accomplished during the initial visit, but 45% of Programs say a one or more additional visits are needed, on average, to complete the Medicaid or CHIP application and enrollment process.
Assister Programs also cite the need for better information on health plan choices. Thirty-one percent of Programs this year said it was often or almost always the case that consumers had QHP questions that weren’t answered by information on the Marketplace website. (Last year, 41% of Programs said this was the case.)
Programs also reported that technical assistance from the Marketplace Call Centers can be uneven. Half of Programs who said they reached out to Call Centers for help with translation services said help was effective most or all of the time. Among those who sought technical assistance with immigration questions, tax-related questions, or questions about QHP choices, less than half (41%, 45%, and 39%, respectively) said that Call Center technical assistance was effective most or all of the time.
Coordination among Assister Programs remains an important, but elusive goal. Ninety percent of Assister Programs said coordination with other Programs is somewhat or very important to their effective operation, but just over half of respondents said they seldom if ever coordinate with other Assister Programs. When coordination did take place this year, similar to last year, most often it was initiated by Assisters themselves or by an outside third party, not by the Marketplace.
Funding uncertainty concerns many Assister Programs. Twenty-seven percent of Assister Programs said they are very certain that funding will be available to support them next year, while 39% are not certain at all. Overall, Marketplaces provided fewer funding resources for Assister Programs in the second year. The federally run Marketplace cut funding available for Assister Programs in FFM and FPM states by about 10% this year from $67 million in FY 2014 to $60 million in FY 2015. Many State-based Marketplaces also reduced their Navigator funding from first year levels; in all state-Marketplace funding for Navigators fell by about 15 percent. The Centers for Medicare and Medicaid Services (CMS) has announced $67 million will be available for Navigators in FFM/FPM states in year three – the same amount awarded in year one and a 12% increase over year two funding levels. CMS has also indicated there will be additional, as yet unspecified, funding for Federal Enrollment Assistance Programs (FEAPs), which supplement the work of Navigators in some FFM states, in year three. Many state-based Marketplaces have yet to decide the level of consumer assistance resources they will fund in year three.
Health insurance brokers continue to help many consumers apply for coverage, mostly through Marketplaces. Before the ACA, private health insurance brokers traditionally offered help to consumers seeking non-group coverage, and they continue to play an important role today. Brokers are paid commissions by insurance companies for each policy they sell. Many are certified to sell non-group coverage through the Marketplace, and this year, the survey included Marketplace-certified brokers (referred to simply as “brokers” in this report.) The vast majority of brokers who sold non-group coverage this year had done so during the first Open Enrollment period and prior to 2014, as well. Most (79%) sold non-group coverage both inside and outside of the Marketplace, though on average, brokers helped almost twice as many consumers apply for coverage through the Marketplace compared to outside.
Non-group sales have increased for most brokers since Marketplaces opened in 2014. Sixty percent of brokers say they are selling more non-group coverage today than they did prior to 2014. Most reported it takes more time to sell a policy and the revenue they earn per-policy is less; but 40% earn more income overall from non-group commissions than they did prior to implementation of the Marketplaces and another 20% said their overall non-group commission income is about the same.
Brokers and Assister Programs engage in similar consumer assistance activities, with some differences. Both brokers and Assisters help consumers complete Marketplace applications, compare plan choices, and answer tax-related questions. Both also help consumers with post-enrollment problems. However, compared to Assister Programs, brokers less often engage in public outreach and education activities. Brokers also provide less help to consumers applying for Medicaid and more help to small businesses seeking small-group coverage.
Brokers and Assister Programs appear to serve somewhat different populations. Brokers were less likely than Assister Programs to serve Latinos, consumers who needed language translation help, consumers who lacked Internet service at home, or consumers with incomes low enough to be eligible for Medicaid. Brokers were also less likely than Assister Programs to say that most of their clients were uninsured at the time they sought help. However, returning brokers reported a higher degree of client continuity from year one compared to Assister Programs, indicating they may be establishing more ongoing relationships with their clients than Assister Programs have been able to do so far.
About the Assister Programs and Brokers Described in this Report
Several types of Assister Programs provide outreach and enrollment assistance in the Marketplace.
Navigator refers to Assister Programs that contract directly with State Marketplaces or with federally facilitated Marketplace to provide free outreach and enrollment assistance to consumers. The ACA requires all Marketplaces to establish Navigator Programs and to finance Navigators using Marketplace operating revenue. For the first Open Enrollment, before Marketplaces had received any operating revenue, SBMs were permitted to use federal exchange grant funding to establish similar Programs, called In Person Assisters (IPAs). Now that those state grants have ended, this year’s report does not distinguish between IPAs and Navigators; instead, all Assister Programs funded directly by Marketplaces are referred to as Navigators. CMS provided $60 million for Navigators to work in 34 FFM and FPM Marketplaces in the second year, compared to $67 million in year one.1 SBM states and consumer assistance FPM states provided over $100 million in funding for their IPA and Navigator Programs in year one.2 However, with the termination of federal grant funding to support consumer assistance, overall state spending on these Programs dropped about 15 percent in year two. 3
Certified Application Counselor (CAC) refers to Assister Programs that are recognized by a Marketplace but do not receive funding from a Marketplace. This designation was created prior to the first Open Enrollment – when funding for Marketplace-paid assisters, at least in the FFM, was still uncertain – to ensure that willing volunteer Programs would also be available to help. CACs must be sponsored by an organization that will attest to the Marketplace that all of its individual Assisters meet minimum requirements. CACs also must provide help to consumers free of charge. Under federal rules, CACs are not required to engage in all activities required of Navigators, and they are not required to undergo training as extensive as that required for Navigators. All Marketplaces are required to recognize and certify CAC Programs, and states have flexibility to establish additional rules for CAC Programs. Although not funded by the Marketplace, many CAC Programs received funding from other outside sources.
Federally Qualified Health Center (FQHC) Programs are operated by health centers funded by the Health Resources and Services Administration (HRSA). FQHCs treat patients regardless of ability to pay and, prior to enactment of the ACA, actively helped patients apply for Medicaid, CHIP, or other available coverage. For the first year of ACA implementation, HRSA awarded $208 million to FQHCs to support enrollment assistance. In the second year, HRSA made permanent enrollment assistance grants to FQHCs totaling about $150 million per year. All FQHC Assisters are required to complete at least the level of training required of CACs. About 6% of FQHCs also serve as Navigators and so received Marketplace funding in addition to HRSA grants. For purposes of this report, FQHCs that also receive Marketplace funding are referred to as Navigators.
Federal Enrollment Assistance Program (FEAP) refers to Assister Programs that contracted with CMS to provide supplemental enrollment help within FFM and FPM states in selected communities where large numbers of uninsured individuals reside. Duties and requirements of FEAPs are similar to those of federal Navigators except that FEAPs provide “surge” assistance. Most have rolled back staff and operations since Open Enrollment ended. In this report, unless otherwise indicated, description of findings about Navigators will include FEAPs because the two types are so similar. For the 2015 coverage year, CMS awarded contracts totaling about $29 million to two organizations to establish FEAPs in 10 states. 4FEAP contracts were initiated for the 2014 plan year with an option for CMS to elect a second year of work. CMS will continue to contract with FEAPs in year three, though the contract amount and work sites have not yet been determined.
Finally, in addition to Marketplace Assister Programs, the ACA authorized creation of state-based ombudsman programs, also called Consumer Assistance Programs, or CAPs. The law requires CAPs to provide outreach and public education and provide enrollment assistance to consumers in the Marketplace. In addition, CAPs must help all state residents resolve questions and disputes with their private health insurance coverage, including helping consumers to appeal denied claims. The ACA requires Marketplace Assisters to refer consumers with post-enrollment problems to state CAPs. The law provided initial funding for states to establish CAPs and 35 were established in 2010. However no new appropriations have been enacted since and most CAPs have not received any new federal funding since 2012.5 Pending additional federal funding, many CAPs remain operational, albeit at reduced levels.
Broker refers to a state-licensed professional who sells private health insurance to individuals and/or businesses. Brokers are sometimes called agents or producers. To sell non-group or small group health plans offered through a state Marketplace, brokers must register with the Marketplace annually, sign a participation agreement, and complete required training. Brokers who sell non-group policies through the Marketplace help consumers complete an application for financial assistance and explain coverage options. Brokers are paid a commission by the health insurance company offering the policy that the consumer selects. Typically insurers pay commissions when a policy is first issued and at renewal for at least several years. Brokers also offer ongoing services to consumers once they’re covered, including help with post-enrollment questions and help buying other insurance products or financial services.