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IN THE MIX: PREPARING
TO BE ASSISTERS
Prepared by California Coverage and Health Initiatives (CCHI)
June 2013
Our Agenda
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


Enrolling California’s Uninsured in Health Coverage
Role of the Exchange in Shaping the Assister/Counselor Roles
Enrollment Entity Roles and Responsibilities
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


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In-Person Assisters
Navigators
Certified Application Counselors
Which Role is Right for You?
Training Opportunities
Enrollment System Guiding Principles
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CCHI believes California’s enrollment system should:
 Build off the strengths of existing organizations
 Involve small CBOs
 Help assisters/enrollment counselors in their role
California’s New Health Insurance
Marketplace
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www.healthexchange.ca.gov
www.coveredca.com
http://www.dhcs.ca.gov
Who Will Need Help Enrolling in
Coverage?
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
In 2014, 5.3 million Californians will be eligible to
purchase insurance through the exchange :
 2.6 million will qualify for premium assistance
 All will benefit from guaranteed coverage
Source: Covered California
Who Are California’s Uninsured?
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By ethnicity:
Source: Covered California
Enrollment Assistance in California
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Covered California has several types of Enrollment
entities and Assister/Counselors:
 Paid Assisters/Counselors
 In-Person
Assisters
 Navigators

Unpaid Assisters/Counselors
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What Does the Enrollment
Assistance Program Aim to Do?
It engages Enrollment Entities and individual counselors
who:
 Conduct outreach and education to help people
figure out their coverage options
 Help consumers and small employers learn about and
enroll in coverage
 Help with the application process, translate materials
and breakdown barriers
Source: Families USA
Who Can Be an Enrollment Entity?
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
Community Based Organizations (CBOs) and
other consumer focused groups
Organizations with existing relationships with key
eligible populations
Assisters/Counselors cannot:
 Have
conflicts of interest
 Be health insurers or accept any form of payment
from insurers related to enrollment
What Will the Enrollment Entities and
Enrollment Counselors’ Role Look Like?
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Covered California is in the process of determining:
 What types of entities are eligible to be
Navigators/IPAs
 How they will be paid
 Oversight and monitoring
 How Enrollment Assistance Program will work with
the Medi-Cal population
Program Overview
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Enrollment Assistance Program
Unpaid
Health Care
Providers
Agents
Other
Entities
Paid
In Person
Assisters
$58/Enrollee
$25/Re-enrollee
Navigators
Grant
Program
In-Person Assistance Program (IPA)
Overview
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Funding Source
IPAs
Establishment Costs
Compensation
Fee-for successful initial
enrollment into Covered
California QHP ($58) or
renewal ($25)
Program starts:
October 2013
Source: Covered California
IPA Program Timeline
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Source: Covered California
Navigator Requirements
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There are six major navigator requirements:
 Provide outreach and education
 Assist with enrollment
 Expertise in eligibility and enrollment
 Offer services in a fair and impartial manner
 Provide referrals to ombudsmen or other consumer
assistance programs
 Make available information in a manner that is
culturally and linguistically appropriate
Navigator Program Overview
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Navigators
Funding Source
Fees on Health Plans
Compensation
Grant program based on
enrollment targets
Program starts:
January 2014, but initial
payments may be delayed
Source: Covered California
Navigator Program Timeline
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Source: Covered California
Comparing IPA and Navigator
Programs
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Roles & Responsibilities
IPA Program
Conduct public education activities to
raise awareness of the availability of
Covered California products
Distribute fair and impartial
information concerning enrollment into
qualified health plans
Facilitate enrollment into qualified
health plan available through Covered
California
Provide referrals to Consumer
Assistance Programs
Provide information that is culturally
and linguistically appropriate
Navigator Program
X
X
X
X
X
X
X
X
X
Source: Covered California
Enrollment Assistance Application
Process
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Eligible organizations and their employees may apply
to register for the In-Person Assistance or Navigator
Program by:
1.
Submitting a completed application
2.
Passing the Assister Fingerprinting and Criminal
Record Check
3.
Completing the required training established
described in Section 6660 and pass the exam
A Third Role: Certified Application
Counselors (CACs)
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Covered California and DHCS will certify staff and
volunteers to become CACs, who will:
 Help consumers apply and enroll in Exchange
coverage and Medi-Cal
 Provide “the same core application assistance
services” and have similar training requirements and
conflict of interest standards to other enrollment
assistance roles
 Not be paid by the Exchange
 Be unable to charge fees to consumers
What is the Role of Insurance Agents?
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In California agents or brokers will:
 Enroll individuals and small employers in
qualified health plans and public programs
 Assist individuals in applying for premium
assistance/tax credits and cost-sharing
reductions in exchanges
Agents and Enrollment Entities Working
Together
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Nonfinancial working partnerships between agents
and Enrollment Entities are encouraged
Regulations prohibit financial relationships between
CEEs and CECs and anyone who holds a current
license from California Department of Insurance
Which Role to Play?
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Organizations will not be able to pursue both
the IPA and Navigator role and should
consider the following:


Does your organization want to offer IPA and
collect a per successful application fee that is only
funded until 2015?
OR
Go after a grant that is likely to be funded over a
longer period of time?
Requirements in Process
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Covered California has finalized the IPA portion of the
Enrollment Assistance Program regulations. These provide
guidance on:
 Background checks, fingerprinting and liability
insurance for individual assisters
 Types of trainings and training topics
 Relationships between agents and Certified Enrollment
Entities
Full-text of the regulations can be found here:
http://www.healthexchange.ca.gov/BoardMeetings/Docu
ments/June%2020,%202013/Enrollment%20Assistance%
20Regulations%20(FINAL).pdf
Training and Oversight
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Training standards for Certified Enrollment Entities
and Counselors include:
 Addressing the needs of underserved and
vulnerable populations
 Familiarity with qualified health plans (QHPs),
public insurance programs, premium assistance/tax
credit and cost sharing
 Understanding eligibility and enrollment rules and
procedures
 Adherence to privacy and security requirements
Enrollment Program Training Topics
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
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Basic concepts about health
insurance and the exchange,
enrollment and individual
responsibility


Outreach methods and strategies
Eligibility, application requirements
and appeals
Enrollment procedures, processes
and tracking systems

QHP/Medi-Cal/Healthy Families
operations, plan options and
benefit limits

Premium assistance/Tax Credits,
deductibles and cost-sharing
requirements
Understanding of cultural and
linguistic standards and the needs
of underserved and vulnerable
populations
Access standards for individuals
with disabilities
Referral to appropriate agencies
for additional information

Code of Conduct and Ethics

Customer services standards

Privacy and security standards
CCHI Member/Partner Areas of
Expertise
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




Basic concepts about health
insurance and the exchange,
enrollment and individual
responsibility


Outreach methods and strategies
Eligibility, application requirements
and appeals
Enrollment procedures, processes
and tracking systems

QHP/Medi-Cal/Healthy Families
operations, plan options and
benefit limits

Premium assistance/Tax Credits,
deductibles and cost-sharing
requirements
Understanding of cultural and
linguistic standards and the
needs of underserved and
vulnerable populations
Referral to appropriate agencies
for additional information
Access standards for individuals
with disabilities

Code of Conduct and Ethics

Customer services standards

Privacy and security standards
New Skill Sets
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




Basic concepts about health
insurance and the exchange,
enrollment and individual
responsibility


Outreach methods and strategies
Eligibility, application
requirements and appeals
Enrollment procedures, processes
and tracking systems

QHP/Medi-Cal/Healthy Families
operations, plan options and
benefit limits

Premium assistance/Tax Credits,
deductibles and cost-sharing
requirements
Understanding of cultural and
linguistic standards and the needs
of underserved and vulnerable
populations
Access standards for individuals
with disabilities
Referral to appropriate agencies
for additional information

Code of Conduct and Ethics

Customer services standards

Privacy and security standards
Next Steps for Your Organization
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Educate your Board and community partners about
the programs
Consider your organizational structure and what
role might work best for your organization
Develop a plan that includes training, goals and a
readiness timeline
Complete the Enrollment Entity Interest form here:
https://assisters.ccgrantsandassisters.org/
Officially apply to become a Certified Enrollment
Entity
Reports Referenced in Presentation
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Covered California, Assisters Program: In-Person
Assistance and Navigator Webinars
Families USA, Interested in helping with enrollment
in the federal insurance marketplaces?
State Health Reform Assistance Network, Designing
Consumer Assistance Programs: Resources from the
Field
CCHI and others, Health Benefit Navigator
Credentialing, Training and Quality Assurance in
California
Who to Contact:
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INSERT your organization’s contact
information HERE
Feedback or Questions about this
Presentation?
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Suzie Shupe
Executive Director
California Coverage & Health Initiatives
707-527-9213
sshupe@cchi4families.org
www.cchi4families.org