The new system for Marketplace enrollment assistance under the Affordable Care Act (ACA) is becoming well established. Some 5,000 Assister Programs helped consumers apply for financial assistance and select health plans for 2016 during the third Open Enrollment (OE3). Eighty-seven percent of Programs have been in operation three years, and 7 in 10 of three year Programs report most or nearly all of their staff have also worked all three years. Eighty-four percent of brokers certified to sell non-group Marketplace health plans this year also have worked all three Open Enrollments. As this system of in-person help matures, important distinctions are emerging among entities which could provide opportunities to develop strategies for identifying and building on those that accomplish the most. At the same time, substantial challenges face many Assister Programs and brokers that hinder their ability to help consumers access and successfully enroll in health coverage.
This report is based on findings from the 2016 Kaiser Family Foundation survey of Health Insurance Marketplace Assister Programs and Brokers. The online survey was conducted from February 11 to March 4, 2016 as OE3 concluded. As was the case in prior years, federal and state-operated Marketplaces provided contact information for directors of their Assister Programs, all of whom were invited to participate. In addition, most Marketplaces provided contact information for brokers certified to sell their qualified non-group health plans, and for the second year, a sample of brokers was also invited to participate in the survey.
Assister Programs combined helped an estimated 5.3 million consumers during the third Open Enrollment, roughly a 10% decline from last year. This decline is significant in light of concerns over the slowing rate of annual Marketplace enrollment growth. It may be that some already-enrolled consumers didn’t seek help again this year, particularly those in Medicaid who face a more straightforward annual redetermination process in many states, or those who elected to auto-renew their qualified health plans. It may also be that other factors, including lack of public awareness and affordability concerns, affect the extent to which eligible uninsured individuals seek help. Survey respondents described several key challenges, including limited resources and inherent complexities in the application and plan choice process that may also constrain the reach and productivity of Assister Programs.
Most help from Assister Programs was provided by those with very large caseloads. About 1 in 4 Assister Programs helped more than 1,000 consumers during OE3, accounting for 80% all consumers helped by Assister Programs. By contrast, 30% of Assister Programs helped 100 or fewer consumers during OE3, and these small caseload Programs account for just 1% of all consumers helped by Assister Programs. Large caseload Programs include all types of Assister Programs – Navigator, Federally Qualified Health Center (FQHC) and Certified Application Counselor (CAC). These large Programs are distinguished from smaller ones in several respects. Large Programs were more likely to help consumers with more complex needs such as language translation (28% of large caseload Programs vs 8% of small caseload Programs), immigration-related problems (23% vs 5%), problems reporting income or household size (56% vs 35%). In addition, large caseload Programs were more likely to help resolve Marketplace data verification problems (96% vs 81%). Large caseload Programs were also more likely to engage in outreach activities, to help consumers resolve post-enrollment problems, and to coordinate with other Assister Programs.
Enrollment assistance shifted toward renewing consumers in 2016, though most who sought in- person help still were uninsured. Last year 53% of Assister Programs said most or nearly all consumers they helped were new Marketplace participants. This year, 29% said this was the case. Increasingly Programs are serving a mix of new and renewing consumers – evidence that consumers need help to remain covered, not just to enroll for the first time. At the same time, a majority of Programs say that most of their clients were uninsured when they sought help. This may indicate some consumers are returning at Open Enrollment having lost their Marketplace coverage during the year. In addition, it suggests Assister Programs remain focused on reaching the uninsured.
Some capacity shortages continue. Overall 79% of Programs said they could serve everyone who sought help throughout OE3, but 21% had to turn some away during surge weeks in December and January. This is unchanged from 2015. Among large caseload Programs, 30% had to turn away at least some consumers.
Enrollment assistance remains time intensive. For the third year, it took 90 minutes on average to help consumers enroll for the first time and like last year, it took 60 minutes on average to help renewing consumers. Like last year, most Programs (71%) said they could help most consumers complete the plan selection process. Also like last year, most consumers who seek help have limited understanding of the ACA and difficulty understanding insurance and comparing plan choices. Complexity in the application itself also challenges many consumers, according to Assisters.
Assister Programs helped hundreds of thousands of consumers with Marketplace real-time data verification problems. Programs helped nearly 230,000 consumers resolve problems related to Marketplace identity proofing. The automated federal identity proofing system, based on credit reporting data, poses challenges for consumers without established credit history, and those who cannot pass it can face significant delays in applying for Marketplace coverage. Several state Marketplaces have streamlined the system, including by authorizing certified Assisters to visually verify identity documents. SBM Programs were more likely than FFM Programs (22% vs 14%) to say identity proofing problems usually could be resolved quickly during the initial visit.
Marketplaces also conduct real time verification of applicants’ immigration status and income, matching it to online data sources. This system also poses challenges to certain consumers, for example, those who are self-employed or experience other income volatility. In 2015, the federal Marketplace alone terminated coverage for 500,000 individuals who could not resolve data match inconsistencies (DMI) related to immigration, and reduced subsidies for 1.2 million individuals who could not resolve DMI related to income. Nationwide, Assister Programs helped an estimated 172,000 consumers with immigration-related DMI during OE3, and 259,000 consumers with income-related DMI. This may be an indication that the volume of DMI problems is declining overall, or it may signify that many consumers faced with such problems are not getting in-person help to resolve them. Small caseload Programs were more likely than large caseload Programs to say they would not help consumers resolve immigration DMI (19% vs. 4%) or income DMI problems (11% vs. 3%).
Medicaid file transfers can still pose challenges, especially in federal Marketplace states. Nearly all SBM states have a single, integrated system that makes eligibility determinations for both Medicaid and Marketplace coverage. In contrast, in the 34 FFM and 4 SBM states that rely on healthcare.gov for Marketplace eligibility and enrollment functions, electronic accounts must be transferred between the federal and state systems to provide coordinated enrollment across Programs. Eight FFM states have authorized the federal system to make final Medicaid eligibility determinations, which can expedite the enrollment process. In the remaining 30 FFM states and 4 SBM states that use healthcare.gov, the federal system assesses Medicaid eligibility and the final determination is completed by the state. Among Programs in assessment states, 34% said the Medicaid eligibility determination was usually completed in a timely manner. Many Programs said they will try to expedite the process by helping clients file a separate application for Medicaid (44% in assessment states and 13% in determination states). Among Programs that helped clients complete separate applications, 46% said one follow up visit was typically required, 20% said 2 or more follow up visits were typical.
Significant numbers of Assister Programs (37%) and brokers (53%) said most clients had questions about health plans that were not answered by information on the Marketplace web site. Most Assister Programs (61%) and brokers (67%) said most or nearly all consumers had difficulty understanding basic insurance concepts. This number is down from years one and two (75%), though still substantial. Two-thirds of Assister Programs said most QHP-eligible clients could select a plan during the initial visit; the rest said at least one follow up visit was needed. Brokers made similar observations.
During the year, Assister Programs also helped consumers enroll through special enrollment periods (SEP) and resolve post-enrollment problems. Assisters helped at least 830,000 consumers enroll through SEPs between Open Enrollments last year. This is a 30% increase over SEP help we estimated following OE1 – possibly because OE1 was much longer leaving fewer months available for SEP sign ups. Assister Programs also helped at least 349,000 consumers report mid-year changes (e.g. in income) to the Marketplace last year. And Programs provided post-enrollment help to at least 745,000 consumers between OE2 and OE3. Like last year, once enrolled many consumers needed help if coverage was terminated unexpectedly, claims were denied, their provider was not in the plan network or their medication was not on the plan formulary. Again as was the case last year, when Assister Programs can’t help resolve post enrollment problems on their own, usually they do not refer to Consumer Assistance Programs, but more often refer consumers back to their health plan or to the Marketplace call center.
On average, brokers each helped 110 consumers apply for Marketplace policies during the third Open Enrollment, unchanged from last year. In addition, nearly all brokers also sold policies off the Marketplace, on average 48 during OE3, also statistically unchanged from last year. Like last year, brokers served consumers with somewhat different characteristics than those helped by Assister Programs and provided somewhat different kinds of help. Compared to Assister Programs, brokers were less likely to help uninsured individuals (30% of brokers said most clients were uninsured vs. 56% of Assister Programs) or consumers who lack Internet at home (60% of brokers said few/no clients lacked Internet vs. 24% of Assister Programs). Forty-eight percent of brokers helped Latino clients vs. 76% of Assister Programs. In addition, brokers were less likely to help consumers with Medicaid applications (47% did so vs. 89% of Assister Programs.) Brokers reported higher rates of client continuity from one year to the next; 64% of brokers said most clients they helped this year were people they had helped the year before, vs. 40% of Assister Programs.
Brokers in FFM states initiate about half of Marketplace applications using alternative enrollment sites. The FFM permits use of alternative enrollment channels that meet federal minimum standards. On average, brokers said they started about 26% of FFM applications directly on insurance company websites and 23% of FFM applications on private web broker sites. By comparison, SBM brokers initiated two-thirds of QHP applications on the Marketplace website. Permitting direct enrollment through alternative channels was adopted with the intent of maximizing public awareness and enrollment opportunities and encouraging technology advances such as new plan comparison tools and apps for mobile devices. In follow up interviews, some brokers cited technology advantages of these enrollment channels including easier data entry and the availability of “dashboard” features to help them track all clients. Others said that not having to set up a healthcare.gov account saved time. Still others noted this shortcut could later prove disadvantageous if consumers needed to follow up with the Marketplace but did not have an account.
Beyond logistics, several brokers mentioned that some alternative enrollment channels also offer non-QHP products, such as cancer policies, short term policies, and other “excepted benefit” products that do not have to follow ACA market rules, such as the prohibition on pre-existing condition exclusions. Alternative enrollment channels made it simpler to obtain premium quotes and enroll consumers in these products, as well. CMS is working on improved ways to monitor the sale of QHPs through alternative enrollment channels. It does not track sale of other types of products through these channels.
Some insurers are ending or reducing broker commissions, especially for SEP policies. Nearly half of brokers (49%) say at least some insurers have stopped paying commissions on all Marketplace policies; 17% say most or all of the insurers they do business with have taken this action. More often brokers (60%) say at least some insurers have stopped paying commissions on Marketplace policies sold outside of Open Enrollment to consumers eligible for SEPs; 33% of brokers say most or all insurers have stopped paying SEP commissions for Marketplace policies. Insurers report that SEP enrollees have higher health care claims on average than people who sign up during open enrollment, and therefore want to discourage use of SEPs. Changes to SEP commissions appear to be taking place more often in FFM states than in SBM states. Nearly half of brokers in FFM states (46%) say most or all insurers they regularly do business with have ended commissions on SEP policies, compared to 10% of brokers in SBM states. Twenty-nine percent of FFM brokers say no insurers have ended SEP commissions on Marketplace policies, compared to 61% of SBM brokers.
Regulators in several SBM states have prohibited these commission changes. Other state regulators and CMS, which directly regulates insurance in five FFM states, have not taken such action. The net impact on consumer access to coverage is not clear. Some brokers commented they will continue to help consumers enroll in QHPs during SEPs, even if unpaid, as a public service and to earn client good will. Others said they will consider selling other coverage, such as short-term non-renewable policies, to SEP-eligible consumers instead.
Most Assister Programs (65%) and brokers (55%) said OE3 went better than OE2. This year, respondents were also asked to rate the ACA overall out of a possible 10 points. On average, Assister Programs rated the ACA 6.5, while brokers on average gave a rating of 4.5. To make the ACA work better, respondents were also asked to select the top three changes they would recommend. Changes most frequently recommended by Assister Programs among their top three were to (1) reduce health plan cost sharing (named by 51% of Programs as one of their top three), (2) expand Medicaid eligibility in all states (32%), and (3) expand premium subsidies for Marketplace plans (30%). Changes most frequently recommended by brokers among their top three were to (1) increase broker commissions (named by 47% as one of their top three), (2) repeal the law altogether (28%), and (3) reduce health plan cost sharing (28%).
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. Some states use a different name to describe these Programs, though in this report all Assister Programs funded directly by Marketplaces are referred to as Navigators. CMS provided $67 million for Navigators to work in 34 FFM and FPM Marketplaces this year, compared to $60 million last year and $67 million in year one.1 SBM state funding for Navigators exceeded $100 million in year one, that amount declined by about 15% in year two. 2 Moving forward, funding for Navigators has become more ad hoc in at least some SBM states. The Connecticut Marketplace, for example, no longer provides for year-round Navigators. Instead, during Open Enrollment, Access Health CT staff and temporary hires provide in-person enrollment assistance through temporary storefront sites and public libraries. During the rest of the year help is available through volunteer CAC assister Programs and the state’s ombudsman office. In Colorado, the Marketplace provides roughly 20 percent of resources for its Navigator Program and applies for philanthropic grants for the rest.
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. Marketplaces are not required to provide funding to CACs; most of these Programs are primarily privately funded, supported by their own sponsoring organizations and other outside sources such as foundations.
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, which now total about $150 million per year. All FQHC Assisters are required to complete at least the level of training required of CACs. About 5% 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 2016 coverage year, CMS awarded contracts totaling about $29 million to two organizations to establish FEAPs in 10 states.3 FEAP contracts were initiated for the 2014 plan year and have been renewed subsequently. CMS will continue to contract with FEAPs in year four, 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 2012.4 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. This year more than 80,000 brokers in federal Marketplace states and 30,000 in state-based Marketplaces were certified to help consumers apply for financial assistance 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.