In Person Assistance in Arkansas
This blog was written by Anna Strong, Director of Health Care Policy for Arkansas Advocates for Children and Families.
Due to the blog's length and popularity, we have also created a PDF version for our readers, which is accessible here.
Those of us who have worked for years to make sure children are enrolled in new or expanded Medicaid and CHIP programs in each state know that an “if you build it, they will come” strategy isn’t the most effective. Over the last 15 years, advocates across the country have put forth time and effort to help their states develop effective outreach programs to make sure every child has health coverage. It takes a comprehensive education and outreach effort to engage, inform, and enroll the hardest-to-reach populations.
The same 50 states that have dramatically reduced the number of uninsured children now face new opportunities to connect more Americans to coverage through the Affordable Care Act’s health insurance exchanges and newly extended Medicaid programs. For the first time, affordable coverage will be available for most parents, childless adults, and uninsured children who do not qualify for Medicaid or CHIP.
Setting the Stage in Arkansas
Here in Arkansas, more than a quarter of the population is uninsured. That’s half a million individuals who are one accident or diagnosis away from bankruptcy. Most of these folks are adults aged 19-64. About half have incomes below 138 percent of the federal poverty level ($31,800 for a family of four), and they will qualify for Arkansas’s new Medicaid program if the state chooses to extend it. The other half will be able to purchase coverage through the Federally Facilitated Exchange Partnership in Arkansas.
During the 2011 legislative session, Arkansas was unable to pass legislation to establish a state-based exchange, so in early 2012, the state's Insurance Department began planning for a partnership exchange. With this model, the state will use a standard exchange from the federal government, and the state will work to ensure that the plan management and consumer assistance components of the exchange make sense for Arkansans. Advisory committees were formed around these two areas, and a steering committee was established to vet recommendations before they land on the desk of Arkansas's insurance commissioner.
I am proud to represent consumers as one of three co-chairs of the Consumer Assistance Advisory Committee. We, along with two dozen committee members, have been tasked with overseeing development of the state's In-Person-Assistance (IPA) program, outreach and education efforts, and the consumer complaints resolution process. Since April, we have focused our efforts on the IPA program. The IPA program will be the "boots on the ground" effort to help uninsured Arkansans, many of whom have never had insurance, obtain coverage through the exchange or Medicaid.
Navigators vs. In-Person Assisters
We have word from the Center for Consumer Information and Insurance Oversight (CCIIO) that states can have two types of programs to help the uninsured get coverage (regardless of the kind of exchange a state has):
- Navigators: States with a state-based exchange will develop their own navigator program. In these states, exchange establishment grant funding can only be used to prepare for navigator programs; it cannot be used for actual operations. In Federally Facilitated Exchanges (FFEs) or partnership exchanges like Arkansas’s, the federal government will implement the navigator program as it is outlined in the Affordable Care Act. This is true even in states like Arkansas where the state has chosen to run the consumer assistance function. In FFEs or partnership exchanges, the federal government will distribute federal grants for navigators to a minimum of two entities in the state, one of which will be a community-based organization. Regardless of the kind of exchange or funding stream, navigators must maintain expertise in eligibility and enrollment specifics, conduct public education, and help consumers select health coverage that meets their needs.
- In-Person Assisters: Additionally, states can develop an In-Person-Assister (IPA) program that will perform similar functions to the navigator program. However, states can use federal exchange establishment grant funds to develop and -- here's the key -- operate the IPA program's operations. This helps solve the issue of a lack of start-up funds in 2014 for navigator or IPA programs. Arkansas has shifted its consumer assistance work to focus solely on the IPA program. The state will use a contract process to distribute planning grant funds to entities that will employ trained IPAs to do outreach, education, and enrollment. All states can have an IPA program, including those with a state-based exchange, and the states can shape them to fit the needs of their specific state.
The idea is that states with both navigator and IPA programs will coordinate the efforts of the two to maximize their impact. Arkansas hopes to brand the two programs as a single initiative so that they are seamless to customers, operating as a single force to help Arkansans learn about and enroll in health plans. Ideally, consumers will simply know that a local organization has assisters available to walk them through enrollment, regardless of which stream is funding that assistance.
Developing an In-Person Assister Program
Arkansas has requested federal funding to develop its comprehensive IPA program. The state aims to have the contract award process ready in early 2013. This way, the state can contract with IPA entities to hire individual assisters who will be trained and certified to perform the functions needed to enroll Arkansans in coverage through the federal online portal. We anticipate heavy outreach beginning in the summer of 2013, leading up to the Exchange’s six-month open enrollment period from October 2013 and continuing through March 2014. Outreach will continue beyond March 2014, but on a more limited basis.
We don’t yet know how many navigators the federal government will hire in Arkansas. Using the information we have today about Arkansas’s uninsured population, we estimate a need for more than 500 individual IPAs who will help enroll uninsured Arkansans. Basing our program on a census model, with well-trained workers who focus their work during a fixed time frame, we anticipate a high need for IPAs during open enrollment. However, after open enrollment ends for the exchange, we expect the need for IPAs to drop by about 75 percent, since only those with life changes (like a change in household size or income), will be able to enroll in coverage offered through the exchange. Enrollment for Medicaid and ARKids First is open year round, so IPAs might also provide assistance to these families outside the open enrollment period, in addition to Medicaid caseworkers.
Arkansas is intent on recruiting IPA entities who serve the rural, lower-income areas of our state. Cultural competency and an intimate knowledge of the community are keys to success. We strongly believe that IPAs working through existing non-profit and service organizations around the state will be the most effective way to enroll 250,000 Arkansans very quickly. In the meantime, we are working hard to engage those entities in the process of developing our IPA program to ensure that it allows them to meet the needs of their communities.
Since April, our Consumer Assistance Advisory Committee has been busy working through our roadmap for the IPA program. We have outlined eligibility for IPAs, set program goals, defined guidelines for certification and training of individual IPAs, and developed a framework for IPA entity funding applications. We are now defining performance metrics and on-going monitoring, with financing and other considerations yet to be discussed.
Because Arkansas is one of the first states at this level of detail in the process AND one of the first states to pursue a Federally Facilitated Partnership Exchange with both a navigator and IPA program, there are many outstanding questions that could change our course of progress:
- How will states ensure that IPAs and navigators maintain a collaborative effort, including shared training, data, and monitoring through the federal portal in a federally facilitated exchange?
- What are the long-term funding opportunities for both IPAs and navigators in state-based and federally facilitated exchanges?
- When can states expect detailed information about the federal online portal, and what functionality, including reporting on IPA and Navigator activity, will be available to states with a federally facilitated exchange?
- When will states receive official guidance on the state-run IPA program from CCIIO?
- Will the federal navigator program be geared toward those entities that are steeped in their communities or to organizations with multiple sites or a national presence?
As we receive finalized information from CCIIO on the IPA and navigator programs, we will move quickly toward developing training programs, opening applications, and rolling out outreach and enrollment efforts to the public. Thanks to the work we’ve already put in, we will have our requirements outlined and ready to guide the implementation process. We are eager to contract with IPA entities and to train individual IPAs on their duties so that we can begin the process of connecting half of a million uninsured Arkansans to health coverage.