Key Questions to Consider in Setting Up a Navigator Program
7. What type of help will consumers need after enrollment and outside of the annual exchange open enrollment period?
Many consumers will need assistance outside of the annual exchange open enrollment period as they experience changes in circumstance, switch between coverage markets, and/or renew and use their coverage. It is important that navigator programs use staff effectively to ensure that they are able to provide assistance throughout the year while maintaining capacity during open enrollment.
Navigators will play a critical role in helping consumers maintain and apply for coverage outside of open enrollment when circumstances change.
Over the course of a year, it is estimated that as many as 29.4 million consumers could experience changes in circumstance that would result in gaining or losing eligibility for exchange coverage and financial assistance.62 This issue is even more acute for individuals with lower incomes, who have the most frequent fluctuations in income. Approximately 50 percent of individuals with incomes below 200 percent of the federal poverty level ($22,340 for an individual in 2012) are expected to experience changes in income that move them between eligibility for Medicaid and eligibility for financial assistance to purchase coverage through an exchange.63
Navigators will play an important role in educating consumers about their responsibilities to report changes in circumstance and about how changes during the year may affect their eligibility for premium tax credits when they file taxes the following year. For example, when deciding how much of a premium tax credit to take in advance, consumers will need to take into account expected or potential changes in income or family circumstance. Navigators can help individuals report changes and adjust this amount during the course of the year, if necessary.
Navigators will also need to provide assistance with enrollment in new coverage options if a change in circumstance affects eligibility. Part of this work will involve conducting outreach and public education throughout the year to ensure that consumers know about their right to apply for coverage or change health plans during a special enrollment period (if they qualify based on a change in circumstance). Events that may qualify individuals for a special enrollment period include losing job-based coverage, gaining citizenship status, moving to a new state, changes in family size or eligibility for financial assistance, a health plan violation of coverage contract terms, or experiencing exceptional circumstances such as a natural disaster. States may be able to link individuals who are likely to qualify for a special enrollment period to navigators when one of these triggering circumstances is made known to the exchange through data matching or when a change in circumstance is reported by a consumer.
Individuals who become eligible for Medicaid can apply for coverage at any point during the year.
Navigators should be able to assist with coverage renewals.
The Affordable Care Act simplifies coverage renewal procedures by requiring exchanges to pre-populate information on renewal forms for qualified health plans and to conduct administrative renewals for Medicaid and CHIP. However, consumers will still need to report changes that are not captured through data matching, ensure that information on their renewal forms is current, and provide supporting documentation. Massachusetts’ experience with enrollment and retention through the Connector revealed that the need to provide information at renewal can be a significant barrier to maintaining coverage and that proactive outreach to consumers is effective in helping them successfully renew coverage.64
Navigators can play a key role in helping ensure that consumers get the care they need when they need it.
The ideal time for consumers to understand their benefits, learn how to use their coverage, and connect with providers is when they first enroll. Approximately 65 percent of the individuals who are expected to enroll in coverage through exchanges will be uninsured. Nearly 40 percent of this population will have gone for more than two years without a check-up and will not have a usual source of care.65 Navigators can help these individuals find providers, including medical and health homes that offer case management services. If an applicant’s family includes members who are undocumented immigrants, navigators can also provide information about low-cost or free health centers and assistance in getting Medicaid coverage for emergency services.
SHIP Tips: Providing Services outside of Open Enrollment
Provide assistance to consumers who seek help outside of open enrollment when they experience problems with their coverage.
Offer services that consumers will need year-round, such as counseling on plan benefits, how to find providers, and consumer rights. Navigators may want to give presentations on coverage, for example, as part of community outreach events regarding health and wellness.66
Continue to engage and expand your referral network and outreach partners by educating stakeholders about health insurance issues and by providing public education sessions in forums that are appropriate to your target population.
Maintain a core year-round staff and recruit highly trained volunteers and additional staff to expand outreach, education, and counseling capacity during open enrollment season.67
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