What Is the Opportunity?

Medicaid DHS payments to hospitals, reflecting their uncompensated care burdens, exceeded $300,000,000 in 2011 in Alabama.  They topped $200,000,000 in Florida, $250,000,000 in Georgia and $150,000,000 in Mississippi. Much uncompensated care is attributable to patients with household incomes just a bit too high for Medicaid eligibility.  Many of those households had no option to accept affordable, job-based coverage.  In part because the IRS has delayed until 2015 enforcement of the Affordable Care Act mandate that employers provide such coverage to their full time employees, this situation is likely to persist in 2014, when CMS will begin to reduce associated DSH payments, even in states that have rejected the government’s offer to fund most of the expense of expanding Medicaid eligibility to households with incomes up to 138% of the Federal Poverty Level (“FPL”).  But many such patients will be able to obtain guaranteed issue, individual health insurance policies through the new Affordable Care Act Exchanges.  Those with household incomes under 400% of the FPL will be eligible for federal premium and cost sharing subsidies to facilitate those purchases.  For a user-friendly online estimator, see http://kff.org/interactive/subsidy-calculator.  It forecasts that two uninsured, non-smoking parents with one child, having an annual household income of $25,000 (128% of FPL), after buying a $662.75 per month silver plan, will pay a monthly premium of just $41.67 (a 94% subsidy), with maximum out of pocket costs of $4,500.

Most such purchases are expected to be made online and may be made when the patient seeks care, assisted by a provider employee or contractor.  Insurance brokers, third party plan administrators and others with benefits administration experience are preparing to provide this service, but hospital billing personnel should be able to handle it with minimal training.

When Will This Opportunity Be Available?

October 1, 2013 – March 31, 2014 will be the first open enrollment period for individual health insurance purchases through the Federally Facilitated Exchange serving Alabama, Florida, Georgia and Mississippi.  Issuers of Exchange-listed policies must insure all applicants, regardless of health status, without exclusion of pre-existing conditions, on a modified community rating basis.

After this open enrollment period closes for calendar year 2014 coverage, certain applicants may qualify for special enrollment opportunities, based on, for example, loss of affordable, job-based coverage, income reduction, or other relevant factors.

What Restrictions Does the ACA Impose?

Probably due to extensive publicity of federal Navigator grants and their cumbersome rules, many providers erroneously have assumed that they would have to seek and win a Navigator grant, then comply with those rules, in order to assist this group of patients with their Exchange applications.  In fact, there are five categories of approved assistance personnel, with ACA regulations ranging from Navigator status (highly regulated) to unregistered and unregulated application assistants.  This chart lists major distinctions, with respect to the Federally Facilitated Exchange.

Title Funding Rules
Navigator $54M in 2014 Navigator grants, to be awarded August 15, 2013. Final rules at 45 C.F.R. § 155.205 et seq. are extensive – e.g. limited grant availability, absolute conflict of interest prohibitions, training, examination and recordkeeping requirements.
Non-Navigator Assistance Personnel Available, but not through the ACA. Final rules at 45 C.F.R. § 155.205 et seq. substantially parallel Navigator rules.
Certified Application Counselors None. Final rules at 45 C.F.R. § 155.225 are relatively relaxed, with no conflict of interest bar.  Organizations, including providers, may be authorized to grant CAC status to their employees.
Authorized Representatives None. Final rules at 45 C.F.R. § 155.227 are minimally burdensome.  The applicant (or a court), rather than the Exchange, designates an authorized representative.
None. None. None, as long as no “certified application counselor” representation is made.  See 78 F.R. 42,843 (July 17, 2013).

About $150,000,000 in non-Navigator grants was awarded in July 2013 to health care centers, and to others for distribution to health care centers, to fund their assisted Exchange enrollment of uninsured patients.  Other public and private funding may be available.

Tax-exempt providers subject to the ACA’s Community Health Needs Assessment mandate of 26 U.S.C. § 501r may be able to take credit for such assistance efforts in their CHNA documentation.

What Do State Laws Require?

No enforceable state law may interfere with the operation of federal rules regarding Navigators, Non-Navigator Assistance Personnel, Certified Application Counselors or Authorized Representatives. For example, a state may not require that they be licensed insurance agents.  But the ACA rules adopt by reference a number of generally applicable state laws (state guardianship orders and Medicaid application assistance certifications, for example) and permit states to provide funding for positions not federally funded.

What Should Providers Do?

Providers who want to pursue this opportunity should obtain professional guidance regarding the applicable state and federal rules and then determine whether to provide enrollment assistance through existing staff, new hires, or enrollment assistance contractors.