Navigating Medicaid, CHIP and the Exchanges

States are busily working to transform their tugboat-type eligibility and enrollment systems into sleek 12-meter racing yachts of the America’s Cup variety. But will simplified, streamlined eligibility and enrollment systems mean smooth sailing for everyone? Not likely. No matter how fast and dynamic these new systems are, it still will take all hands on deck to maneuver what for many will be the uncharted waters of health coverage.

Too metaphoric for you? Look at this way – about 16 million people who will gain coverage in 2014 have incomes below 138 percent of the federal poverty level and be eligible for Medicaid. Many have never been able to afford health insurance. Another 10 million or more will qualify for cost-sharing reductions and/or premium tax credits, adding a new element of complexity to understanding health insurance. Those accessing health insurance through the exchange will have to choose between plans with different coverage levels and costs. And many families will get coverage from different sources (i.e. kids are covered in CHIP, parents in the Exchange). So while these new eligibility systems may remove many of the paperwork barriers that keep eligible people out of Medicaid and other public coverage programs today, there is still a very strong need for outreach, public education and enrollment assistance.

The Affordable Care Act (ACA) anticipates this need and establishes Navigator programs to conduct outreach and help people enroll and retain coverage. But it gives states leeway in determining the scope of these programs. A logical way to approach the design of a Navigator program would be to chart out the “who, what and where” so that assistance can be targeted and tailored to meet the needs of consumers. Unfortunately, in many states, that’s not where the discussion starts. The issue of navigators hit rough waters early on as insurance brokers and agents resisted the notion that anyone other than those licensed to “sell” insurance serve as Navigators. The fact is 32 million diverse people need to be connected to coverage and we will need all hands on deck – and all types of assistors – to meet their diverse needs. It would be shortsighted to not tap the expertise of so many community organizations that serve low-income families and are trusted anchors and beacons in their communities.

States are beginning to set sail in defining their navigator programs. In Maryland, the state commissioned an extensive study on Navigators and worked with a stakeholder advisory committee to make recommendations to the Legislature. Legislation has now been proposed in Maryland (as well as North Dakota) with provisions relating to navigators. In California, advocates have spent months working on developing Navigator recommendations to the state. Meanwhile, the California Exchange board has issued a request for proposals for a vendor to develop its outreach and marketing plan, including the design and implementation of a navigator program.

There are many facets to designing and implementing effective Navigator and community enrollment assistance programs: conducting a needs assessment; integrating assistance for Medicaid, CHIP and Exchange plans; selecting, certifying and training Navigator; identifying funding mechanisms; and evaluating these programs to ensure that no consumer is left high and dry. In the coming months, we’ll be taking a closer look at emerging Navigator programs and work with key stakeholders to provide buoys to guide state partners as you navigate these sometimes murky waters in your own state.  

Tricia Brooks
Tricia Brooks is a Senior Fellow at the Center for Children and Families