If you read the first blog in this series, you know we’re excited about the new Certified Application Counselor program because it builds on the existing and immensely effective infrastructure of community-based application assistance in many states. Here are seven ways to strengthen the proposed CAC program rules to better protect and meet the needs of consumers.

1) Make CACs available to consumers in all 50 states. The rules make CACs a state option in Medicaid/CHIP but a requirement in all Exchanges. Medicaid and CHIP agencies are required to provide consumer assistance but may lack sufficient resources, particularly as we ramp up for open enrollment. CACs will boost a state’s consumer assistance capacity to effectively meet consumer demand. Moreover, community-based organizations and providers are likely to provide assistance, with or without certification. Thus, certification in every state ensures that these organizations and individuals have the training and skills, and that there is oversight, to assure reliable, effective assistance. Given that CACs perform essentially the same functions as navigators, in-person assisters and brokers and agents, states will be able to leverage training, standards and infrastructure to coordinate the various types of assistance programs.

2) Strengthen standards to protect consumers from assisters with an inherent conflict of interest. CACs must serve in the best interests of clients and should be prohibited from receiving compensation for enrollment from a QHP or specific managed care organization (MCO) that provides coverage for any of the insurance affordability programs. Moreover, we recommend that the regulations be strengthened to explicitly exclude insurance issuers, their subsidiaries and licensed insurance brokers and agents from being certified as CACs given their inherent financial conflict of interest associated with enrollment. While our preference is to exclude these entities, if the final rule does not include this exclusion, there should be stricter disclosure standards and strong monitoring and oversight to assure the best interests of consumers are served.

3) Provide a web portal for CACs in both Medicaid/CHIP and the Exchange and use the web to inform consumers about CACs and other assisters. States should have a designated web portal for use by all assisters, including navigators, in-person assisters and CACs. It should have a secure mechanism for granting rights only for those activities the CAC is certified to perform, and only for activities authorized by the consumer. (The rules require such a portal in Medicaid but are silent regarding the Exchange.) An assister portal will increase the proportion of applications that are submitted electronically, thereby providing more applicants with access to electronic verification and real-time eligibility while increasing the state’s administrative efficiency and ability to conduct oversight. The health coverage websites are a great place to connect consumers with assistance and inform them of the functions and responsibilities of CACs and other assisters, including any limitations or restrictions on the services they provide. For example, the website should clearly disclose to a consumer (before s/he selects and authorizes a CAC) if the assister is not required to provide impartial information on the full range of QHP options.

4) Ensure that training is robust and appropriate.  Training is critical to the quality and effectiveness of the CAC program. The regulations allow Medicaid CACs to perform one, some or all activities, and thus training should include baseline competencies needed by all assisters (i.e. privacy standards, use of the IT infrastructure) and specific modules that correspond to the different activities CACs may perform. Training related to enrollment in a QHP should explicitly include advance premium tax credits (APTC), cost-sharing subsidies and tax reconciliation. Additionally, CACs should be trained to provide services that are culturally and linguistically competent, and accessible to individuals with disabilities.

5) Protect consumers by requiring states to develop an oversight mechanism to ensure the quality and effectiveness of CAC programs. States should be required to implement an oversight mechanism to ensure that CACs provide quality services, comply with minimum CAC standards and serve the best interest of consumers. In particular, it will be important to examine enrollment patterns that suggest steering to specific plans, which may not be in the best interest of consumers.

6) Ensure that states don’t restrict CACs by requiring they be licensed as insurance brokers or prohibiting them from assisting with plan selection and enrollment. The regulations request comment on whether states should be allowed to create additional standards or otherwise limit eligibility of certified application counselors beyond what is proposed. We believe the Exchange should have the flexibility to set higher consumer protection standards than is proposed in the rule. However, such standards should be consistent with navigator requirements and disallow a state from requiring that CACs be licensed insurance brokers and agents. We’ve seen a number of misguided legislative proposals seeking to restrict navigators from fulfilling their duties while conflicting with federal law and regulations. Likewise, we do not believe states should have the flexibility to stop a CAC from assisting consumers through the entire process, which includes plan selection and enrollment.

7) Recognize the value of CACs and clarify that states are not prohibited from funding the essential work they perform. We strongly support protecting consumers by prohibiting application assisters from imposing direct charges on applicants or beneficiaries, as the rules clearly state. However, we believe that CACs provide a valuable service to states and neither Medicaid/CHIP agencies nor Exchanges should be restricted from providing these organizations with resources to provide consumer assistance. It would be extremely helpful for HHS to provide states with sub-regulatory guidance on the availability of federal funding to help support grants or payments to CACs. In particular, information about how Medicaid administrative claiming can be used to match community-based investments in application assistance would be very helpful.

Comments on the proposed rules can be submitted by searching for CMS-2334P here. Coming up next in our consumer assistance blog series: “Where oh where did the in-person assisters go?”