Trusted community-based organizations and health care providers have been a key part of our nation’s success in bringing the rate of uninsured children down to an historic low. These community partners will also be an important resource in connecting consumers to new coverage options under the Affordable Care Act. In particular, certified application counselors (CACs) are needed to supplement limited navigator resources particularly in the states where the state has elected to neither create its own marketplace or partner with the federal government.

What have we learned from the final CAC regulations and guidance on how the CAC program will work in the 34 states with either a federally-facilitated marketplace (FFM) or state consumer partnership marketplace (SPM)? In this blog, I noted that there were a few changes and several clarifications in the final CAC rules. The most striking change is that while all marketplaces must have a CAC program, they can choose to designate CAC entities, certify individual CACs or both. The FFM will only certify CAC entities  (which I’ll describe in detail below).

What are the responsibilities of individual CACs?

Certified application counselors must:

• Provide information about the full range of QPH options, Medicaid and CHIP
• Assist individuals in applying for coverage through a QHP in the marketplace and the insurance affordability programs
• Help facilitate enrollment in a QHP, Medicaid or CHIP
• Agree to serve consumers’ best interests
• Comply with privacy and security standards
• Disclose conflicts of interest
• Complete training and pass a certification exam

What are the differences between navigators and CACs?

Compared to navigators, CACs perform similar but more limited functions. Certified application counselors:

• Are not required (but may) do outreach
• Are not subject to the same stringent conflict of interest standards but must disclose potential conflicts of interests
• Do not have to meet cultural and linguistically appropriate standards (CLAS) beyond other obligations they already have but should refer people with limited English proficiency to navigators and other sources of assistance
• May provide reasonable accommodations for people with disabilities directly or refer them to other assistance resources.
• Do not have to refer consumers to ombudsman or other consumer assistance programs

How will CACs be selected to work in the 34 states with an FFM or SPM?

Although not specified in the regulations directly, the preamble states that the FFM will only designate organizations (not certify individuals directly), thereby delegating some oversight of individual CACs to the designated entity. Specifically, the FFM is looking for organizations that 1) have processes in place to screen staff and volunteers who are certified to ensure they will protect personal information; 2) engage in services that position them to help connect people to coverage; and 3) have experience providing social services to the community. The preamble goes on to say that the FFM will limit CAC entities to:

• Community Health Centers (such as FQHCs)
• Hospitals
• Health Care Providers
• Indian Health Services and Providers
• Ryan White HIV/AIDS providers
• Behavioral or mental health providers
• Agencies with experience providing social services such as SNAP outreach, energy assistance, or tax assistance, which are:
  • Non-federal government entities
  • 501(c) organizations
  • Local government agencies such as health departments, libraries

What are the responsibilities of CAC designated organizations?

An organization that applies for and has been designated by the Exchange for this work must ensure that those staff members and volunteers it certifies as application counselors meet and comply with the application counselor certification and other requirements. They will not be required to conduct training, as staff or volunteers who will be certified must complete the federal training and receive a passing grade on all components of the exam. And while federal training is enough to become certified, CAC entities may want to consider supplementing the federal training with more state-specific information as my colleagues and I suggested in our state supplemental training outline that’s linked to this blog.

What’s the process for becoming a federal CAC entity?

Organizations will need to apply; a sample application can be found here. Designated entities will also need to sign a written agreement (not yet released), assuring that they and their CACs will comply with:

• CAC regulations (45 CFR 155.225) including privacy and security standards
• Disclosure of potential conflicts of interest
• Successful training completion

What about CACs in the states that are running their Marketplaces?

That’s a good question. All exchanges are required to have a CAC program. However, states running their own marketplaces also have been able to create and fund other non-navigator assistance (aka in-person assisters) through federal exchange establishment grants (aka 1311(a) funds). If I were a betting woman, I’d bet that these states will be slower to launch a CAC program. Some may even decide to morph their in-person assistance program into a CAC program as the federal funding for in-person assistance runs out at the end of the first year of operation of the marketplace (2014). States can use their federal funds to establish the CAC program, including developing training, but may not fund CAC’s through federal funding.

So what about funding for CAC’s?

The FFM has indicated that it will NOT provide funding to CAC entities and as noted above federal establishment grants cannot be used for that purpose. However, the federal regulations clearly state that CAC entities may receive funding from other sources to support their CAC activities.

We’ll keep our eye out for further developments on Navigators and Certified Application Counselors, particularly in FFM states. So check back soon!