Using community-based organizations, including community health centers and hospitals, to assist with Medicaid and CHIP enrollment has been a core element of successful state strategies in maximizing children’s health coverage over the years. Based on the latest 50-state survey on Medicaid and CHIP eligibility and enrollment, 23 states provided funding to these key community partners in 2012, while other states provide training and support without financial compensation. So we were pleased that the latest proposed Medicaid and Exchange regulations build on the existing infrastructure in many states by creating another category of assister – Certified Application Counselors (CACs) – to connect consumers to the ACA’s expanded coverage options.

While a welcomed addition to the mix of assisters, the new proposed CAC program adds to outstanding questions about navigators and in-person assisters, as well as the supply and demand for consumer assistance, as we speed toward open enrollment. In this first of a four-part blog series on consumer assistance, we compare CACs in Medicaid, CHIP and the Exchange and note similarities to other types of assisters. In part two, we’ll highlight seven ways to strengthen the proposed CAC program. The third blog asks where oh where did the in-person assisters go? And in the series finale, we’ll explore that while assister types abound, will assisters be plentiful enough?

What will certified application assisters do? The proposed rules suggest that states could have a single certification program and accept application counselors certified by another program. However, there are differences in how the regulations describe what CACs will do in the exchange vs. Medicaid/CHIP. The Medicaid/CHIP rules describe assistance as “providing information on insurance affordability programs and coverage options, helping individuals complete an application or renewal, gathering required documentation, submitting applications and renewals to the agency, interacting with the agency on the status of such applications and renewals, assisting individuals with responding to any requests from the agency, and managing their case between the eligibility determination and regularly scheduled renewals.” Furthermore, CACs may be certified to do one, some or all of the permitted assistance activities.

On the Exchange side, the preamble indicates that CACs will “in essence, provide the same core application assistance service that is also available directly through the Exchange, as well as through navigators and licensed agents and brokers.” So CACs will do what navigators do, right? That is, they conduct outreach; maintain experience in eligibility, enrollment and all insurance affordability program specifications; provide information and services in a fair, impartial and culturally competent manner; and facilitate selection of a QHP. Generally speaking we’ve been told that in-person assisters (IPAs) are a lot like navigators. But what little we know about IPAs is largely based on what we’ve heard since there is a lack of written guidance relating to them. We do know, however, that unlike navigators, IPAs are not required by law but also not prohibited from being funded through exchange establishment grants.

Who can serve as certified application counselors? The Medicaid proposed rule mentions “trusted community-based organizations, providers, or other organizations with expertise in social service programs.” The Exchange will certify “employees and volunteers of organizations, which may include health care providers and entities, as well as community-based organizations, among other organizations.” While many of these same organizations could be navigators, there are more defined navigator types such as labor unions and chambers of commerce.

Why certify application counselors? Many of the organizations that may serve as CACs are likely to offer application assistance, with or without certification. Thus, a well-designed certification program will ensure appropriate training; require compliance with privacy and confidentiality requirements (which is critical for accessing IRS and other eligibility-related data); and enable important oversight to ensure that consumers are protected and that their best interests are served. Additionally, the CAC program provides a path for small organizations to provide assistance that may not chose to apply for a navigator grant. Last but not least, certification will give consumers a sense of confidence in working with a CAC, in essence a good housekeeping seal of approval.

How do CACs in Medicaid/CHIP compare to the Exchange and with other assister types? Based on the proposed regulations, we’ve identified these key differences and similarities:

• CAC programs in Medicaid/CHIP agencies are a state option. In the Exchange, they are required.
• The Exchange must accept any CACs that Medicaid/CHIP certifies but the reverse is not required.
• CACs are authorized and registered by Medicaid, while CACs register with the exchange, suggesting that Medicaid agencies can be selective in choosing CACs while Exchanges must accept anyone who registers, gets trained and signs an agreement.
• If Medicaid opts to have a CAC program, it must provide a web portal for CACs to use. There is no corresponding requirement in the Exchange.
• Requirements for CAC cultural and linguistic competency and accessibility are generally vague and much less defined than requirements for navigators.
• While state laws may apply conflict of interest standards to CACs, the federal regulations do not disqualify an entity with a conflict of interest from being certified, as is required of navigators. The regulations do require that relationships with QHPs and conflicts of interest be disclosed.
• The rule omits any discussion of funding CACs in Medicaid/CHIP, although as noted earlier a number of states do so. However, the preamble states that CACs are not funded through the Exchange, through grants or directly.

We continue to press for additional clarification on navigators and in-person assisters, and hope that the final rule on CACs will answer some of the outstanding questions. In the meantime, comments on the proposed CAC program are due on February 21. Our next blog will explore seven steps to strengthen the proposed CAC program, just in time to fuel your thinking if you plan to provide feedback to CMS.