With roughly two months left to submit their health exchange plans to the feds, and a little over a year away from opening enrollment, states are confronting a key piece of the online insurance marketplaces that has so far received little attention: navigators, the insurance brokers and/or non-profit groups that will explain to the general public just what exactly an “exchange” is, anyway.
The navigators are “an absolute core value” of the marketplaces, says Christine Ferguson, executive director of the exchange in Rhode Island, a state that is further along in its planning than most. As conceived under the Affordable Care Act (ACA), navigators will be people’s first contact point with the exchange. They’ll explain how to apply and what insurance options are available, guiding (or “navigating”) consumers through the system. They could be insurance brokers or non-profit organizations: states that develop their own exchanges are responsible for selecting and contracting navigators.
More than 20 million people are expected to buy insurance through the exchanges, so the pressure will be on navigators to perform.
“They’ll be one of the key faces of the exchange,” Ferguson says. “They’re going to be one of the things that are tangible for people. They will make or break the experience that people have.”
But despite their importance, navigators have taken a backseat in the planning process to the technical infrastructure and eligibility systems that will be the backbone of the exchanges. “A lot of the pieces have not been landed on yet,” Ferguson says of her state’s own navigator development. Rhode Island is still engaging in preliminary talks with stakeholders and potential navigators—no official movement is imminent.
Some states, including California and Nevada, have already drafted recommendations about what their navigator programs will look like. States will need those kinds of details to secure conditional approval for their exchanges in January, according to final rules released by the U.S. Department of Health and Human Services (HHS) in August. Applications are due Nov. 16.
Ferguson says that states have to first finalize some of the elementary aspects of the exchanges before completing their work on navigators—for example, will small businesses choose plans or will their employees? If it’s the former, insurance brokers might make more sense as navigators because they already work with the small-group market. If it’s the latter, non-profits that are experienced with individual service might be a better fit.
“Until we make those decisions, deciding who you want to help consumers move through the system is a little bit premature,” says Ferguson.
The reality is that the exchanges require a lot of work. Almost everyone involved agrees that states have been forced to work under an aggressive timetable. While states are trying to develop the structure of a complex interactive website, coordinating with insurance providers and the federal government in a way they never have before, something that is effectively customer service hasn’t been a priority.
But states do seem to be wising up.
“States that are establishing their exchanges have been focusing on getting the basic infrastructure in place,” says Jennifer Tolbert, principal policy analyst at the Kaiser Family Foundation, who is tracking state navigator planning. “But we’re beginning to see now is a focus on the part of states on the navigator program, what it’s going to look like. They aren’t at the point of making concrete decisions, but states are realizing they need to figure out what they’re doing."
There is also a question of funding. The Affordable Care Act (ACA) expressly forbids states from using establishment grants (of which the Obama administration has already awarded more than $1 billion) to fund the navigators. It’s a conundrum for states with their own exchanges: all are relying on federal grants to pay for all of the exchange’s other functions through 2014, the first year of operation.
A commonly floated financing mechanism is charging insurers to sell their plans on the exchanges. But the navigators would presumably need to be up and running prior to the start of enrollment in October 2013—and that’s before any plans would be sold on the marketplaces. However they choose to resolve the issue, states need a concrete funding plan to receive exchange approval from HHS.
“States for the most part haven’t yet tackled the financing issue, and then there’s this timing issue,” Harris says. “They’ll have to come up with some funding somehow.”
Rhode Island is considering some of the common ideas to pay for its own navigators: either charging insurers to participate in the market or tacking an administrative fee onto premiums sold on the exchange. As for the timing problem, Ferguson says that the state is seeing great buy-in from its insurance companies about the exchange in general. She expects they would be amenable to an agreement that would allow the state to have navigators paid for and ready by October 2013, although no firm plans have been developed yet.
“There’s enough interest in Rhode Island, there’s a lot of synergy that makes the timing issue, while challenging and tricky, not as potentially contentious,” Ferguson says. “I have every reason to believe that after so much work has been done, we’ll be ready.”
State-run exchanges like Rhode Island’s, however, are the exception. At a tech conference in Baltimore last week, federal officials acknowledged that there would likely be 35 to 40 federal-run exchanges in 2014. That will likely leave the bulk of the navigator planning to the Obama administration, although states that opt for a partnership exchange can take over the navigator function.
According to guidance released by the U.S. Department of Health and Human Services (HHS), federal-run exchanges will award grants to eligible businesses and groups to serve the navigator function. As with state-run exchanges, the plan is for them to be funded, trained and open for business by October 2013.
Opponents of the ACA (more than half the states, going by those who joined the lawsuit to overturn it) remain skeptical that the feds will be able to implement navigators with so many states opting for the federal model. Tony Keck, South Carolina’s secretary of health and human services and an opponent to the overall concept of exchanges, says his office hasn’t heard about any on-the-ground planning by federal officials to contract navigators in his state. It’s a concern, he says, because although HHS is overseeing the navigator, they’re still serving Keck and his office’s constituents.
Federal officials declined to comment on planning efforts in specific states, instead referring to the official guidance on federal exchanges.
“This is a huge task. The feds have been conspicuously absent on the ground for somebody who needs to set up a huge system in less than a year,” Keck says. “Everybody is massively behind on this. But to pretend it’s not happening, I think, is dangerous for the feds. I just can’t get into their heads. I’m dumbfounded.”