What Is the Problem?

Alabama hospitals alone annually render uncompensated care worth more than $300,000,000. It tops $200,000,000 in Florida, $250,000,000 in Georgia and $150,000,000 in Mississippi. Much is attributable to patients with household incomes just a bit too high for Medicaid eligibility.  Many of those households had no option to accept affordable, job-based coverage. In part because the IRS has delayed until 2015 enforcement of the Affordable Care Act mandate that employers provide such coverage to their full time employees, this situation is likely to persist in 2014, when CMS will begin to reduce associated DSH payments, even in states that have rejected the government’s offer to fund most of the expense of expanding Medicaid eligibility to households with incomes up to 133% of the Federal Poverty Level (“FPL”).  


What is the Opportunity?

But many such patients will be able to obtain guaranteed issue, individual health insurance policies through the new Affordable Care Act Exchanges. Those with household incomes under 400% of the FPL will be eligible for federal premium and cost sharing subsidies to facilitate those purchases. Those purchases are designed to be made online and may be made when the patient seeks care, assisted by a provider employee or contractor. Insurance brokers, third party plan administrators and others with benefits administration experience are preparing to provide this service. Healthcare providers with sufficient resources can provide this service themselves and no special certification or license is needed.


When Will This Opportunity Be Available?

October 1, 2013 – March 31, 2014 will be the first open enrollment period for individual health insurance purchases through the Federally Facilitated Exchange serving Alabama, Florida, Georgia and Mississippi. Issuers of Exchange-listed policies must insure all applicants, regardless of health status, without exclusion of pre-existing conditions, on a modified community rating basis.  

After this open enrollment period closes for calendar year 2014 coverage, certain applicants may qualify for special enrollment opportunities, based on, for example, loss of affordable, job-based coverage, income reduction, or other relevant factors.

What Restrictions Does the ACA Impose on Enrollment Assistance?

Probably due to extensive publicity of federal Navigator grants and their cumbersome rules, many healthcare providers erroneously have assumed that they would have to seek and win a Navigator grant, then comply with those rules, in order to assist this group of patients with their Exchange applications. In fact, there are five categories of approved assistance personnel, with ACA regulations ranging from Navigator status (highly regulated) to unregistered and unregulated application assistants. The chart above lists major distinctions between them, with respect to the Federally Facilitated Exchange.

Health care providers can offer patients either certified or non-certified application assistants to assist them with open enrollment. If the Exchange certifies a provider to do so, then the provider may designate (and train and monitor, as required) its employees to be Certified Application Counselors. But nothing requires a provider or its employees to obtain that certification in order to provide patient enrollment assistance. Non-profit providers subject to the ACA’s Community Health Needs Assessment mandate may be able to take credit for such assistance efforts in their CHNA documentation.


What Do State Laws Require?

No enforceable state law may interfere with the operation of federal rules regarding Navigators, Non-Navigator Assistance Personnel, Certified Application Counselors or Authorized Representatives. For example, a state may not require that they be licensed insurance agents. But the ACA rules adopt by reference a number of generally applicable state laws (state guardianship orders and Medicaid application assistance certifications, for example) and permit states to provide funding for positions not federally funded.


What Should Providers Do NOW?

Providers who want to pursue this opportunity should obtain professional guidance regarding the applicable state and federal rules and then determine whether to provide enrollment assistance through existing staff, new hires, or enrollment assistance contractors.


Pepper Crutcher is a partner with Balch & Bingham in their Jackson, MS office. Crutcher is a frequent author and speaker on the ACA strategies and publishes an ACA blog found at www.acareview.com.