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Certified Counselors May Help Uninsured Enroll in Exchanges in States Hostile to Overhaul

By John Reichard, CQ HealthBeat Editor

July 16, 2013 -- There’s little reason to assume that states whose leaders opposed passage of the health care law are now going to do much to promote the availability of coverage for the uninsured when exchanges open in the fall.

Nor is there much evidence officials in those states will do much to help guide consumers through what likely will be a complex process of weighing coverage options, applying for tax credits to cut premium costs, and filling out applications. And federal funds to promote the law will be meager in those states.

But a category of helpers called “certified application counselors” (CACs), many of whom already have a track record of providing help to the uninsured, got a boost under a final regulation the Obama administration has issued.

Certified application counselors could provide the uninsured real assistance in the 34 states that declined to set up their own exchanges because they didn’t want to cooperate with the health law (PL 111-148, PL 111-152). Released July 12, the final rule requires that all states have certified application counselor programs, whether they rely on the federal exchange in whole or in part, or operate their own exchange.

The federal exchange and state exchanges will certify organizations as certified application counselors. Those organizations can, in turn, certify their own employees or get volunteers to serve as CACs, Washington and Lee University Law School Professor Timothy Jost said in a recent blog post on the Health Affairs website.

Certified individuals or organizations must agree to comply with certain requirements in the final regulation, and certified organizations must oversee compliance by their employees or volunteers.

The federal exchange can certify just organizations, while state exchanges can certify both organizations and individuals, Jost said. Others can help exchange customers enroll, but they can’t present themselves as being certified to perform that function.

Diverse Group Will Counsel
The rule lists a number of organizations that can serve as certified application counselors: hospitals; community health centers; behavioral and mental health providers and other caregivers; nonprofit social service agencies; and local governmental agencies, such as health departments or libraries.

“Medicaid-certified application counselor organizations are explicitly listed as organizations that may serve as exchange CACs,” Jost wrote. He noted that the Medicaid counselor program has operated successfully in many states.

Tricia Brooks, a professor at the Georgetown University Center for Children and Families said in a blog post earlier this year that “using community-based organizations, including community health centers and hospitals, to assist with Medicaid and [Children's Health Insurance Program] enrollment has been a core element of successful state strategies in maximizing children’s health coverage over the years.”

The counselors will help applicants figure out if they are eligible for coverage and tax credits, assist them with enrollment, while providing information in an impartial way without guiding them into a particular plan.

The federal exchange will list on its website all organizations considered certified application counselors,

Brooks said the counselors could have an impact in states served by the federal exchange as well as in other states. “Although the final regulations do not require CACs to perform outreach duties, there is little question that many will do so,” she said in an email message Tuesday. “CACs have the potential to create awareness at the local level, so the depth and breadth of their work can be far-reaching and this adds much value to effort to connect people to coverage.

“The types of organizations that will be CACs in [federal-exchange] states are likely to be either mission-driven to help low-income families access services that will improve their health and economic security or have an inherent interest in getting more people insured as health care providers do or both,” she said.

But “some organizations will be more effective than others.”

State legislation could still be an obstacle to the counselor programs, she said. It “could have a chilling effect on participation and it will be really important for the federal government to ensure that misguided state legislation does not interfere with CACs helping people get coverage,” she said.

Still, she predicted that “CACs are likely to be widely available and certainly in every state. Whether there will be a CAC in every community depends on the extent to which they are recruited or encouraged to join the effort.”

The Federation of American Hospitals has expressed strong interest in the certified application counselor program. And an American Hospital Association spokeswoman said that many hospitals are likely to provide application assistance but said she didn’t know how many would see CAC status.

Brooks said “I would certainly expect all nonprofit and rural hospitals to participate. That was my experience in New Hampshire.” Brooks ran the Children’s Health Insurance Program (CHIP) in the state and did outreach and application assistance support for both Medicaid and CHIP.

But with hospitals and health centers expected to become certified application counselors, one major question is whether the people they sign up for coverage will contribute to too many bad risks coming into insurance exchanges to keep coverage affordable in the long run.
Brooks said “the challenge is to be successful in launching a multi-faceted and comprehensive outreach and marketing campaign that brings in healthy people, as well as those with higher needs.” Providing young people with tax credits to help pay for coverage will go a long way in that regard, she said.

John Reichard can be reached at [email protected].

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