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Thursday, February 20, 2014

Consumer Assistance Programs Lose Federal Funding Just When A New Group of Consumers Need Their Services

When consumers encounter problems with their health insurance after enrolling (many for the first time), they need access to unbiased experts to answer their questions. Although federally funded consumer assistance programs do just that, their continued funding is in peril. 

How big is the problem? 

Only 12 states plus the District of Columbia, the Virgin Islands, and the Northern Mariana Islands still have federally funded programs—down from 33 states plus the District of Columbia, Puerto Rico, the Virgin Islands, Guam, and American Samoa—and their grants will soon expire. This drop in funding comes at a bad time—enrollment is starting to pick up steam as consumers rush to enroll in health plans before the open enrollment window closes on March 31. 

Evidence is mounting that lack of funding is causing real problems for consumers, many of whom are in new plans or still need help resolving their enrollment-related problems, a point we emphasized in Tuesday’s article in Politico. 

The irony in all of this is that the Affordable Care Act specifically authorizes funding for consumer assistance programs (also called health care ombudsman programs). And though the federal government provided an initial $30 million for consumer assistance in 2010, it has not given additional funds since 2012. 

How consumer assistance programs help health care consumers understand their health insurance

The Affordable Care Act charges consumer assistance programs with educating consumers about their health insurance rights and responsibilities, assisting with health insurance appeals, and helping resolve problems with premium tax credits. 

The issues have a real human impact: 

  • A family applies for marketplace coverage, but their enrollment is not processed quickly enough to prevent them from incurring medical expenses on their own; once they do enroll, they need help getting coverage and financial assistance for their new premiums and previously incurred expenses. 
  • A person loses her job and wants advice about whether to take COBRA or whether she can get financial assistance to buy a new plan in the health insurance marketplace. 
  • A person with multiple sclerosis wants help appealing when his health plan tells him that the medicine he needs is experimental, even though his doctor recommended this drug for his condition.

Navigators must be able to make referrals to consumer assistance programs for complex problems 

Navigators can also help with health insurance enrollment. This help, while highly valuable, is mainly limited to assisting consumers with enrollment, and correcting problems related to the eligibility or amount of financial assistance available to consumers. 

Other issues, which are sometimes more complex, are referred to consumer assistance programs. And if those programs aren’t funded, these consumer problems are not addressed. 
In fact, consumer assistance programs are such an important resource that health plans are required to list them on notices to consumers about how to appeal the insurer’s decision.

Federal government should renew funding to strengthen consumer assistance programs 

The Affordable Care Act does a good job outlining the responsibilities of consumer assistance programs, but not as good a job in assuring funding. The law provided $30 million of funding the first year, and authorized “further appropriations as needed.” In 2010, 33 states and the District of Columbia, Puerto Rico, the Virgin Islands, Guam, and American Samoa established or expanded consumer assistance programs with federal grants (there was little assistance for the remaining states, however). This year, only 12 states plus the District of Columbia, the Virgin Islands, and the Northern Mariana Islands continue to operate their consumer assistance programs with federal grants.   

Consumer assistance programs will be critical in 2014 as enrollment continues to grow

Elisabeth Benjamin, Vice President of Health Initiatives at the Community Service Society of New York, says it best: “The loss of the federal funding has been a serious problem for consumers because it’s not fair to enroll people into coverage and not have the support people really need to be able to use it. It’s a path to nowhere.”

This year, many consumers have health insurance for the first time. Many are in new health plans and are just learning how to use them. So, in addition to solving problems related to health insurance, consumer assistance programs are equally critical to helping consumers learn how to use their insurance effectively. 

The Department of Health and Human Services should ensure that expert helpers are available to fill this critical component of the consumer’s experience in the health insurance marketplace.