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Consumer Assistance Programs: A Vital Piece of the Health Care Reform Puzzle

Priya Mendon, Director, NYC Managed Care Consumer Assistance Program (NYC MCCAP)Families USA: January 30, 2010

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Outline of Presentation

Federal health reform and consumer assistance programso Filling the gap for families and communities perplexed and overwhelmed

by health care reform

o A variety of models exist in the states

Discussion: How consumer assistance can enhance federal health reform proposals

Case Study: CSS’s consumer assistance model

Implementing a consumer assistance program in your state

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Health Care Reform and

Consumer Assistance Programs

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The Issue: Federal Health Care Reform May Engender a Health System Shock Federal health reform is confusing. Consumer assistance

programs can fulfill two vital functions: o Defense of reform billo Assistance implementing complex reform on the ground

Consumers will need help understanding how to:o Use the health insurance exchange, access subsidies, exemptions, and fines

under individual mandate?o Address capacity and navigation issues raised by their enrollment into new

providers and insurers?

Vulnerable communities will need extra help:o People with disabilities, special needs (HIV/AIDS), chronic illnesses; elderly

consumers; and culturally and linguistically vulnerable populations, etc…

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Consumer Assistance Programs Help Patients Successfully Interact with Every Level of the Health Care System

Pharmacies

Doctors/Providers

InsurancePlans

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Address patients’ needs:• Selecting a plan • Primary care • Pharmacy & DME• Specialty care• Referrals• Eligibility & renewal• Billing problems• Navigation assistance

Hospitals

Health Plan

Recommend Policy Improvements

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Four Basic Consumer Assistance Models in Use Across the Nation Localized Capacity Building Modelo Community based organization networko Operates a centralized helpline from the network hubo Trains and conducts community outreach o In NY, helped transition of 2.8 million from fee-for-service to managed care

Hotline Modelo Operates a hotline that serves consumers on a variety of health care

related issues over the phoneo Includes IT and electronic software capacity to do enrollmentso MA program helped with implementing reform (call volume increased by

400%)

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Four Basic Consumer Assistance Models in Use Across the Nation (cont’d) Legal Services Model

o Provides legal expertise to consumers on health care-related issueso Helps consumers establish and keep coverageo Helps navigate and access insurance benefits o CA: Health Consumer Alliance run through 9 legal services programs

& two statewide support centers

Government Ombudsprogram Modelo Government run program that assists with problems regarding health

care and insurance optionso Operates a helpline that serves consumers in the Stateo DC newly started up; CT Office of the Healthcare Advocate

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Consumer Assistance in Federal Reform

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Consumer Assistance in Current Federal Reform Proposals by Leadership

Senate Bill #3590 (§§1002, 1311): o 2010: Initial $30 million for states to create Consumer Assistance

Programs or Ombudsman in first year Money granted to States (can keep or re-grant)

o 2014: Navigators established by Exchanges to assist consumers with enrollment (includes community and consumer-focused nonprofit organizations)

House Bill #3962 (§§ 244,305):o Federal Ombudsman ensure geographic, cultural & linguistic access;

assist with complaints, grievances, enrollmento Consumer Assistance, toll-free hotline, internet, complaints, enrollment;

may contract with “other entities” to perform these services

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Case Study:CSS’s Consumer Assistance

Program

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CSS’s Managed Care Consumer Assistance Program

Subcontracted with nearly 30 CBOs over past 10 years o Assists clients with obtaining, using, and keeping public and private health

insuranceo Provides navigational assistanceo Served over 130,000 clients to dateo Policy feedback loop (sentinel function) for stakeholders/policy makers

Links patients to providers and plans – improving health care quality and outcomes

Funding o $4 million/year through NY City Council/NYC DOHo NYSOFA funding for Medicare work

Reaches diverse, hard to serve populations11

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What Services Does MCCAP Provide?

MCCAP provides direct services in four main ways:o Education: Informs and educates health consumers and

advocates about health care programs and services

o Counseling: Provides advice and support to consumers on a variety of health-related issues

o Navigation: Helps empower consumers to be able to access their health coverage and be their own advocates

o Sentinel Function: Provides policy feedback to policymakers and other stakeholders

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Disseminates Information in An Accessible Manner

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NYC MCCAP Consumers by Language Spoken

NYC MCCAP Consumers by Income

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Percent of NYC MCCAP Consumers by Type of Insurance

NYC MCCAP Consumer Issues

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* Other includes Union and Veteran.

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Implementing a Consumer Assistance Program

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Steps to Consider

Start-up funding Feasibility study Identification of an operational model (services provided, contractual

issues) Materials and training development Outreach/education Data collection system and reporting Quality assurance Evaluation Policy feedback mechanism Sustainability: access long-term private or public sources of funds

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Contact NYC MCCAP

Priya Mendon: 212-614-5331; pmendon@cssny.orgHelpline: 212-614-5400; mccap@cssny.orgWebsite: www.nycmccap.org

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