As we enter the fall of 2014, the window of opportunity to influence what benefits are required in Marketplace plans is opening. While the essential health benefits (EHB) package is already set for 2015, advocates have the opportunity to influence the EHB in the future. Although 2016 may seem far away, it is not when you consider the 2016 health insurance plan development timeline. The back-and-forth communications between insurers and departments of insurance will most likely start in the spring of 2015. The plan development timeline therefore pushes the advocacy timeline even earlier, shifting our attention to, well, now. So what should consumer health advocates be thinking about as they ponder a future EHB standard? Demand that decision makers get consumer input right.

EHB Take 1: Where did we end up?

In an interesting twist, the Department of Health and Human Services (HHS) delegated the task of EHB development to the states in response to the Institute of Medicine’s study of a potential EHB standard. In this “hot potato” hand off,  states suddenly became the central decision maker as to what benefits would be included in their state EHB – within some boundaries, of course, set by HHS. States selected (or defaulted) a benchmark or reference plan from a list of plan options (three largest small group plans, three largest state employee benefit plans, three largest federal employee benefit plans, and the largest commercial HMO). You can read a refresher here.

In the final tally, the majority of states opted to use the largest small group plan for the benchmark. Advocates were frustrated by this outcome and overwhelmed by the process, which gave them no transparent path to provide the consumer perspective. As we head into the next selection process, we remain concerned about some key substantive challenges. These include but are NOT limited to how plans set limits on numbers of visits within benefit categories; how anti-discrimination provisions are (or are not) enforced on the federal level; how habilitative care (a new important benefit category especially for children and people with substance use disorders) is defined at the state level; how pediatric services are represented across all benefit categories; and how women’s health services are included in plans. These challenges are outlined in greater detail here.

Common frustrations for advocates from the 2014 EHB process included little or no state engagement, a lack of transparency about plan details, and no clear way for consumers to weigh in. While there were efforts to hold forums and/or offer comments, this was not consistent across states and they were often not fruitful because forums evolved into loose feedback sessions without clear agendas or facilitation.

Over this past year, advocates have continued to monitor how the EHB is or is not working for consumers. This work, largely without access to needed data, relies on consumer feedback, appeals, complaints, and input from assisters and Navigators—all of which, when pieced together, tell us the story of EHB. However, without a clear and transparent process, it will be challenging to influence the EHB moving forward. It is time to re-engage with stakeholders and openly discuss how to have a robust and transparent review of the EHB and determine its future. Advocates in Florida are beginning to think about how to have more public conversations about their state’s EHB to avoid what happened in 2012, when Florida leaders failed to choose a benchmark plan and defaulted to the small group plan option. Their proactive approach advocating for transparency in reviewing EHB provides us an example of how other states can jumpstart engagement with stakeholders.

EHB Take 2: Florida advocates demand consumer input.

As we move into the next phase of planning, Florida advocates remind us that we need to return to our overarching principle around EHB: a transparent, consumer-driven process that results in a robust benefit package for all consumers. Consumer health advocates can play a vital role in elevating consumer experience and informing the future shape of EHB. Advocates must elevate consumer stories and identify effective vehicles to amplify them to decision makers at the state and federal levels.  

This past month, KidsWell Florida, led by Florida CHAIN, urged Florida Insurance Commissioner Kevin McCarty to use his authority to convene a workgroup tasked with reviewing and making recommendations on the state’s EHB package in time for the 2016 plan year. Advocates reached out to their coalition membership, encouraging them (and their partners) to sign on to a letter requesting that Commissioner McCarty play a proactive role reviewing its EHB package. Included in this request was a specific ask for consumer representation in a workgroup convened by the commissioner to review Florida’s EHB package.

While EHB differs among our 50 states, so do key concerns about EHB state level details. Florida advocates are particularly concerned about habilitative services. Advocates see a potential EHB workgroup as one vehicle to voice concerns about how habilitative services is defined and its impact on some populations – specifically, concerns about children’s access to critical health services. Given the possibility that any changes to EHB will require policy changes, Florida advocates are wasting no time engaging supporters and key stakeholders. So far, more than 25 Florida advocates, organizations and providers have signed on to the letter. And in late August, advocates from Florida CHAIN delivered and presented the letter to the commissioner at the Florida Health Insurance Advisory Board meeting.

Florida advocates’ approach provides one example of how state advocates can prioritize consumer issues as we all prepare for EHB: Take 2.  

On Monday, the Department of Health and Human Services (HHS) released Navigator grant recipients for the 2014 open enrollment period. In total, $60 million dollars were awarded to 90 organizations in the 27 states with Federally-facilitated Marketplaces and the seven states with Partnership Marketplaces. While the majority of awards went to the same grant recipients as 2013, there are also many new grantees for 2014. In particular, HHS selected new recipients based on their requirement that all Marketplaces must have at least one Navigator entity that is a community and consumer-focused nonprofit. Additionally, HHS chose new grantees who demonstrated a strong capacity to reach specific, hard-to-reach populations.

We welcome the 2014 grant recipient decisions because of their ability to help enrich the enrollment experience for consumers in several ways. First, awarding 2014 grants to many of the 2013 recipients will provide consumers with consistency and familiarity in Navigator programs. Newly-enrolled consumers can now turn to the same Navigators they worked with last year for assistance with renewing or switching their coverage. In addition, selecting new Navigator recipients who are uniquely-positioned to reach populations with high numbers of uninsured consumers will help ensure the remaining uninsured are aware of their coverage options and financial assistance opportunities.

We would also like to acknowledge the organizations who served as Navigators last year but will not participate in this year’s efforts. We know they worked tirelessly to bring the ACA to their communities, many of them in unique and creative ways. We hope they will continue to bring their dedication and new ideas to the table by participating in the broader outreach and education efforts in their states. To learn about the many innovative outreach, education and enrollment strategies employed by state-based consumer health advocates during the first open enrollment period, see our report: Connecting Consumers to Coverage: Mobilizing for Enrollment.

Overall, we feel the combination of new and old grant recipients will provide for a robust and effective enrollment assistance system during the next open enrollment period. By allowing both the newly-enrolled and remaining uninsured to learn about their options from community members they know and trust, they will be better able to enroll in or renew meaningful, affordable coverage.

The expanded non-profit hospital community benefit requirement under the Affordable Care Act creates an important opportunity for community-based organizations and advocates working with their local non-profit hospital to address unmet community health needs. As we previously wrote about  here, the IRS’ proposed rules for non-profit hospitals encourage them to address disparities in health and financial barriers to care. Addressing these barriers and challenges can be accomplished through hospital community benefit spending, and it all starts with the Community Health Needs Assessment (CHNA).

Through funding from the Kresge Foundation and the Surdna Foundation, our Hospital Accountability Project (HAP) has worked closely with three communities (Bronx, NY; Minneapolis, MN; and Portland, OR) over the past several months. The HAP team provided technical assistance to a lead organization in each community and designed and co-facilitated a pilot curriculum for building grassroots capacity and fostering engagement in local non-profit hospital community benefit activities, including the CHNA.

What did we learn from these pilot sites? We learned that most community groups do not have enough background and context about the importance of non-profit hospital community benefits. They were shocked to learn that in 2002, the Congress Joint Committee on Taxation estimated the value of community benefit to be more than $12 billion. That figure is likely much higher today. Furthermore, as community members considered hospitals in the role of anchor institutions, meaning that they are usually one of the biggest employers in their communities and they are unlikely to relocate, they gained new perspective on the reasons for and benefits of close collaboration. A community group partnering with hospitals not only makes sense for the issues they are tackling, but also because the ACA requires hospitals to engage with vulnerable communities, which are often already served by coalitions and organizations in the community.

The groups we worked with also wanted to understand the financial information related to hospital community benefit spending reported annually on the IRS Form 990 Schedule H. We are working with The Milken Institute School of Public Health at The George Washington University, through funding from the Robert Wood Johnson Foundation, to develop and test a Community Benefit Web Tool prototype. This prototype will provide easy access to community benefit investment information from the Schedule H form, and, when finalized, will enable users to compare hospital investments on the basis of factors such as geographic location, community economic status, and hospital characteristics, such as number of beds and teaching status.

Our experiences with these three pilot sites taught us a great deal about how to prepare communities to engage with their local hospital community benefits activities. For example, many non-profit hospitals have been conducting their first CHNAs, and grassroots groups want to “get in on the ground floor.” Grassroots groups can partner with and help hospitals compile data about their community’s unmet health needs, prioritize those needs, identify and implement strategies to address community needs, and evaluate the impact, as we discussed in our recent CHNA Health Equity blog.

As a result of this work, we developed and tested a pilot curriculum, collectively titled: Putting People First: Working with Hospitals to Address Community Health. As part of Putting People First, we have made some exciting new resources available to help advocates and community-based organizations understand what community benefit is, how they can engage in the CHNA process, and how to partner with local non-profit hospitals to address some community needs that might not ordinarily be thought of as leading to good health outcomes. This includes workforce development, housing and economic development activities. We discussed these opportunities more in depth in our December 2013 webinar with the Democracy Collaborative and in our presentation What it Takes to be Healthy.

We look forward to sharing additional resources and tools with you, as they are developed. In an effort to share and learn more about how you are getting involved in your local non-profit hospitals’ community benefit planning process, we will be hosting a learning community call on September 26, 2014 from 1:00-2:00pm EDT. If you would like to participate, please click here.

For more information about the Putting People First curriculum and resources, please contact Michele Craig, Hospital Accountability Project Outreach and Training Coordinator at mcraig@communitycatalyst.org.

Almost two decades ago, the National Association of Insurance Commissioners (NAIC) adopted a model state law to regulate the adequacy of health plan provider networks. The model law contained a general standard that services be accessible without “unreasonable delay.” Seventeen years later, the federal government adopted this as the standard for qualified health plans (QHPs) in the new health insurance Marketplaces created under the Affordable Care Act (ACA).

Why update the model law now?

The NAIC’s model law – as reflected in federal and most state rules for Marketplace QHPs – did little to curb insurers’ rush to narrow their provider networks in the plans they sold for 2014. Fully 48 percent of QHPs came into the Marketplaces with narrow networks. The media published stories about consumers who were upset that physicians and hospitals they were used to seeing were no longer in their plan networks. Politicians weighed in, asking for more robust oversight of networks. The truth is, leading up to 2014, very few states had adopted the NAIC’s model law and fewer still did any proactive regulation to ensure networks were adequate.

Into this regulatory vacuum stepped the federal government, which indicated in March that it will conduct a review of network adequacy for 2015 QHPs, and signaled a future rulemaking in which they would adopt a tougher standard, perhaps modeled on the regulation of Medicare Advantage plans. This got the attention of state regulators, who immediately fired off a letter to HHS, asserting that the regulation of network adequacy was best handled by the states. Yet they also acknowledged that the NAIC model law needs to be updated to reflect changes in health plans and in the health marketplace, which has evolved since the 1990s to include an alphabet soup of plan network designs.

What is the process and timing for updating the model law?

Early in 2014, the NAIC created the Network Adequacy Model Review Subgroup, composed of state insurance regulators, to revise the model law. The subgroup’s first step was to invite various stakeholders to provide oral testimony. On separate conference calls the subgroup heard from provider groups, consumer advocates, insurance companies and accreditation organizations. The subgroup then asked these groups to provide written suggestions for updates to the model, which staff compiled into a master chart. The NAIC consumer representatives submitted comments that focused on (1) a more robust, quantifiable standard for network adequacy, (2) better oversight of plan compliance, (3) an end to balance billing by out-of-network providers working in in-network facilities, and (4) greater transparency of provider networks.

The subgroup is now engaged in a painstaking series of weekly conference calls, going line-by-line through the model law and attempting to achieve consensus on revisions. NAIC staff estimate that, so far, an average of 100 people have participated on each call, including consumer advocates, provider groups and insurers, as well as state officials. Although progress is slow (on the first call it took 20 minutes to revise the law’s title), the subgroup hopes to complete its revisions before the next NAIC national meeting, scheduled for mid-November in Washington, DC.

Why is this important and how can consumer advocates play a role?

NAIC’s model laws frequently serve as the template for state regulation of insurance products, and many insurance departments and legislatures will look first to NAIC’s language before drafting any network adequacy rules in their state. But it may be difficult to achieve consensus, with many stakeholders resisting stricter standards, more proactive oversight and transparency of plan networks. Ultimately, sometime this fall, insurance commissioners will need to vote on changes to the model, and advocates will need to weigh in to encourage them to include the NAIC consumer representatives’ key recommendations.

-- Sabrina Corlette, Senior Research Fellow & Project Director
Georgetown University's Center on Health Insurance Reforms 

With the November elections looming, many organizations that we wouldn’t normally think of as hubs for engaging voters are playing an important role in ensuring eligible citizens are able to register. Community health centers, trusted spaces for obtaining health care, are among those entering the realm of voter registration. And their work in this area makes perfect sense. Low-income individuals are some of the most frequent clients of community health centers, all too often having been ostracized by other health care providers in their communities because they are uninsured. These health care clinics are well positioned to empower many of their current clientele who come in seeking medical care. Additionally, low-income individuals are disproportionately less likely to  be registered to vote, similarly disempowered from civic engagement because of the belief that the systems in place fail to support their families’ and communities’ needs.

Given this overlap, Nonprofit VOTE has long focused on advising community health centers as they integrate voter registration into their primary goals and responsibilities. With many health centers focused on greater community engagement, Nonprofit VOTE aims to help them recognize voter registration as a tool for empowering low-income consumers. By increasing the number of registered voters, communities can better advocate for their elected officials to respond to their needs—be it changes at the statewide or local level. With local health clinics facilitating the completion of a voter registration form, consumers are empowered to walk out of a health center with their health issues attended to, as well as the tools to participate in the next election.

Community health centers can incorporate voter registration into all aspects of their work, beginning with training and educating staff on the importance of registration. Nonprofit VOTE found that when staff members are informed regarding the direct positive impacts of voter registration on community health, they’re more invested in sharing these benefits among clients, as well as their own family and friends. Getting people registered to vote, and consequently starting a dialogue on the health disparities entrenched by social determinants of health, is a huge step forward in raising awareness on community health needs. These conversations are important in trying to understand complex health issues that aren’t limited to a single household, but are common health problems in the community. Becoming a registered voter can transform an individual’s perception of what she can do to impact her own community, which can, in turn, lead to people taking better care of themselves and their neighbors.

Rather than remaining on the sidelines, community health centers can actively integrate consumers into a valuable set of data on registered voters that will elicit the attention of their policymakers. A recent Nonprofit Vote webinar reiterated that high visibility—such as posters and distribution of  “I Pledge to Vote” buttons or stickers—and enthusiasm were both important to engaging consumers in voter registration opportunities.  Nonprofit Vote emphasized that a great opportunity to synthesize voter registration in health centers exists by tying it into outreach, education and enrollment efforts for health insurance coverage into Medicaid and Marketplaces. Simply by making “the ask,” staff members could inquire, just as they do about health insurance status, whether patients were interested in registering to vote, and subsequently provide the materials to do so. Through reimagining the different ways that health centers can connect consumers to their communities, Nonprofit Vote shares their tips on how these centers can help create a stronger safety net for vulnerable populations.

For more information on how to register voters in your area or work in collaboration with your community health centers, please feel free to read through the slideshow from the webinar or visit http://communityhealthvote.net/blog/.

-- Jessica Liao, Health Equity Intern