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A slew of new state laws and regulations on the Navigator program — along with increased scrutiny from a GOP-led congressional oversight committee — could have a “chilling effect” on local operators of the programs that are designed to help people understand their options on the insurance exchanges.
Many of the state and federal actions come on the heels of HHS’s awarding of $67 million in grants to 105 Navigator applicants in August.
Supporters of the Affordable Care Act (ACA) describe the restrictions on Navigators as “intimidation” by health reform critics, and contend it could dampen enrollment in some health plans on the exchange.
Among the recent actions, Republican members of the House Energy and Commerce Committee asked Navigator grant recipients to respond to a series of questions, including to account for any discussions they may have had with insurers about the insurer supporting the Navigators or the Navigators promoting the insurers’ plans.
Faced with this and other state-level scrutiny, some of the Navigators have simply returned the money.
Cardon Outreach, an organization that provides Medicaid outreach services, became the latest entity to back out of its grant to operate a Navigator program. On Sept. 13, the organization returned more than $800,000 citing concerns over the emerging federal and state regulatory scrutiny. Cardon Outreach was set to operate Navigator programs in four states: Florida, Oklahoma, Pennsylvania and Utah.
“When we originally heard about the Navigator grant opportunity and applied for it, we felt like it was something we could perform successfully,” Charles Kable, chief legal officer at Cardon Outreach, tells HRW. “For the better part of 20 years, our business has been providing outreach and enrollment assistance to folks for Medicaid coverage across the U.S.”
But Kable asserts the program stoked “state sovereignty concerns,” and prompted new regulations that placed unforeseen limitations on what Navigators can do within states.
“That changed significantly the scope of the project from our perspective,” he says. “We didn’t bank on committing a significant percentage of my time, for example, to monitoring compliance for this program in addition to the standard, traditional compliance elements that we have in place. This was new.”
At least 17 states with federally facilitated exchanges have enacted laws that impose state-specific requirements on Navigators, according to a recent report by the Commonwealth Fund, a nonprofit health care research group.
Most of the laws require Navigators to obtain state licensure or approval before operating in the state. Many establish training requirements, require criminal background checks, and authorize disciplinary measures against Navigators, according to the report, while some of the laws also require Navigators to secure financial protection against wrongdoing.
Kable says he expects these kinds of regulations will continue in the short term. “And from my view, that was too much of an uncertainty for us to move forward,” he says. “It would be one thing if it was nose to the grindstone, do the job. But these regulations change that significantly.”
Another group that dropped its Navigator grant was the Cincinnati Children’s Hospital Medical Center, which returned more than $124,400 to the feds.
“Our decision was based on a recently enacted law in Ohio that excludes any organization or person that receives payments from a health care payer for any purpose from being designated as a Navigator,” hospital spokesperson Terry Loftus tells HRW. “We already have a comprehensive financial counseling office here at Cincinnati Children’s that assists children who are eligible to enroll for Medicaid. This will continue to be a priority for us.”
Supporters Claim Regulations Are ‘Intimidation’
Similarly, nonprofit West Virginia Parent Training and Information Inc. recently returned its $365,000 Navigator grant after state Attorney General Patrick Morrisey (R) directed the nonprofit group to answer 26 questions about the group’s personnel and hiring practices. Sen. Jay Rockefeller (D-W.Va.)
slammed Morrisey after the nonprofit withdrew. “Our attorney general, who hates all of this Affordable Health Care Act, has intimidated one of the groups, so they’ve withdrawn, and it’s really something that should be investigated,” Rockefeller said, according to a Sept. 8 story in the Charleston Sunday Gazette-Mail.
In a prepared statement, Morrisey asserted that the Navigators, many of whom are seasonal workers without a background in health care, will not understand thousands of pages of regulations after only 20 hours of online training. “Why move forward with this navigator program before it is fully vetted? How will the public know the difference between an Obamacare navigator and a scammer?” he said.
But a senior Obama administration official at a Sept. 18 White House press conference dismissed concerns over the program. “Let’s put this in context,” said the official, who asked not to be identified. “These are almost all long-standing, long-serving patient information counselors that have been utilized not just for this law, but in other contexts as well, in Medicare and other places,” he said.
“They are committed to providing straight-up information,” the official continued. “They’re contracted very, very carefully. They have rigorously gone through training. If you are a Navigator grantee, you are required to comply with security standards that have been outlined in their contract.” The official contended the ACA critics are using the Navigators as targets, “to try and intimidate them to not provide these services, which I think is antithetical to anything we’ve seen ever in the past.”
One health reform observer says the trend of Navigators dropping out is concerning. Groups might be prompted to do so “because of the state’s eligibility requirements or because of the chilling effect that some of these state laws could have,” explains Katie Keith, a former research professor at Georgetown University and a co-author of the Commonwealth Fund report on Navigators.
“The concern is that would-be Navigators, especially smaller organizations, might conclude that these types of requirements are too high of a burden to meet and decline to participate,” she tells HRW.
House Panel Asks for Detailed Information
For their part, Republicans on Capitol Hill say they want to ensure that privacy and security issues with the Navigators are addressed. There concerns were expressed in an Aug. 29 letter by GOP members of the House Committee on Energy and Commerce to each Navigator awardee. The letter requested the grantees provide detailed responses by Sept. 13 to six multifaceted questions. These included:
The head of health care advocacy group Families USA was even blunter.
“There is no question that these efforts are largely prompted by a desire to obstruct the implementation of the Affordable Care Act, so that fewer people would get enrolled than otherwise would get enrolled,” Executive Director Ron Pollack tells HRW. “In a number of states, they are requiring even volunteers to pay a significant amount of money before they provide any advice to neighbors or friends or others who are trying to figure out what type of plan they may enroll in, or information about the subsidies.”
Pollack says it’s hard to quantify the impact of these efforts. “It clearly has had some dampening impact in some places. I think ultimately it’s not going to have a huge impact because as more and more people learn about…others who are comparably situated as they are [and understand] what they are getting, they will understand that it’s a really good thing to get enrolled in coverage,” he says.
Keith agrees the state laws are unlikely to sink the Navigator’s outreach and enrollment efforts. “These laws might make it more difficult for Navigators to accomplish their task, but these organizations are committed to the populations they serve,” she says.
Florida Grantee Moves Ahead
Everything appears on track for the University of South Florida’s (USF) Navigator program. USF received $4.2 million, the second-largest Navigator grant, to oversee a consortium of 10 organizations in all but three counties across the state. The grant will be administered by The Florida Covering Kids & Families program at the USF Chiles Center for Healthy Mothers and Babies.
Jodi Ray, project director of the USF program, says she has not identified any state-based issues that would hinder her efforts.
“The Navigators are getting trained, pulling together key stakeholders and reaching out to the communities with information,” Ray tells HRW. She says the kind of assistance that Navigators can provide is key to ensuring that people get enrolled.
“Facilitated enrollment keeps people from getting lost along the way to completing an application,” Rays says. “It’s overwhelmingly successful in ensuring that people who started the process actually completed the application and obtained health insurance.”
Many of the state and federal actions come on the heels of HHS’s awarding of $67 million in grants to 105 Navigator applicants in August.
Supporters of the Affordable Care Act (ACA) describe the restrictions on Navigators as “intimidation” by health reform critics, and contend it could dampen enrollment in some health plans on the exchange.
Among the recent actions, Republican members of the House Energy and Commerce Committee asked Navigator grant recipients to respond to a series of questions, including to account for any discussions they may have had with insurers about the insurer supporting the Navigators or the Navigators promoting the insurers’ plans.
Faced with this and other state-level scrutiny, some of the Navigators have simply returned the money.
Cardon Outreach, an organization that provides Medicaid outreach services, became the latest entity to back out of its grant to operate a Navigator program. On Sept. 13, the organization returned more than $800,000 citing concerns over the emerging federal and state regulatory scrutiny. Cardon Outreach was set to operate Navigator programs in four states: Florida, Oklahoma, Pennsylvania and Utah.
“When we originally heard about the Navigator grant opportunity and applied for it, we felt like it was something we could perform successfully,” Charles Kable, chief legal officer at Cardon Outreach, tells HRW. “For the better part of 20 years, our business has been providing outreach and enrollment assistance to folks for Medicaid coverage across the U.S.”
But Kable asserts the program stoked “state sovereignty concerns,” and prompted new regulations that placed unforeseen limitations on what Navigators can do within states.
“That changed significantly the scope of the project from our perspective,” he says. “We didn’t bank on committing a significant percentage of my time, for example, to monitoring compliance for this program in addition to the standard, traditional compliance elements that we have in place. This was new.”
At least 17 states with federally facilitated exchanges have enacted laws that impose state-specific requirements on Navigators, according to a recent report by the Commonwealth Fund, a nonprofit health care research group.
Most of the laws require Navigators to obtain state licensure or approval before operating in the state. Many establish training requirements, require criminal background checks, and authorize disciplinary measures against Navigators, according to the report, while some of the laws also require Navigators to secure financial protection against wrongdoing.
Kable says he expects these kinds of regulations will continue in the short term. “And from my view, that was too much of an uncertainty for us to move forward,” he says. “It would be one thing if it was nose to the grindstone, do the job. But these regulations change that significantly.”
Another group that dropped its Navigator grant was the Cincinnati Children’s Hospital Medical Center, which returned more than $124,400 to the feds.
“Our decision was based on a recently enacted law in Ohio that excludes any organization or person that receives payments from a health care payer for any purpose from being designated as a Navigator,” hospital spokesperson Terry Loftus tells HRW. “We already have a comprehensive financial counseling office here at Cincinnati Children’s that assists children who are eligible to enroll for Medicaid. This will continue to be a priority for us.”
Supporters Claim Regulations Are ‘Intimidation’
Similarly, nonprofit West Virginia Parent Training and Information Inc. recently returned its $365,000 Navigator grant after state Attorney General Patrick Morrisey (R) directed the nonprofit group to answer 26 questions about the group’s personnel and hiring practices. Sen. Jay Rockefeller (D-W.Va.)
slammed Morrisey after the nonprofit withdrew. “Our attorney general, who hates all of this Affordable Health Care Act, has intimidated one of the groups, so they’ve withdrawn, and it’s really something that should be investigated,” Rockefeller said, according to a Sept. 8 story in the Charleston Sunday Gazette-Mail.
In a prepared statement, Morrisey asserted that the Navigators, many of whom are seasonal workers without a background in health care, will not understand thousands of pages of regulations after only 20 hours of online training. “Why move forward with this navigator program before it is fully vetted? How will the public know the difference between an Obamacare navigator and a scammer?” he said.
But a senior Obama administration official at a Sept. 18 White House press conference dismissed concerns over the program. “Let’s put this in context,” said the official, who asked not to be identified. “These are almost all long-standing, long-serving patient information counselors that have been utilized not just for this law, but in other contexts as well, in Medicare and other places,” he said.
“They are committed to providing straight-up information,” the official continued. “They’re contracted very, very carefully. They have rigorously gone through training. If you are a Navigator grantee, you are required to comply with security standards that have been outlined in their contract.” The official contended the ACA critics are using the Navigators as targets, “to try and intimidate them to not provide these services, which I think is antithetical to anything we’ve seen ever in the past.”
One health reform observer says the trend of Navigators dropping out is concerning. Groups might be prompted to do so “because of the state’s eligibility requirements or because of the chilling effect that some of these state laws could have,” explains Katie Keith, a former research professor at Georgetown University and a co-author of the Commonwealth Fund report on Navigators.
“The concern is that would-be Navigators, especially smaller organizations, might conclude that these types of requirements are too high of a burden to meet and decline to participate,” she tells HRW.
House Panel Asks for Detailed Information
For their part, Republicans on Capitol Hill say they want to ensure that privacy and security issues with the Navigators are addressed. There concerns were expressed in an Aug. 29 letter by GOP members of the House Committee on Energy and Commerce to each Navigator awardee. The letter requested the grantees provide detailed responses by Sept. 13 to six multifaceted questions. These included:
- The work that will be performed with the funds obtained by the grant, as well as the number of employees and how any other portion of the grant may be spent;
- The training or education that employees, volunteers or representatives must complete, including from federal and state entities;
- The processes and procedures in place to monitor, review or supervise employees;
- How the organization will utilize the information obtained during performance of the Navigator grant;
- Whether the organization has been contacted by any insurance company or provider to discuss the grant; and
- All documentation and communications related to the organization’s Navigator grant, including materials submitted to obtain the grant and communications with HHS, CMS and other federal or state entities.
The head of health care advocacy group Families USA was even blunter.
“There is no question that these efforts are largely prompted by a desire to obstruct the implementation of the Affordable Care Act, so that fewer people would get enrolled than otherwise would get enrolled,” Executive Director Ron Pollack tells HRW. “In a number of states, they are requiring even volunteers to pay a significant amount of money before they provide any advice to neighbors or friends or others who are trying to figure out what type of plan they may enroll in, or information about the subsidies.”
Pollack says it’s hard to quantify the impact of these efforts. “It clearly has had some dampening impact in some places. I think ultimately it’s not going to have a huge impact because as more and more people learn about…others who are comparably situated as they are [and understand] what they are getting, they will understand that it’s a really good thing to get enrolled in coverage,” he says.
Keith agrees the state laws are unlikely to sink the Navigator’s outreach and enrollment efforts. “These laws might make it more difficult for Navigators to accomplish their task, but these organizations are committed to the populations they serve,” she says.
Florida Grantee Moves Ahead
Everything appears on track for the University of South Florida’s (USF) Navigator program. USF received $4.2 million, the second-largest Navigator grant, to oversee a consortium of 10 organizations in all but three counties across the state. The grant will be administered by The Florida Covering Kids & Families program at the USF Chiles Center for Healthy Mothers and Babies.
Jodi Ray, project director of the USF program, says she has not identified any state-based issues that would hinder her efforts.
“The Navigators are getting trained, pulling together key stakeholders and reaching out to the communities with information,” Ray tells HRW. She says the kind of assistance that Navigators can provide is key to ensuring that people get enrolled.
“Facilitated enrollment keeps people from getting lost along the way to completing an application,” Rays says. “It’s overwhelmingly successful in ensuring that people who started the process actually completed the application and obtained health insurance.”
