1. www.cssny.org 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

2. www.cssny.org Outline of Presentation Federal health reform and consumer assistance programs o 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: CSSs consumer assistance model Implementing a consumer assistance program in your state 2

3. www.cssny.org Health Care Reform and Consumer Assistance Programs 3

4. www.cssny.org 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 bill o 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… 4

5. www.cssny.org Consumer Assistance Programs Help Patients Successfully Interact with Every Level of the Health Care System Consumer Assistance Programs Pharmacies Doctors/ Providers Insurance Plans 5 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

6. www.cssny.org Four Basic Consumer Assistance Models in Use Across the Nation Localized Capacity Building Model o Community based organization network o Operates a centralized helpline from the network hub o Trains and conducts community outreach o In NY, helped transition of 2.8 million from fee-for-service to managed care Hotline Model o Operates a hotline that serves consumers on a variety of health care related issues over the phone o Includes IT and electronic software capacity to do enrollments o MA program helped with implementing reform (call volume increased by 400%) 6

7. www.cssny.org Four Basic Consumer Assistance Models in Use Across the Nation (contd) Legal Services Model o Provides legal expertise to consumers on health care-related issues o Helps consumers establish and keep coverage o Helps navigate and access insurance benefits o CA: Health Consumer Alliance run through 9 legal services programs & two statewide support centers Government Ombudsprogram Model o Government run program that assists with problems regarding health care and insurance options o Operates a helpline that serves consumers in the State o DC newly started up; CT Office of the Healthcare Advocate 7

8. www.cssny.org Consumer Assistance in Federal Reform 8

9. www.cssny.org 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, enrollment o Consumer Assistance, toll-free hotline, internet, complaints, enrollment; may contract with other entities to perform these services 9

10. www.cssny.org Case Study: CSSs Consumer Assistance Program 10

11. www.cssny.org CSSs 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 insurance o Provides navigational assistance o Served over 130,000 clients to date o 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 DOH o NYSOFA funding for Medicare work Reaches diverse, hard to serve populations 11

12. www.cssny.org 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 12

13. www.cssny.org Disseminates Information in An Accessible Manner 13

14. www.cssny.org NYC MCCAP Consumers by Language Spoken NYC MCCAP Consumers by Income 14

15. www.cssny.org Percent of NYC MCCAP Consumers by Type of Insurance NYC MCCAP Consumer Issues 15 * Other includes Union and Veteran.

16. www.cssny.org Implementing a Consumer Assistance Program 16

17. www.cssny.org 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 17

18. www.cssny.org Contact NYC MCCAP Priya Mendon: 212-614-5331; pmendon@cssny.org Helpline: 212-614-5400; mccap@cssny.org Website: www.nycmccap.org 18