Policy & Regulation News

CMS Announces Patient Navigator Funding, Enrollment Changes

The agency has announced cuts to the patient navigator program funding, as well as streamlined processes for exemption from the individual mandate.

patient navigator individual mandate

By Sara Heath

- CMS has announced the recipients of $10 million grant funding for patient navigator programs, considerably slashing the resources states will have to connect patients with comprehensive health insurance.

The patient navigator program was developed as a part of the Affordable Care Act (ACA). Per the law, state exchanges must set up patient navigator services that help patients understand the different health insurance plans and make informed decisions about which plans are best suited for unique patient needs.

CMS is currently following through on this portion of the ACA, stating that the grant funding will support a positive patient experience while shopping on the exchange. The process of purchasing a health insurance plan can often be frustrating, confusing, and low health literacy can limit patient options for coverage.

Earlier this year, CMS announced it will be awarding a total of $10 million in funding for patient navigator programs to be split among the states. The $10 million awards are a far cry from the $36 million such programs received in previous years, experts pointed out.

These cuts are in an effort to run patient navigator programs in a more efficient and leaner manner, according to CMS administrator Seema Verma.

READ MORE: CMS Overhauls ACO Programs, Pushes for Beneficiary Engagement

“We are committed to making sure that consumers have a positive experience,” said Verma. “The grants announced today mark a new direction for the Navigator program aimed at providing a more cost-effective approach that takes better advantage of volunteers and other community partners.”

“This new direction will increase accountability and ensure the grants are effective in helping consumers find health coverage that meets their needs,” Verma continued. “We will continue to monitor the impact of these changes with the primary goal of ensuring consumers have the resources to select a health plan that best fits their needs.”

Patient navigator programs are being left to make due with considerably fewer funds than previous years, with some states looking at hundreds of thousands of dollars in funding cuts. In Arizona, a patient navigator program’s funding has gone down from $707,136 in 2017 to $300,000 in 2018.

In Kansas, one patient navigator program will see cuts from $516,061 in 2017 to $200,000 in 2018.

Some states are seeing increases in patient navigator funding, however. The navigation service provider in Indiana, for example, will receive $300,000 in grant funding this year, compared to $168,565 last year.

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Patient navigator programs must leverage more cost-efficient strategies to leave their programs running, Verma explained. Applicants had to demonstrate volunteer preparedness and community health partnerships that would reduce the amount of federal funding necessary to operate a navigation program.

Previous statements from CMS suggested that most of the individuals purchasing a health plan via a federally-facilitated exchange (FFE) did not need the assistance of a patient navigator to purchase their plan.

In 2017, patient navigators receiving part of the $36 million in federal funding enrolled less than 1 percent of healthcare consumers who purchased a plan on an FFE. A similar finding was observed in 2016, CMS reported.

Industry groups assert that patient navigators are an integral cog in the insurance exchange process. As patients who have not previously had affordable access to health insurance begin shopping for coverage, they may need guidance in understanding key benefit characteristics.

Patient navigators help patients make their own informed decisions about their care.

READ MORE: Healthcare Pros Expand Patient Navigators for Continuity of Care

CMS does not necessarily disagree with this idea. However, the agency asserts that independent agents and brokers may be more cost-efficient in meeting these patient-centered goals. CMS aims to promote the use of patient navigators while fostering a leaner approach, the agency said in announcing the patient navigator application process.

“It’s time for the Navigator program to evolve, which is why we are announcing a new direction for the program today,” Verma said at the time. “This decision reflects CMS’s commitment to put federal dollars for the federally-facilitated exchanges to their most cost effective use in order to better support consumers through the enrollment process.”

This is the first enrollment period during which CMS is implementing this skinnier approach, and as such the agency says it plans to monitor the effectiveness of leaner patient navigator programs.

In addition to funding announcements, CMS has also proposed a more streamlined process for healthcare consumers to claim a hardship exemption from the tax penalty imposed when one does not have health insurance coverage, otherwise known as the individual mandate.

CMS says the individual mandate harms middle-income families. Of the $3 billion in tax revenue collected from individual mandate penalties, just under 80 percent came from families making $50,000 per year or less.

“Today’s announcement shows how President Trump’s Administration is working to ease the burden of Obamacare,” Verma stated. “Although the tax cuts signed by the President earlier this year eliminate the mandate penalty starting in 2019, Americans are still under threat of the penalty for this tax year of 2018. This guidance will simplify how consumers claim the hardship exemption from the individual mandate directly on their tax return.”

Proponents of the individual mandate state that the provision creates a healthier patient pool for healthcare payers. When there is a higher proportion of healthier individuals enrolled on a payer plan, premiums and other out-of-pocket patient costs go down.

These moves add to the agency’s efforts to reverse certain provisions of the ACA. According to Verma and other CMS officials, the efforts intend to put the patient at the center of healthcare and place more healthcare decision-making in the hands of the patients.

Critics of these efforts say the Administration is working to undermine the ACA, building off of efforts for skinny repeal that fell through in 2017.


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