Empowering Health Care Consumers

Grantee Name

Public Health Solutions

Funding Area

Empowering Health Care Consumers

Publication Date

March 2019

Grant Amount

$150,000

Grant Date:

April 2016 – November 2018

Since the opening of the New York State of Health Marketplace in 2014, more than 4.5 million New Yorkers have enrolled in a health plan through the Marketplace.

Although enrollment has been largely deemed a success, gaps in the system regarding consumer education have been reported. Many of those enrolled are new to insurance and may be confused about using health insurance and its benefits, including provider networks or how to handle denied claims. Consumer education for insurance is limited and hard to find, and it is increasingly clear that there is room to better address the needs of insured New Yorkers.

In 2016, NYSHealth awarded Public Health Solutions (PHS) a grant to assess New York State consumers’ post-enrollment health insurance needs and available resources and provide recommendations to meet their health insurance navigation needs.

Outcomes and Lessons Learned

PHS set out to develop a comprehensive blueprint of recommendations to enhance the current system of consumer assistance services and post-enrollment support in the State. This blueprint would examine the existing consumer assistance structure and how it addressed consumers’ needs; identify potential actions to make the system more efficient and effective; leverage the knowledge and resources of existing community-based consumer assistance systems; and make actionable recommendations for policies, strategies, and funding allocation. Under this grant, PHS:

  • Collected data on the State’s consumer assistance systems and current post-enrollment resources from a variety of sources, including the Department of Financial Services (DFS), Office of the Attorney General, and Department of Health (DOH).
  • Conducted interviews and/or fielded surveys with health plans and enrollment assistor staff, such as Marketplace Navigators and Certified Application Counselors and community health advocates from consumer assistance programs.
  • Prepared a report on how various entities—health insurance plans, State agencies, and nonprofit advocates—provide post-enrollment assistance to New Yorkers, along with opportunities for improvement.

The project found that:

  • State consumer assistance agencies are vitally important, but their full potential is compromised by a lack of uniform, comprehensive, or easy-to-access information for consumers.
  • Some consumer assistance data from health insurers are unreported, such as how consumer complaints were resolved and a health plan’s rate of claims denials.
  • Community-based assistance programs are essential to meeting consumers’ health insurance needs, but need to be more accessible to New Yorkers.
  • Consumer assistance organizations can provide a window into systemic issues facing consumers (e.g., consumers often have limited information about premium costs and provider networks when selecting a plan).
  • Basic data, such as the number of consumer complaints filed, aren’t available in a comprehensive, uniform, and interactive format for State oversight or for use by consumers and advocates to examine systemic gaps.

Based on these findings, PHS developed recommendations to address the needs and challenges experienced by consumers:

  • Develop clear, accessible, and consumer-informed materials (both online and printed) by DFS and DOH, including toolkits with sample documents, checklists, and FAQs on processes/timeframes for resolving problems and filing complaints and appeals; model language for health plan member handbooks, contracts, and notices; and other consumer assistance topics such as health insurance plan practices that align with consumer rights and those that do not.
  • Leverage resources, simplify procedures, and coordinate functions among enrollment assistors by co-locating community health advocates at State Navigator locations; training Navigators and Certified Application Counselors on making referrals to community health advocates; holding regular meetings among government and nonprofit assistance entities to share information and respond to common consumer questions, complaints, and systemic issues; and distributing uniform scripts and one-pagers on post-enrollment FAQs and resources to other State and city agencies likely to be contacted by consumers for help.
  • Standardize consumer inquiries and claims complaint, appeals, and outcomes data and publish in user-friendly formats (e.g., require health plans to use uniform reporting codes for claims data and create a public online, searchable database for comparing data in these categories).
  • Require health plans to submit to State agencies more robust data on the number and types of consumer complaints, how long it took to address complaints, and what the resolution outcomes were. Such data could help identify systemic issues and problematic patterns and ensure they are promptly addressed through standardized protocols.
  • Increase federal and State funding for consumer protection and assistance. 

PHS was able to collect robust information from State government agencies, enrollment assistors, and nonprofit organizations. However, it faced challenges in collecting sufficient and comparable data on consumer assistance resources from health insurance plans. A survey was fielded to health plans on their consumer assistance resources; success stories and best practices; staff capacity and funding; and types of consumer inquiries and concerns. Although plan information would be de-identified, there was a low response rate by the health plans. A misunderstanding of and concern about the intent of the survey among the health plans may have contributed to their lack of participation. With this limited information, PHS couldn’t adequately assess how well health plans are (or are not) meeting the insurance navigation needs of consumers.

Additionally, the project was conducted as more of an audit of the overall consumer assistance system, with findings and recommendations focused on identifying deficits in the system. It could have been placed greater emphasis on existing capacity and strengths that could be expanded upon. NYSHealth could have provided clearer guidance earlier in the project to appropriately re-balance the scope of the analysis.

This grant was one of the first awarded under NYSHealth’s newly launched priority area of Empowering Health Care Consumers in 2016—which in its nascent stage was still transitioning from the Foundation’s prior emphasis on consumer insurance coverage and access issues. By the time PHS had completed its work, the project was no longer aligned with this priority area’s core strategies of promoting information transparency and engaging patients as partners in decision-making. Because of this misalignment, the limited information collected from health plans, and the scope of the analysis, the project did not result in an NYSHealth-produced report.

 Co-Funding and Additional Funds Leveraged: N/A