State insurance regulators have statutory responsibility and authority for helping consumers work through their insurance coverage problems and responding to consumer inquiries. To carry out that responsibility, regulators rely heavily on their Consumer Services Divisions, and the consumer service representatives (CSRs) who staff them, to serve as the front line of state regulation for insurance consumers.
Since the passage of the Affordable Care Act (ACA) and other recent reforms — especially those that went into effect on January 1– CSRs have a whole new set of marketplace rules, benefit requirements, and other mandates to become familiar with. Assuring that CSRs have up-to-date easily accessible information on these new requirements presents a significant challenge to insurance regulators.
CHIR staff who participate as technical assistance professionals (TAPs) in the Robert Wood Johnson State Health Reform Assistance Network (“State Network”) have drawn on their industry and regulatory experience to develop a Consumer Services toolkit that helps regulators address the new challenges. The toolkit takes the form of a Consumer Services Manual and three related appendices and can be found on the State Network website. The resources are posted in Word format so that state regulators can easily adapt them to their state’s benefit mandates and other state-specific requirements.
The main body of the Consumer Services Reference Manual includes entries covering insurance basics (for new hires) and those ACA provisions that CSRs are likely to be asked about. The entries are divided into10 sections, organized by subject matter. An easy-access index directs CSRs to entries, which appear in plain, non-legalese language to allow CSRs to review items quickly when working with consumers. An 11th section, “Process for Responding to Consumer Inquiries,” provides a place for states to describe their processes and procedures for handling various types of complaints and inquiries.
The appendices include a glossary with more than 200 health insurance terms and definitions as well as commonly-used acronyms, drawn from a number of sources that are credited in the document. Many of the definitions were either edited or re-written in full by the Georgetown team to make them relevant and useful to CSRs.
The second appendix is a template that states can use to provide an easy-to-use crosswalk from the ACA essential health benefits (EHB), and any state-specific benefit mandates, to their locations and descriptions in the state’s benchmark plan. The third appendix is a reference table illustrating the applicability of ACA provisions to grandfathered and self-funded plans. The table will allow CSRs to easily determine which plan’s benefits are subject to ACA provisions and which are not.
The Consumer Services Toolkit will be updated periodically and can be useful to state insurance regulators, whether the tools are used together or separately. Consumers are best served by assistance from well-informed CSRs who have the universe of new ACA information at their fingertips. To that end, the Consumer Services Toolkit will help to assure that consumers have access to top quality assistance with their health insurance problems and questions.