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Chapter 1
Section 1 Patient Protection and Affordable Care Act (PPACA) History of the Affordable Care Act
Section 2 Highlights of the Affordable Care Act Section 3 The Individual Mandate
Section 4 Medicaid Expansion Section 5 The Exchange
Section 6 Qualified Health Plans (QMBs) Section 7 SHOP Exchange
Section 8 Premium Tax Credits Section 9 Families and Individuals Section 10 Small & Larger Employers Section 11 Program Integrity Section 12 Self-Test
Section 1: The Patient Protection and Affordable Care Act (PPACA)
Objectives:
Understand how the ACA applies to you and
others
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The Affordable Care Act, also known as the Patient Protection and Affordable Care Act (PPACA), and informally as Health Care Reform or Obamacare, was signed into law by President Barack Obama on March 23, 2010. The aim of the Act is a healthcare law aimed at improving the healthcare system of the United States by expanding healthcare coverage to more Americans, as well as slowing down the unsustainable rising cost of healthcare.
The Affordable Care Act aims to help small business owners offer health insurance for their workers. This Act should help increase the number of primary care physicians, nurses, physician assistants and other health care professionals to meet the needs of the newly-insured.
Health care reform in the United States has a long history dating back at least 100 years. Reforms have
often been proposed but have rarely been accomplished:
1912 – Teddy Roosevelt – Proposed Universal Health Care 1935 – President Franklin Roosevelt – Implemented Social Security 1942 – President Franklin Roosevelt - Established Price Controls 1945 – President Harry Truman – Proposed Universal Health Care 1965 – President Lyndon Johnson – Established Medicare
1974 - President Richard Nixon – Proposed employer mandate to provide healthcare and to replace Medicaid with state-run health insurance
1993 – President Bill Clinton – Proposed employer mandate to provide health insurance through regulated health maintenance organizations
2005 – President George W. Bush –Created Medicare Part D 2010 – President Barack Obama – Passed Health Care Reform
Healthcare Reform Law will make health care more affordable; guarantee choices when purchasing
health insurance; expand health coverage to more Americans; and enhance the quality of care received.
Why was it critical that we reform our healthcare system?
More than 32 million people in this country have no health insurance.
After the economic downturn people lost their jobs and their health insurance. In 2011, close to 50 million people across the country now had no health insurance.
More than 60% of all bankruptcies are due to medical bills that families are not able to pay.
Providers were treating more and more people who had no way of paying for their services.
Those most in need of health insurance had no protections and they could be denied coverage or dropped from their health insurance for illnesses or pre-existing conditions.
Section 2: Highlights of the Affordable Care Act
Two of the goals of the Affordable Care Act are:
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The ACA will change the United States Healthcare system and how it operates. Some improvements have already taken place. Here are some highlights of the policy changes that have already gone into effect and will help protect individuals and families.
For those families who get private insurance (for example, people who get health insurance through employers) there are certain laws that have been changed that are there to help protect families.
Kids can’t be denied coverage if they become sick or for a preexisting condition. Young adults up to age 26 can now stay on their parent’s health insurance plans.
Health insurance carriers can no longer put a lifetime dollar limit amount on how much costs they will cover
Health insurance carriers are required to spend more of the premium dollars they receive on health care services (known as Medical Loss Ratio).
In 2020, it fully closes the Medicare Part D prescription coverage gap known as the donut hole. Some of the more noticeable changes will happen January 1, 2014. Starting in January, 2014, there will be two key things that take place. The first of these is now everyone must have health insurance; this is what is known as the “individual mandate.” We’ll talk more about the mandate, and exemptions from the mandate, in the next section. Because the ACA requires everyone to have insurance, the federal government is helping individuals who don’t have health insurance offered by their employer or who simply can’t afford to buy private health insurance. They are doing this in two different ways:
Expanding Medicaid coverage to those whose income is 138% or below the federal poverty level regardless of disability status.
Establishing a Health Benefit Exchange in every state. In our state, it is called the Washington Healthplanfinder where people who make between 138% -400% of the FPL can receive subsidies to help pay for their health insurance.
Section 3: The Individual Mandate
What is the Individual Mandate?
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assistance in the form of tax credits that can be used to make their healthcare coverage more affordable. The ACA does allow for some exemptions from the individual mandate.
Who is exempt from the mandate?
You may be exempt from the individual mandate if you meet one of the following criteria: Members of certain religious sects:
If someone is a practitioner of a religious sect that has been in continuous existence since 1950 and is “conscientiously opposed” to accepting benefits from any public or private insurance, they are exempt. For example, Amish people fall into this category.
Members of Health Care Sharing Ministries (HCSM):
These are nonprofit organizations where members share the same faith and similar lifestyles. HCSMs act as “clearinghouses” for members who have medical expenses and those who wish to share the burden of those medical expenses.
Your family’s income is below the tax filing threshold
The lowest cost health insurance plan option exceeds 9.5% of an individual’s income. You are not a citizen or legal resident of the US
How much is the penalty if I don’t qualify for an exemption and don’t buy health insurance?
The following table outlines the fees for the penalty. The Internal Revenue Service (IRS) is responsible for enforcing the penalty. The penalty will also go up significantly in 2015 and 2016.
2014:
$95 per adult
$47.50 per child (up to $285 for a family) or 1% of income, whichever is greater
2015:
$325 per adult
$162.50 per child (up to $975 for a family) or 2%,
whichever is greater
2016:
$695 per adult
$347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater
When is the Individual Mandate satisfied?
To satisfy the ACA’s individual mandate to have healthcare coverage beginning January 1, 2014, a person is deemed in compliance through the following options:
Medicare
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A plan offered by an employer
Medicaid or the Children’s Health Insurance Program (CHIP) Insurance bought on your own that is at least at the Bronze level
A grandfathered health plan in existence before the health reform law was enacted
How can I prove I am exempt from the Individual Mandate?
The Washington Healthplanfinder has a form a consumer may use to verify he or she meets the exemption criteria.
Section 4: Medicaid Expansion
What is Medicaid?
Medicaid is the United States safety net program that provides healthcare coverage for families and individuals with low income and resources and that have certain disabilities. Pregnant women and children may also eligible for Medicaid. It is a means-tested program jointly funded by the state and federal government and is administered by the states.
What is the Federal Poverty Level?
The “Federal Poverty Level” is a standard income below which any individual or family is determined to live in poverty. it is based on everyone’s income in your house unless you are the only person in your household. The Federal Poverty Level (FPL) is used to determine who can qualify for government assisted programs, including Medicaid. Here is a table that gives you the FPL of households based on an annual income for 2013:
Household Size 100% 138% 150% 200% 300% 400% 1 $11,490 $15,856 $17,235 $22,980 $34,470 $45,960 2 15,510 $21,404 23,265 31,020 46,530 62,040 3 19,530 $26,951 29,295 39,060 58,590 78,120 4 23,550 $32,499 35,325 47,100 70,650 94,200 5 27,570 $38,047 41,355 55,140 82,710 110,280 6 31,590 $43,594 47,385 63,180 94,770 126,360 7 35,610 $49,142 53,415 71,220 106,830 142,440 8 39,630 $54,689 59,445 79,260 118,890 158,520
For each additional person, add $4,020 $5,548 $6,030 $8,040 $12,060 $16,080
How did the ACA change Medicaid?
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Before the ACA went into effect low income families that met certain criteria were eligible for Medicaid. The ACA has expanded the eligibility level up to 138% for individuals between the ages of 19 to 65 (parents, and adults without dependent children) regardless of disability status.
Creates a new Medicaid group - Newly Eligible Individuals age 19 up to 65 who:
o Have income below 138% FPL
o Meet citizenship requirements
o Are not incarcerated
o Are not eligible for Medicare
Changes income and deductions for existing Medicaid groups:
o Children
o Pregnant Women
o Families (Parents/Caretaker Relatives)
Utilizes Modified Adjusted Gross Income (MAGI) methodology to calculate income
o Countable income
o Income deductions
Provides additional methods for determining income and deductions
o Household composition - mirrors federal income tax filing rules
o No asset/resource limits
o 12 month certification periods
Adopts a new simplified application and renewal process for:
o Medicaid (Apple Health)
o Children's Health Insurance Program (CHIP)
o Private insurance offered on the Health Benefit Exchange Retains current Medicaid eligibility standards for the following groups:
o Aged, Blind or Disabled individuals
o Foster Care children
Section 5: The Exchange
What is the Washington HealthPlanFinder, and how is that different from the Exchange?
The Washington Healthplanfinder is a website with an online portal and application where Washington state residents can go to shop for and purchase healthcare coverage. Everyone who doesn’t already receive health insurance from their employer and needs to get health insurance (either through Medicaid or by getting help with a subsidy) will go to the HealthPlanFinder website to sign up for health insurance.
The Exchange is the marketplace where people can go shopping for insurance - it is strictly an online marketplace that you can access through the HealthPlanFinder website. The Exchange is for people who make too much money to qualify for Medicaid. Subsidies will offset the premiums to make health plans more affordable for lower income individuals and families. The Exchange will provide subsidies for individuals who fall between 138% - 400% of the FPL. Families and individuals can shop for their health insurance plans through the Exchange.
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Some Exchange basics:
• Health Plans will be available to individuals & small employers in the Exchange.
• The Exchange and the Office on the Insurance Commissioner will: Set-up Standards for the Qualified Health Plans & Certify participating plans.
• Under the Affordable Care Act (ACA), insurers will be required to offer plans that fit within four levels of coverage: bronze, silver, gold and platinum. Essential benefits are a set of health care service categories that must be covered by health plans in the individual and small group markets. Insurers don't have to offer plans in all four levels, but all insurers must offer at least one silver and one gold plan.
• Health Savings Accounts (HSAs) may be used to help an individual or family pay any of their out-of-pocket costs for a plan in which they have purchased on the exchange. The maximum dollar amount for an HSA is $2,500.
Section 6: Qualified Health Plans (QHPs)
A healthcare coverage plan must meet certain standards before it is offered to consumer on the Washington Healthplanfinder. All plans, regardless of the level of coverage, must include a set of minimum essential benefits. This list includes:
Ambulatory patient services, such as doctor's visits and outpatient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health
treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
The amount covered for these minimum essential benefits will vary depending on a specific plan’s actuarial value. The exchange will only market plans that have four levels of coverage as described below.
Four levels of coverage
The four levels of coverage - Bronze, Silver, Gold and Platinum - are based on actuarial value, a measure of the level of financial protection a health insurance policy offers. It indicates the percentage of health costs that a health plan would pay for an average person. The four levels provided in the ACA are illustrated in the chart below.
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group markets. Essential benefits must include items and services within at least certain 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
While the scope of benefits will be the same among the plans, the value of those benefits will vary across the Bronze, Silver, Gold and Platinum levels. This means the amount of cost-sharing required will differ in those tiers. Bronze plans will have the least generous coverage with more out-of-pocket costs for enrollees, and platinum plans will have the most generous benefits.
However, no health plan will be allowed to charge cost-sharing - including deductibles, co-payments or co-insurance - greater than the limits for high-deductible plans (in 2010, the limit was $5,950 for an individual and $11,900 for a family). And health plans for small businesses are barred from charging deductibles greater than $2,000 per year for individual coverage or $4,000 per year for family coverage (this amount will be annually adjusted for inflation). No health plan can apply a deductible or any cost-sharing for certain preventive health services.
How will the levels of coverage differ?
The four levels provided in the ACA are illustrated in the chart below.
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Actuarial value is different from the premium for the health plan. Premiums for different plans at the same level will vary from one insurer to another, based on the overall use of services by enrollees, the prices of health care services negotiated by the insurer, and how the plan controls the services its enrollees use.
In addition to these four levels of coverage, some individuals will be able to purchase catastrophic plans with an even lower actuarial value. Catastrophic plans will cover essential health benefits but have high deductibles. Only young adults under 30 and individuals exempted from the individual mandate because they cannot find affordable insurance are allowed to purchase catastrophic plans.
Section 7: Premium Subsidies
The premium subsidies are designed to make premiums affordable for individuals & families with lower income:
Only available to individuals & families with income up to 400% FPL Will reduce monthly premiums
Can be claimed as a credit on annual tax return Must apply through Washington Healthplanfinder
How Premium Tax Credits work for individuals and families making between 138% and 400% FPL:
Income Level Premium as Percent of Income Up to 133% FPL 2% of income 138-150% FPL 3-4% of income 150-200% FPL 4-6.3% of income 200-250% FPL 6.3-8.05% of income 250-300% FPL 8.05-9.5% of income 300-400% FPL 9.5% of income
Section 8: Small Business Health Options Program (SHOP)
Large Employer Requirements
Small businesses with fewer than 50 full-time equivalent employees are exempt from the law’s requirement to provide health insurance for their employees or pay a tax penalty.
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If a business has up to 25 employees, pay average annual wages below $50,000, they can provide health insurance starting in 2014, and get a small business tax credit that goes up to 50% in 2014 (up to 35% for non-profits) for qualifying businesses.
Employees of companies with few than 50 employees can purchase insurance through the Washingtonhealthplanfinder.
Why set-up SHOP’s?
By setting up SHOP’s wherein small business owners can compare health plans and buy employee insurance they can reduce cost and have more options.
Large Employer Requirements
Large employers with over 50 FTE’s equivalent are required to offer a minimum level of health
insurance. The minimum level is defined as "Bronze level" where the health insurer plan will pay at least 60 percent of the cost of each health service or treatment; higher levels of coverage include "Silver" with 70% insurer payment, "Gold" at 80% insurer payment and "Platinum" at 90% is permitted. They must pay a tax penalty if they do not provide affordable health insurance and an employee uses a tax credit to help pay for insurance through an exchange.
To be considered affordable coverage, the employee’s portion of the premium can’t exceed 9.5 percent of the employee’s taxable household income.
Larger Employers offering non-qualifying coverage:
May be assessed the lesser of up to $3,000 per year for each FTE receiving income-based assistance, or, up to $2,000 for every FTE.
Large Employers not offering minimum essential coverage:
May be assessed $2,000 per FTE (first 30 full-time employees excluded) if at least one full-time employee receives income-based assistance to buy coverage in the Exchange.
Section 9: In-Person Assisters Program Integrity
The Washington Healthplanfinder training program for navigators and in-person assisters must ensure the Affordable Care Act’s goal to expand access to healthcare coverage is realized. To this end, navigators and in-person assisters who complete a required training program will satisfactorily perform their specific duties assisting consumers shop, compare and enroll in a Qualified Health Plan (QHP) offered on the Washington Healthplanfinder.
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The seven guiding principles are:
1. Duty to the Consumer – ensuring consumer’s health care coverage needs come first
a. Describing Navigator services and how Navigators are paid to provide those services b. Presenting information to consumer that is impartial, not invested in any certain plan, not
influencing selections, and ensuring consumer’s best interests are served c. Accepting no financial or other benefit as a result of enrollment d. Avoiding actual or appearance of conflicts of interest
e. Protecting health information – upholding privacy laws
f. Readily offering option of working with another Navigator or organization
2. Community and Consumer Trust – trusted community resources with demonstrated expertise and cultural competency
a. Having established community presence and understanding community’s unique strengths and needs
b. Recognized as credible and reputable voice for those they serve
c. Readily refer to experts to help with grievances, complaints, concerns about health plans, coverage, or eligibility
d. Having procedures to ensure organization’s representatives uphold and are accountable
3. Promoting Health Equity – promoting coverage access for populations historically facing greatest barriers to care
a. Addressing disproportionate access for underinsured and uninsured to improve coverage and health outcomes
b. identifying those experiencing greatest disparities and barriers and facilitating enrollment c. Build and sustain capacity to serve these populations through outreach, expanded location and
hours, and culturally relevant language
4. Knowledge and Skills – possessing knowledge and skills needed to deliver high quality services
a. Fulfill HBE certification and training requirements b. Demonstrate cultural sensitivity and linguistic competence
c. Impart up-to-date knowledge of QHPs and public programs, eligibility, enrollment, tax credits and available subsidies
d. Refer to appropriate resources for assistance not available through the Exchange.
5. Timeliness and Accuracy – accurate and up-to-date information
a. Effectively inform communities and consumers about changes impacting health coverage
6. Enduring Relationships – remaining a resource after initial enrollment
a. Helping families understand options available to cover all members
b. Helping newly enrolled to establish ongoing relationships with primary care providers c. Helping consumers evaluate coverage options when their financial circumstances change d. Helping families understand complex health care language/systems
e. Assisting consumers to use their plan’s health care services, including prevention and wellness
f. Connecting consumers with other resources
7. Seamlessness – as part of a larger system
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d. Increase health literacy by helping consumers to use their benefits
e. Communicate and coordinate among In-Person Assister organizations to ensure high quality, consistent services across the state
The integrity of the navigator and in-person assister program will be assured through the continuous collection and analysis of data related to performance measures and outcomes. Such data will help identify program vulnerabilities and provide support to Lead Organizations and their In-Person Assister partners.
The oversight and enforcement of In-Person Assisters must include the continuous monitoring of their performance to ensure compliance with all applicable federal and state laws and regulations. Strategies designed to monitor In-Person Assister performance include regular audits of plan enrollments to identify any unusual patterns and random contacts with
consumers to inquire about their experience working with a navigator. Performance measures for In-Person Assisters consist of the following:
Number of contacts with consumers
Number of consumer profiles completed
Number of consumer complaints
Number of completed enrollments
Number of disenrollments
Random consumer surveys
Audit of trends indicating steering of consumers to certain QHPs
Time to complete actions
If an In-Person Assister’s performance is less than satisfactory or a conflict of interest exists, immediate action will be taken to correct the problem. In a case of conflict of interest, the navigator will be de-certified while in the case of a knowledge or skill deficiency, remedial action may be appropriate. This may include the retraining and re-certification if the In-Person Assister desires to remain in this role.
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Chapter 1 Practice Test 1. TRUE or FALSE?
The Patient Protection and Affordable Care Act (also known as “Obamacare”) is now federal law. 2. IF you have insurance through your employer, your children can stay on your plan until they
reach what age? 3. TRUE or FALSE?
Your child can be denied coverage for health insurance because they have a pre-existing condition, like asthma or diabetes.
4. The Federal Poverty Level (FPL) is based on the income of: a. Everyone in your household
b. Full time workers in your household c. Just the head of household
5. Medicaid will now cover families at what percent of the Federal Poverty Level? a. 100%
b. 138% c. 175% d. 200%
6. The WA HealthPlanFinder is a website where you go to: a. Shop for subsidized health insurance plans
b. Enroll for the first time, or to renew your coverage for Medicaid
c. Enroll kids into subsidized health care who are up to 300% of the FPL (What? Are the kids supposed to earn up to 300% of the FPL or the parents?)
d. All of the above
7. Families may qualify for subsidies through the Exchange to help them pay for their health insurance. What is the income range for people to qualify for these subsidies?
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b. 138% FPL – 200% FPL c. 200% FPL – 400% FPL d. 138% FPL - 400% FPL
8. For a family of four at 400% of the FPL, their annual household income is: a. $45,000
b. $57,500 c. $85,000 d. $92,200 9. TRUE or FALSE?
If you are an undocumented immigrant over the age of 18 you will now be eligible for Medicaid 10. TRUE or FALSE?
In Washington State if you are an undocumented immigrant’s child between the ages of 0-18, you can get access to health insurance.
11. What is the individual mandate?
12. What will individuals and families use to report their income? a. Adjusted Gross Income
b. Modified Adjusted Gross Income c. Paycheck stubs
d. Bank account statements 13. TRUE or FALSE?
If your employer offers you health insurance that costs you less than 9.5% of your income, you can still get subsidies to buy health insurance in the Exchange.
14. TRUE or FALSE?
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15. Open enrollment to get a health insurance plan through the exchange starts on October, 1, 2013, but that coverage will become effective:
a. Immediately b. After 30 days c. November 1, 2013 d. January 1, 2014
Chapter One Quiz
1. When was the Patient Protection and Affordable Care Act signed into law? A. January 13, 2013
B. July 15,, 2011 C. March 23, 2010 D. October 22, 2009
2. Which president first introduced the idea of healthcare reform regulations? A. Teddy Roosevelt
B. Harry Truman C. Dwight Eisenhower D. Bill Clinton
3. How much does the United States currently spend on healthcare as a percentage of Gross Domestic Product (GDP)?
A. 7% of GDP B. 13% of GDP C. 18% of GDP D. 22% of GPD
4. What are the primary goals of the Affordable Care Act?
A. Provide healthcare coverage for many people that currently do not have insurance B. Reduce the number of insurance companies operating in each state
C. Curb the rising cost of healthcare D. All of the above
5. What changes to the US healthcare system have already changed as a result of the ACA? A. Medicaid has expanded to new populations
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D. Insurance companies no longer collect paper applications for insurance plans 6. Medicaid expansion covers everyone below what Federal Poverty Level
A. 100% B. 125% C. 138% D. 150%
7. The online marketplace where individuals and families can go to shop and buy health insurance plans in Washington State is called:
A. Washington Health Planfinder B. Insurance Plans for Washington C. Washington State Insurance Plan Finder D. Washington Health Benefit Exchange 8. Who is exempt from the Individual Mandate?
A. Members of certain religious sects B. Members of Health Care Sharing Ministries
C. People whose family income is below the tax filing threshold D. All of the above
9. For a family of four, what is the approximate Federal Poverty Level? A. $18,000
B. $23,500 C. $25,000 D. $27,500
10. How much is the Premium Tax Credit for an individual or family between 150% and 200% of the Federal Poverty Level?
A. 3 – 4% of income B. 4 – 6.3% of income C. 6.3 – 8.05% of income D. 8.05 – 9.5% of income
11. How many ‘metallic’ plan levels or tiers will individuals and families be offered in the exchange? A. 2
B. 4 C. 6 D. 8
12. The actuarial value is an indication of the following: A. The amount of the premium for the insurance plan
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C. The co-insurance amount for the insurance plan D. None of the above
13. What is the actuarial value of a Silver plan? A. 60%
B. 70% C. 80% D. 90%
HBE Education Workgroup (EWG)
Navigator Program Integrity Case Studies
Case Study #1
A consumer contacted the HBE to ask why the in-person assister with whom he was working told him that he could not enroll in a plan offered on the exchange but did not explain why. He was confused and wanted to know why his co-workers had been able to purchase a plan on the exchange and yet he was denied.
What factors might have resulted in his inability to use the Washington Healthplanfinder? What could the in-person assister do to help answer this consumer’s question(s)?
Case Study #2
A consumer called the HBE to complain about getting a bill from an insurance agent for payment of a service fee related to a plan in which she enrolled using the exchange. She thought she had actually completed the enrollment process and even saved a Washington Healthplanfinder receipt for payment for the first month’s premium. She asks if she needs to pay the agent’s invoice even though she only accepted assistance from the agent who told her that he was a certified in-person assister
What steps would you take to resolve this issue?
Case Study #3
After reviewing the performance of an in-person assister affiliated with a Korean Community Organization, it appears that the number of enrollments for this population is extremely low. The performance measure established for all in-person assisters affiliated with this same Lead Organization is a minimum of 100 per month yet the in-person assister has only enrolled 10.
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Case Study #4
A call center supervisor answered a call from a very angry consumer. He was yelling and cursing because he had been put on hold for 20 minutes by a call center customer service representative who told him that he was too busy to assist him and he could either hold or call back.
What should the supervisor do in this situation to calm the caller?
How can she provide this angry consumer with a more positive experience when calling the Washington Healthplanfinder?
Case Study #5
A random consumer survey asking consumers to evaluate their experience using the Washington Healthplanfinder revealed that at least 25 consumers all reported having a frustrating experience working with a single in-person assister in their community. The most common complaint is that the assister asked them for information but was never able to answer their questions during the shopping experience. Several even reported that they did not enroll at the time they were working with the in-person assister opting rather to visit the exchange another day.
What could be causing this assister to be either unwilling or unable to answer consumers’ questions?
