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What are Consumer Assistance Programs (CAPs)?

In this blog post, the No Surprises Act, Good Faith Estimate and Consumer Assistance Programs are defined and discussed. 

The No Surprises Act (NSA) went into effect Jan. 1, 2021. This legislation was created to prevent surprise medical bills for insured and uninsured patients throughout the United States. Part two of the NSA includes rules regarding the good faith estimate (GFE), which is a federally required cost estimate that all providers must give to uninsured or self-pay patients for all medical items or services.

For more information about the NSA or GFE, watch our free NSA webinar or read more on our blog

As part of the NSA, the Department of Health and Human Services (HHS) is currently seeking comment on how to provide additional GFE assistance to uninsured or self-pay individuals that face challenges with literacy, communication, language and disabilities. HHS also seeks to provide additional assistance to LGBTQ+ persons. 

HHS looks to utilize state consumer assistance programs (CAPs), legal services or other aid that may help patients with GFEs. 

What are CAPs?

Consumer assistance programs, or CAPs, are programs that provide guidance about health coverage through government plans such as ACA plans and Medicaid. Since these assistance programs can be run by state or federal government departments, programs may vary by state. 

Back in 2010, each U.S. state or territory could apply for a CAP grant to expand or build new programs to help consumers understand health coverage options (per the legislation found in  Section 1002 of the ACA). The grants are now completed and there are no outstanding CAP grants in use.

Consumer assistance research

In the spring of 2020, the Kaiser Family Foundation (KFF) surveyed consumers most likely to use or benefit from consumer assistance (i.e., non-elderly adults covered by marketplace health plans, qualified health plans or Medicaid and uninsured persons). 

The following are some of KFF’s findings:

  • Nearly 18% of consumers (~7 million people) that looked for coverage or actively renewed coverage received consumer assistance in the 2019 year. 

  • 40% of those that received assistance (~2.8 million people) thought it was unlikely they would have found coverage without help.

  • Another 12% of target consumers (~5 million people) tried to find help, but did not get it. 

KFF also sought to understand why consumers needed help from assistance programs. The following are a few findings from those who received assistance on why they sought assistance: 

  • 62% said they did not understand their coverage options.

  • 52% said the process of applying for government health plans was too complicated to complete on their own.

  • 18% did not have internet access at home.

  • 18% had problems with the marketplace website.

  • 15% needed assistance in Spanish.

Virtually all states have similar (if not the same) consumer help resources listed on the Centers for Medicaid and Medicare Services (CMS) webpage about CAPs. For instance: CMS has a list of what resources are available in Utah, which include many department phone numbers and web addresses for the following resources:

  • HealthCare.gov’s Plan Finder
  • Utah Insurance Department
  • Utah Medicaid Program
  • Utah Division of Workforce Services
  • Utah Children’s Health Insurance Program (CHIP)
  • U.S. Department of Labor
  • Senior Health Insurance Information Program (SHIP)
  • U.S. Department of Veteran Affairs
  • U.S. Center for Consumer Information and Insurance Oversight

Though consumer assistance programs have been helpful for 7 million people, but sadly that's only 18% of all the people that were targeted for assistance. CAPs in any form seem to be necessities to help many understand government health coverage options, though could be bolstered to improve more than the 18% that have received help in the past.

This year, the HHS seeks comment on how to utilize CAPs, as well as legal services or other aid that may help patients with GFEs. Consumer assistance programs have proven their helpfulness, but HHS has said nothing yet on how they will utilize CAPs, legal aid or any other assistance to better serve those receiving good faith estimates. 

Likely, nothing will come down the pipeline until at least November 2022 and won’t be effective until at least Jan. 1, 2023. 


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