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.
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.
Note that “CAPs” can also stand for “Childcare and Parent Services.” This is a different type of program that assists with the cost of child care rather than healthcare.
Consumer Assistance Programs (CAPs) provide a range of support services to help individuals navigate the complexities of health insurance and healthcare coverage. CAPs, managed by either state or federal entities, offer the following essential services:
Guidance on Health Insurance Options
CAPs assist individuals in understanding and choosing among available health insurance plans, including ACA Marketplace plans, Medicaid, and Medicare options. This guidance is especially beneficial for low-income families, individuals with disabilities, and non-English speakers.
Eligibility and Enrollment Assistance
Determining eligibility for various government programs can be confusing. CAPs help people assess their eligibility and assist with enrollment processes, reducing barriers to accessing healthcare.
Help with Claims and Appeals
For those facing issues with claim denials or complex insurance policies, CAPs offer support in filing appeals and understanding the nuances of health plan benefits, ensuring consumers receive the coverage they’re entitled to.
Cost and Billing Assistance
CAPs often help consumers estimate out-of-pocket costs, understand deductibles, and manage unexpected bills. This service is particularly valuable for individuals with high medical expenses or those needing assistance with reimbursement processes.
Language and Accessibility Support
CAPs provide resources for non-English speakers and those with disabilities, offering translated materials, interpreters, and support for individuals requiring TTY or other accessible communication formats.
By offering these services, Consumer Assistance Programs empower individuals to make informed healthcare decisions and increase access to coverage, especially for those who face significant barriers.
In the spring of 2020, the Kaiser Family Foundation (KFF) surveyed consumers most likely to use or benefit from consumer assistance (i.e., low-income families and other 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 with eligibility who were targeted and 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.
In 2022 the HHS sought 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.
Rivet’s Estimates software offers accurate good faith patient pricing estimates that you can send to patients via HIPAA-compliant text and/or email, or print out the estimate right in your office. Patients will see their deductible/out-of-pocket maximum met, diagnostic codes, their financial responsibility and their plan’s financial responsibility, prior authorization flags, customized disclaimers and more.
To see Rivet's estimates and discuss billing pain points, request a demo now.
1. What are Consumer Assistance Programs (CAPs)?
Consumer Assistance Programs (CAPs) are state- or federally-managed programs that help individuals understand and access health insurance options, such as ACA plans, Medicaid, and Medicare. CAPs also provide support with claims, appeals, and billing.
2. Who is eligible for Consumer Assistance Programs?
Eligibility varies by state and program. Generally, CAPs target individuals who need help navigating healthcare coverage, including low-income families, individuals with disabilities, non-English speakers, and those unfamiliar with insurance options.
3. How do CAPs help with health insurance claims?
CAPs provide guidance for individuals facing claim denials or complex insurance policies. They assist with filing appeals, understanding reimbursement processes, and ensuring that consumers receive the coverage they are entitled to under their health plan.
4. Can CAPs help non-English speakers?
Yes, many Consumer Assistance Programs offer language support, including translation and interpretation services, as well as materials in languages like Spanish to aid non-English speakers in understanding their healthcare options.
5. What is the role of CAPs in the No Surprises Act?
The No Surprises Act includes provisions for additional support through CAPs, particularly for individuals requiring Good Faith Estimates (GFEs). HHS is exploring how CAPs and legal aid might further assist uninsured or self-pay individuals.
6. Are CAPs the same as Childcare and Parent Services programs?
No, although they share the same acronym, Childcare and Parent Services (also called CAPS) is a different program focused on assisting families with childcare costs, whereas Consumer Assistance Programs help with healthcare coverage.
7. How can I find CAP resources in my state?
You can access CAP resources through the Centers for Medicaid and Medicare Services (CMS) website, which lists state-specific resources and contact information for CAP-related support, or by visiting the official health insurance website for your state.
8. Do CAPs provide financial assistance for healthcare costs?
While CAPs do not provide direct financial assistance, they help individuals understand subsidies, out-of-pocket expenses, and the best available coverage options to manage healthcare costs effectively.
9. How have CAPs impacted healthcare access?
CAPs have helped millions of Americans understand their healthcare options and navigate insurance enrollment. Despite this, there is room for growth in expanding CAPs’ reach, as only a small percentage of eligible individuals currently receive assistance.
10. Can I receive CAP assistance if I have a disability?
Yes, CAPs offer services for individuals with disabilities, including accessibility support, TTY options, and other resources tailored to meet specific communication and healthcare access needs.