CSS Becomes State Health Care Ombuds Agency

David R. Jones, The Urban Agenda

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How often have you been confused by a health insurance program or payment?  Do you understand the new federal health care reform law?

The federal health care law enacted in March 2010, the Affordable Care Act (ACA), promises to provide health care that is more affordable and more accessible for many people.  Still, the complex and fragmented nature of our health insurance system often leaves consumers confused.  Hundreds of thousands of frustrated people call insurance regulators every year looking for help.  The advent of federal health reform may bring new challenges for health care consumers.

To get help about health insurance coverage or to find a local CHA agency, call the Community Health Advocates helpline at 888-614-5400, or e-mail cha@cssny.org.

Congress, recognizing these concerns, included a provision in the ACA to help prepare individuals and families for the impending changes to our health care delivery system by establishing a funding stream to support independent consumer assistance programs (CAPs), or ombuds programs, in the states.  The law allocated $30 million in funding for such programs in 2010, with authority to allocate additional funds in the coming years.

Community Health Advocates (CHA), a program of the Community Service Society (CSS), is a program designed to help New Yorkers understand and access health care in the neighborhoods in which they live and work.  It is one of the largest health care consumer assistance programs in the country.  CHA provides free independent assistance to the most vulnerable and underserved populations across New York State.  The work of CHA will be more important than ever as implementation of health reform begins.

Access to Health Care

CHA helps consumers with all types of coverage as well as uninsured New Yorkers.  In New York City, 1.4 million residents are uninsured and two-thirds of the uninsured population lives below 200 percent of poverty – about $37,000 for a family of three.  Another 1.1 million uninsured New Yorkers reside outside the city.

CHA helps consumers with insurance enrollment – sorting through the existing options, figuring out whether they qualify for a public program, helping them when it is time to renew.  For people who cannot afford but who are eligible for coverage, CHA works to find free or discounted health care options.  

CHA educates enrollees about using their health insurance and accessing the care they need, informs people of their rights, and directly resolves issues with health plans, including billing problems and coverage denials.  In addition, it provides valuable real-time feedback to policy makers which inform the ongoing development of health care policy.  

CHA runs a central toll-free live-answer hotline and an internet intake system, staffed by health insurance and coverage experts, which helps consumers wherever they may be.  CHA services are also provided through a network of 25 community based nonprofit organizations (CBOs) located throughout the state, including ten in New York City.  These CBOs are trained by CSS staffers to conduct quality community education workshops and individualized counseling for people who face barriers to accessing health care services.  Relationships with community partners form the strength of the CHA program because these agencies are trusted resources in their respective communities, and people who might not traditionally seek assistance at government agencies for health issues go to them for help.

The program is culturally sensitive and linguistically diverse, providing information and services in nearly every language, including Spanish, Chinese, Russian, Yiddish, Korean, Polish, Urdu, and American Sign Language.  The central hotline can answer calls with a telephone translation service which operates in over 100 languages.

Statewide Consumer Assistance

CHA’s forerunner was our Managed Care Consumer Assistance Program (MCCAP), a citywide program funded through the Department of Health and Mental Hygiene that was launched in 1999 to help consumers understand and enroll in Medicaid Managed Care.  CSS’s Community Health Advocates was created in November 2010.  A state contract designated CHA as New York State’s health care ombuds program, advocating for everyone who needs quality affordable care all over the state.  Unique consumer assistance programs are being set up in over 40 states.  Such programs will be critical in facilitating the transition to provisions of the Affordable Care Act. 

When fully implemented, the ACA has the potential to provide health security, stabilize family finances, reduce racial disparities in health outcomes, and provide affordable quality health care.  But obtaining affordable health insurance is just a first step.  Many do not understand how to use it effectively and are unable to get the care they need.  The new ACA law offers coverage for uninsured people with pre-existing conditions, allows parents to add young adult children as dependents on their own job-based coverage, and provides discounts for people in Medicare Part D who hit the donut hole of coverage.  It prevents insurance companies from denying services to their enrollees for a pre-existing condition and helps states to curb excessive premium hikes.  CHA agencies can help New Yorkers inquiring about these and many other changes in health care being brought about by the Affordable Care Act.

For far too long, health care has been absent from the lives of many low-income and working poor New Yorkers.  Many lost their jobs in the recession, particularly black and Latino workers, and cannot afford premiums for employer-sponsored benefits, forcing them to live without health insurance.  This can impact their ability to get and keep a job.  Joblessness is a direct route to poverty.  The Affordable Care Act will do more to advance social, racial, and economic equity in the United States than any federal legislation since the Civil Rights Act.

David R. Jones is president and CEO of the Community Service Society (CSS), the leading voice on behalf of low-income New Yorkers for over 160 years.  The views expressed in this column are solely those of the writer.  The Urban Agenda is available on CSS’s website: www.cssny.org.

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