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Washington Health Benefit Exchange:

Proposed Navigator Program

January 2013

This report outlines the key components of the proposed Navigator Program for Washington’s Health Benefit Exchange, including: the role of the Navigator (as shaped by stakeholder input); In-Person Assistance; training approach, performance metrics, collaborations; Navigator Network Structure; selection criteria; primary responsibilities; sizing of the Program, compensation; distribution of funds and budget considerations.

WASHINGTON HEALTHPLANFINDER: PROPOSED NAVIGATOR PROGRAM (1/11/13 DRAFT)

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TABLE OF CONTENTS Executive Summary ................................................................................................................................................... 3

SECTION I ....................................................................................................................................................................... 7

Stakeholder Engagement........................................................................................................................................... 7

Stakeholder Surveys .................................................................................................................................................. 7

Stakeholder Interviews .............................................................................................................................................. 8

Exchange Vision and Goals ........................................................................................................................................ 9

Navigator Program Guiding Principles ....................................................................................................................... 9

Excerpts from Navigator Program Guiding Principles ............................................................................................. 10

Role of the Navigator: Duties and Responsibilities ................................................................................................. 11

Navigator Checklist .................................................................................................................................................. 12

In-Person Assistance ................................................................................................................................................ 13

Agents and Brokers .................................................................................................................................................. 14

Navigator Training ................................................................................................................................................... 14

Navigator Curriculum Sample Overview .................................................................................................................. 15

Navigator Program Metrics ..................................................................................................................................... 17

Key State Agency and Tribal Partnerships ............................................................................................................... 19

American Indians and Alaska Natives (AI/AN) ......................................................................................................... 20

Key Internal Exchange Collaborations ..................................................................................................................... 21

SECTION II .................................................................................................................................................................... 23

Navigator Network Approach: Lead Organization Centric Model .......................................................................... 23

Lead Organization Selection Criteria ....................................................................................................................... 25

Lead Organization Responsibilities .......................................................................................................................... 26

SECTION III ................................................................................................................................................................... 28

The Goal: Local, Community-Oriented Navigator Networks .................................................................................. 28

Estimating the Size of the Navigator Program and In-Person Assistance Budget ................................................... 28

Budget Projection .................................................................................................................................................... 29

Assessment of Likely Exchange-Eligible Population and Allocation of Resources Methodology ............................ 31

Federal Poverty Level (FPL) ...................................................................................................................................... 31

Uninsured ................................................................................................................................................................ 32

Simple Needs-Based Index ...................................................................................................................................... 33

Broad Needs-Based Index ........................................................................................................................................ 34

Compensation Approach for Lead Organizations (Still under development) .......................................................... 39


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Compensation Approach for Navigator Organizations ............................................................................................ 40

Timeline ................................................................................................................................................................... 40

Attachment A: Navigator Program Guiding Principles

Attachment B: Washington State Navigator Resource Allocation Assessment


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WASHINGTON HEALTHPLANFINDER PROPOSED NAVIGATOR PROGRAM EXECUTIVE SUMMARY This report outlines the state’s plan1 for a Navigator Program that provides the outreach, education and

enrollment support to achieve the Washington Health Benefit Exchange’s vision of “redefining people’s

experience with health care.” Section I describes stakeholder engagement; the role of the Navigator and

In-Person Assister; the training approach, program metrics, and internal/external partnerships. Section II

outlines the network approach for outreach, education and enrollment support. Section III covers

enrollment projections and expected costs. Highlights of these sections include:

Stakeholder Engagement

The Navigator Program is aligned with the Board’s vision and objectives. It reflects design features

shaped by a highly-engaged technical advisory committee (TAC) consisting of key stakeholders appointed

by the Exchange Board. The Navigator TAC’s collective knowledge and experience has significantly

enhanced the Navigator Program and we have benefitted from the quality of their input and

engagement. Additional stakeholders contributed through state-wide surveys, interviews and other

avenues for gathering input.

Role of the Navigator/In-Person Assistance

Navigator support will be targeted to consumers who are harder to reach, perhaps because of a cultural

or linguistic difference, low income or a disability. Consumers may need more assistance if they are

unfamiliar with health insurance coverage or are intimidated by the application process. Navigators will

be trained and certified to provide assistance to consumers eligible for enrollment in a Qualified Health

Plan (QHP) or Medicaid. They will assist individuals to compare plan options and costs, understand

available tax credits and cost sharing reductions. Navigators will help individuals complete the application

process and initiate enrollment in a plan selected by the consumer. Navigators will provide impartial

assistance and must be free of any conflict of interests.

During the initial open enrollment, demand for assistance from a knowledgeable resource is expected to

be extraordinary. Navigator resources will be significantly supplemented by the addition of In-Person-

Assistance. Federal support for In-Person Assistance is available through 2014 and Washington will fully

leverage this support to meet consumer demand. In-Person Assisters (IPAs) may provide Navigator

functions or have a more limited scope. If performing application-through-enrollment support, the

Assister must meet the same standards that apply to Navigators. If assistance is limited to outreach,

education, or other support services, certification as a Navigator is not required.

1 Federal guidance on Navigators is expected to be released in January 2013. While this guidance is not expected to

require any modifications to this report, any necessary changes will be brought to the attention of the Board on a timely basis.


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Navigator Training

Exchange trainers will educate lead organization trainers, and these trainers will then instruct the

Navigators (and Assisters) working within their network. This model creates a strong knowledge base in

the community, while ensuring the Exchange retains responsibility for providing a uniform curriculum

statewide. A comprehensive curriculum will reinforce Navigator requirements around impartiality,

confidentiality, and sensitivities to the cultural and linguistic differences of consumers likely to enroll in

the Exchange.

Navigator Program Metrics

The Washington Healthplanfinder offers rich data collection opportunities for reporting key performance

measures, such as volume of enrollment activity, type of coverage, and demographic characteristics.

Some data not tracked in the Healthplanfinder is also valuable for lead organizations to report, such as

the number of education/awareness events conducted and demographics such as education level,

months/years since prior coverage; and how a consumer currently receives health care..

Key State Agency and Tribal Partners

There are four key partnerships in the Navigator Program:

(1) Office of the Insurance Commissioner’s (OIC) knowledge and experience in consumer assistance

through the SHIBA program is invaluable to the Navigator Program, particularly the training component.

OIC plays an active role on the Navigator TAC and continues to make resources and expertise available to

Navigator staff.

(2) Health Care Authority (HCA) is responsible for the Medicaid program and Navigators will assist

Medicaid enrollees, so a strong day-to-day working relationship will benefit low income and uninsured

enrollees.

(3) Department of Social and Health Services (DSHS) currently performs Medicaid determinations and will

implement use of the Healthplanfinder as a technology solution. DSHS staff is engaged in planning for

system design, training and implementation.

(4) American Indian and Alaska Native (AI/AN) stakeholders and representatives will work with the

Exchange to establish an independent Navigator Network that meets the unique needs and customs of

these populations. The Exchange is recruiting a Tribal Liaison who will lead this important effort.

Proposed Navigator Network Approach: Lead Organization Model

Consumers will be most inclined to trust Navigators who are members of their own communities, and we

plan to provide flexibility in how “communities” are formed. The Exchange plans to establish lead

organizations in designated geographic areas around the state. Lead organizations will have the flexibility

to determine the organizations best suited to provide Navigator services in their area and will oversee

the operations within their network. Counties are a convenient means of establishing reasonably sized


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service areas, but other options will be considered. Some areas may have one lead organization for two

or more small counties, while others may propose two lead organizations for a single county that is very

large. A lead organization may also serve a designated population, such as all members of a particular

ethnic group. Lead organizations may be either public or private entities.

This model draws Navigators from the “community” and allows one lead organization to deliver

Navigator services in a collaborative and efficient manner. Lead organizations will develop an education

and outreach plan to identify target populations and strategies to connect with them. Lead

organizations will also act as the financial agent and manager, monitor performance, conduct training,

and report performance data to the Exchange.

Enrollment Projections and Budget

Washington anticipates that up to 672,000 individuals could enroll for health care coverage (including

Medicaid) through the Exchange by the end of 2014.2 It is estimated that 20-25 percent of those who

enroll will need help from a Navigator or In-Person Assister. To help determine how the Navigator

Program might geographically focus resources and allocate funding, Wakely Consulting analyzed the

population of Washington to assess likely candidates for Navigator and In-Person Assistance support.

This analysis looked at population, household income, the number of uninsured, and other factors to

project the portion of Washington’s Navigator and In-Person Assister resources that a given county might

receive. The Navigator Program will use a broad needs-based index calculated from these factors to

disseminate funding to lead organizations.

The Navigator-In-Person Assistance budget for the period July 1, 2013 through December 31, 2014 is nine

million dollars. Of that, one million will be set aside for statewide efforts and six million will be allocated

to lead organization contracts. The remaining two million will be allocated in the second year to

organizations experiencing higher than expected demand or to cover other unforeseen circumstances.

(The Exchange’s request for supplemental In-Person Assistance funding is still pending approval.)

Lead Organization Compensation

The proposed compensation approach for lead organizations (and Navigator Organizations) is based on a

combination of (1) base pay that is paid in equal monthly increments and (2) outcome payments tied to

the achievement of enrollment goals. Organizations that fall short of enrollment targets will receive

compensation for the proportion of the target that is met. In addition, a payment differential of 25

percent is available to organizations that facilitate 50 percent or more of their enrollments from a target

group.

2 Washington State: Health Care Reform Update. Manatt. September 2012.


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Timeline

The first day of open enrollment is less than nine months away and Navigators must be ready to deliver

services beginning October 1, 2013. To meet this critical date, the Navigator Program needs Board

approval of the Navigator Program Implementation Plan by January 2013.

Approval of Navigator Program Plan January 2013

Exchange Issues RFP March 15, 2013

Submission Deadline April 30, 2013

Evaluation/Selection/Contracting Initiated May 30, 2013

Contracting Continues June 30, 2013

Contracts Begin July 1, 2013

Navigator Lead Organization Training July-August 2013

Navigator Organization Training-Certification August-September 2013

Open Enrollment Begins October 1, 2013


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SECTION I

Stakeholder Engagement

Washington has encouraged a broad and diverse group of stakeholders to participate in the Navigator

Program development process and the Exchange has benefited from their collective input in shaping

program recommendations. The primary stakeholders advising the Exchange on Navigator Program

development sit on the Navigator Technical Advisory Committee (NTAC), a group of nine Board-

appointed representatives selected for their expertise, experience and professional perspectives of

navigator-like entities and the at-risk populations that they serve in the state today. The Navigator

Manager meets regularly with the NTAC and actively solicits their counsel on policy and operational

issues. Meetings are open to the public and attendees are provided with an opportunity at each meeting

to pose questions and offer comments. All stakeholders are further encouraged to participate in the

design and development process by providing public comment during meetings or submitting comments

via the public website.

NTAC members include:

Devon Love, Center for Multicultural Health (Appointed 6/13/12)

Lara Welker, Whatcom Alliance for Healthcare Access (Appointed 6/13/12)

Michelle Sarju, Open Arms Perinatal Services (Appointed 6/13/12)

Rhonda Hauff, Yakima Neighborhood Health Services (Appointed 6/13/12)

Sofia Aragon, Washington State Nurses Association (Appointed 6/13/12)

Vicki Lowe, Jamestown S’Klallam Tribe (Appointed 6/13/12)

John Hamje, Office of the Insurance Commissioner (Ex-Officio) (Appointed 6/13/12)

Bethany Phenix, Community Minded Enterprises (Appointed 12/19/2012)

Jon Gould, Children’s Alliance (Appointed 12/19/2012)

STAKEHOLDER SURVEYS In November 2011, prior to the formation of the NTAC, Exchange consultant GMMB conducted a

statewide survey of 570 Washington residents (age 18 and older and in various income brackets) and

interviewed stakeholders from 16 community organizations from several sectors, including health care

associations, brokers, insurance carriers and consumer advisory organizations. The purpose of these

activities was to engage residents and stakeholders on the early direction of the Navigator Program and

to solicit input and recommendations on the qualities or traits most important for a Navigator and the

types of organizations best suited to deliver this service. Key findings from the GMMB research suggest


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the following considerations are important in the design and development of Washington’s Navigator

Program:

Navigators must be very knowledgeable in all aspects of Exchange business in order to deliver

accurate, relevant and current information to individuals and small businesses.

Navigators must be able to explain the options in clear, simple language appropriate to the

communities being served and need experience working in communities where homelessness,

poverty and low income is prevalent.

Navigators must be viewed as trustworthy sources of impartial information, optimally those

organizations that individuals already come into contact with on health matters.

The Navigator network should include a broad array of organizations that reflect the diversity of the

target population, and be skilled at meeting their unique cultural and language needs.

Approximately 30 percent of respondents indicated they would prefer or need the type of in-person

assistance that a Navigator would offer. Those who reported the highest need for Navigator

assistance are individuals:

Under 400 percent of federal poverty level

Age 40 to 64

With a high school degree or less

Who infrequently use the Internet

STAKEHOLDER INTERVIEWS In October 2012, Wakely Consulting interviewed more than 20 stakeholders to solicit input for the

development of the Navigator program and to listen to any recommendations or concerns. Wakely’s

findings confirm that stakeholders generally concur with the direction of Washington’s Navigator

Program. Key findings of the Wakely interview process include the following observations:

Stakeholders are generally united in a belief that the Navigator role should include a focus on

reducing health disparities, with a minority of interviewees expressing caution that this scope might

cause the program to overreach and potentially miss some opportunities to facilitate enrollment

given both time and resource constraints.

There appears to be strong consensus that the Statewide Health Insurance Benefits Advisors (SHIBA)

Program is highly valued and very effective for its current mission to provide Medicare and health

care coverage information to residents across the state, but is likely at risk for being overextended if

heavily relied upon in the Navigator Program. Interviewees enthusiastically commend SHIBA’s

volunteer advisors but support a Navigator program that relies primarily on participants with an

occupational position that can be more reliably leveraged on a day-to-day basis.

County Public Health Departments (or similarly capable entities, including private organizations) were

recommended by several interviewees as potentially appropriate entities to “steer” or manage

county-based navigator networks. This input helped lead to the design decision to largely rely on


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county-based navigator programs that encourage a strong local community approach to assisting

Washingtonians where they live.

Brokers (also known as licensed insurance producers) are currently compensated by carriers for

Direct Pay or Individual Market enrollments, with interviewees estimating that more than half of the

Direct Pay market is assisted by brokers. Interviewees questioned if and how brokers would be

allowed to facilitate enrollment in the Individual Exchange market (and if allowed to do so, how their

role would compare with that of the navigator role).

There appeared to be a lack of wide-spread understanding of how Call Center staff would likely

facilitate a majority of the enrollment

Stakeholder input and the key findings compiled by GMMB and Wakely have been used by the Navigator

Manager, NTAC and the Exchange to guide discussions and make decisions about how to design the

Navigator Program as a part of the overall Customer Support Program.

EXCHANGE VISION AND GOALS The Navigator Manager and the NTAC support the vision, mission and objectives adopted by the

Exchange Board and are committed to ensuring that the Navigator Program embraces the priorities and

principles of the Board and the Exchange. To this end, the design and development of the Navigator

Program reflect the following considerations:

Vision: Redefining People's Experience with Health Care Mission: Radically improving how Washingtonian’s secure health insurance through:

innovative and practical solutions

easy-to-use customer experience

our values of integrity, respect, equity and transparency; and

by providing undeniable value to the healthcare community (patients, providers, plans) Board Objectives:

Increase access to affordable health plans

Organize a transparent and accountable insurance market – to facilitate consumer choice

Provide an efficient, accurate and customer-friendly eligibility determination process

Enhance health plan competition on value – price, access, quality, service and innovation

NAVIGATOR PROGRAM GUIDING PRINCIPLES NTAC members are a hard-working, committed group of individuals who continue to give their time and

talent generously to support the development of a consumer-oriented, effective Navigator Program.

Early in their formation, the NTAC members decided to develop Guiding Principles to ground their work


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in principles and values believed to be fundamental to Navigator work. The product is a comprehensive,

thoughtful document that the NTAC uses as a compass when discussing challenging program areas.

The following is an abbreviated version of the NTAC’s Guiding Principles. For a complete copy of the

Guiding Principles, see Attachment A– Navigator Program Guiding Principles.

EXCERPTS FROM NAVIGATOR PROGRAM GUIDING PRINCIPLES Duty to the Consumer: Navigator organizations and representatives have a duty to put the health care

coverage needs of each consumer first. Navigator representatives explain a consumer’s options and

provide information about those options that help a consumer select the best plan for the consumer and

the consumer’s family. They must perform their Navigator duties impartially within professionally

accepted ethical standards.

Community and Consumer Trust: Navigator organizations must be trusted resources in the communities

they serve. Navigator representatives must demonstrate expertise and cultural competency in assisting

those they serve, including communities of color and vulnerable populations, low-income families,

individuals who are not functionally literate or have low-English literacy, families or individuals with

special health care needs, individuals with physical or mental disabilities, and individuals with substance-

abuse issues.

Promoting Health Equity: One of the Exchange’s overall objectives is to increase access to health care,

particularly for populations that have not had this access in the past. The Navigator program is of

paramount importance to promoting access to coverage for members of communities who have

historically had the greatest barriers to care, including lack of insurance.

Knowledge and Skills: Navigator representatives must possess the necessary knowledge and skills to

deliver high quality services. This includes knowledge of qualified health plans and other public health

programs and the competency to accurately explain relevant benefits, enrollment processes, and

eligibility requirements.

Timeliness and Accuracy: Navigator organizations must provide accurate and up to date information for

consumers. Navigator organizations must be able to nimbly and effectively inform communities and

community members about changes that may have an impact on their health coverage.

Enduring Relationships: A trusted Navigator organization remains a resource to community members

after the initial enrollment.


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ROLE OF THE NAVIGATOR: DUTIES AND RESPONSIBILITIES The ACA names five functions for Navigators:

Conduct public enrollment activities to raise awareness of the availability of QHPs;

Distribute fair and impartial information concerning enrollment in QHPs, and the availability of premium tax credits and cost-sharing reductions;

Facilitate enrollment in QHPs;

Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman or any other appropriate state agency or agencies, for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or determination under such plan or coverage; and

Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the exchange.

Around the context of these five functions, states enjoy wide latitude under the ACA in defining

Navigators’ roles, and Navigators are but one resource consumers can call upon for assistance in

understanding their eligibility and enrollment options. While many consumers will contact the

Healthplanfinder’s Call Center for assistance or enroll online directly, some consumers will need or prefer

the specialized attention of a Navigator. As envisioned by the ACA, Navigators are expected to support

consumers who may be harder to reach, perhaps because of a cultural or linguistic difference or a

disability. Or consumers might need more assistance because they lack familiarity with health insurance

coverage or are intimidated by the application process. For Washingtonians who need it, the Exchange is

committed to providing Navigator support services at the community level where the consumer is more

likely to connect with a trusted resource. As explained in depth below, lead organizations will be selected

to manage Navigator networks at a county or other type of “community-defined” level.

During the initial open enrollment period, the primary focus for Navigators in Washington State will be

one-on-one education and enrollment assistance to consumers. Navigators will be trained and certified

to facilitate enrollment in Medicaid or a selected QHP. Navigators will help eligible individuals learn

about and take advantage of advance premium tax credits and cost sharing benefits. Navigators will help

individuals to compare plan options, understand related costs and fees, and initiate enrollment.

Navigators will assist individuals to complete the online application accurately, explain the various

elements of the application, and answer any questions. The role of the Navigator is to facilitate

enrollment from a position of neutrality, free of any conflicts of interest. Further, while Navigators will

assist consumers with the process by explaining the options, plan differences, and costs, Navigators will

not make recommendations or provide subjective advice. Navigators will be available to provide

assistance in person, by phone, or though interactive technology to individuals throughout the State.

Additional Navigator functions, such as outreach, education, referrals, and coordination of services will

be supplemented by the addition of federally funded In-Person Assistance resources during the initial

open enrollment period in 2013 and through 2014. In-Person Assistance enables the Exchange to

dedicate substantially more resources to supplement Navigator application and enrollment efforts, as

well as accomplish targeted outreach and education goals.


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NAVIGATOR CHECKLIST The Navigator “checklist” below provides a snapshot of what a Navigator will actually do in the field:

Fulfill training and certification requirements

Remain up to date with the most current information available that may change or impact plans and program services.

Explain the role of the Navigator, the application and enrollment process, and consumer resources for complaints or questions.

Provide information and explain options impartially, without steering or recommending consumers toward or away from any particular plan or option.

Explain the results generated through the on-line application. o If a QHP, assist the consumer to compare the plan benefits and

costs and how each plan aligns with the consumer’s or the families’ health-related issues and needs.

o Facilitate selection of a QHP. o Explain subsidies or cost sharing options available and how to

use them. o Facilitate completion of application for subsidies or cost share

options selected by the consumer. o If eligible for a Medicaid Program, explain the enrollment

process.

Provide counseling and assistance for families as their financial circumstances change to explain options available to remain insured.

With the consumer’s consent, collect information about the individual and/or family members needed to complete an Exchange application

Assist the consumer to complete the on-line application

Based on information collected from a consumer, assess the need for services outside the Exchange and provide information and referral to other community services or public programs that may benefit the consumer.

Conduct public education events and activities designed to reach various populations to inform the community about Exchange related services, QHPs and other programs available through the Exchange, as well as subsidies and cost sharing benefits.

Conduct outreach in a variety of locations throughout the community(s) served to provide information about Exchange related services, QHPs and other programs available through the Exchange.


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IN-PERSON ASSISTANCE A new In-Person Assistance funding provision under the federal exchange establishment grants was

made available to states in August 2012. The Washington Health Benefit Exchange applied for this

funding in anticipation of the demand and need for consumer support during the first 18 months of the

Exchange’s operation. The availability of In-Person Assistance to supplement the Navigator Program

during initial enrollment and throughout 2014 will position the Exchange to assist significantly more

people. For example, Navigator organizations will be able to locate Navigator and In-Person Assister

representatives at strategic locations throughout the community where individuals and families are

already likely to be present, such as community service offices, community health centers, religious

institutions, clinics, and others. Providing in-person support in community locations will increase the

likelihood of reaching individuals and groups who may not hear about the Exchange through traditional

media outlets.

The Exchange also needs to ensure that Navigators and In-Person Assisters who conduct outreach and

assist with applications and enrollments from community locations and in rural areas have adequate

technology to efficiently perform their work. The Exchange will make technology tools available to lead

organizations as needed to ensure that Navigator organizations can equip Navigator/In-Person Assisters

appropriately.

To leverage the Navigator network already planned, the majority of In-Person Assistance funds will be

disseminated to lead organizations to supplement Navigator resources. With these additional resources,

organizations will have the capacity to begin outreach and education earlier, raising community

awareness about Exchange benefits and promoting the open enrollment period. In addition to material

provided by the Exchange, organizations will be able to develop outreach and educational materials and

conduct events that reflect the cultural, language and social needs of their local communities. By

developing material and events designed to address the unique needs of their communities,

organizations will greatly increase enrollments and health care coverage for those who have had very

limited access to care.

In addition to helping with application and enrollment, outreach and education, In-Person Assisters will

have a role in providing follow up assistance subsequent to open enrollment. Organizations will provide

assistance to individuals who have questions about how to get started, about coverage for family

members, and about changes in family status or income that impacts their insurance and necessitates

change requests or other interventions by a Navigator. In-Person Assisters can be used to provide this

support.

The Exchange will also commit a portion of In-Person Assistance funding to organizations with a

statewide presence in Washington. These are organizations that have a broad reach and play a key

leadership role with service organizations, medical institutions and other entities who currently assist

individuals with health care coverage needs and who will need to be oriented to the Exchange and how


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to partner with it. The Exchange will develop training and education material for these organizations to

use with their members and partner agencies throughout the state.

As the availability of continued federal support beyond 2014 is uncertain at this time, the Navigator

Program plans on transitioning all in-person functions to Navigators as Program demand declines to a

maintenance level of services in 2015. By 2015, Navigator organizations will phase out In-Person

Assistance. This gradual transition will enable Navigator organizations to assess the level of staffing

needed to maintain the program and anticipate in advance the need to phase out the use of In-Person

Assistance over time. Should federal support continue to be available beyond 2014, the continued use of

In-Person Assisters will be reassessed to ensure that Washington is well positioned to bring affordable

health care to as many Washingtonians as possible.

The Exchange envisions that all individuals providing Navigator/In-Person Assistance must complete

appropriate training. Organizations that choose to use In-Person Assisters to perform application-

through-enrollment support must also ensure that these Assisters meet the same training and

certification requirements that apply to Navigators. If functions are limited to community outreach,

education, coordination with other service organizations, or other supportive services, certification is not

required.

AGENTS AND BROKERS Licensed agents and brokers have considerable knowledge about the health care insurance options in

Washington and are a trusted resource for helping people select and enroll in coverage. We expect that

agents and brokers will also be a key partner in assisting individuals for whom enrollment in a Qualified

Health Plan offered by the Exchange is the right choice. To facilitate full participation, the Exchange is

working with the agent-broker community to develop a business model that supports their work.

Exchange guidance and training will define the roles of agents and brokers and shape a process that

encourages collaboration and/or referral between Navigators and the agent-broker when it is in the best

interests of a customer.

NAVIGATOR TRAINING The Navigator Manager and NTAC considered a number of training implementation options and

ultimately decided to use a train-the-trainer approach. Under a train-the-trainer model, the Exchange

will be responsible for educating lead organization trainers, and these trainers will then train the

Navigators (and Assisters) working within the lead organization’s network. The Exchange will develop all

training materials, administer and process the certification exam, and distribute the exam results. The

Exchange will also be responsible for maintaining Navigator documentation, which will include

assurances on confidentiality and conflict of interest requirements. Once a Navigator has successfully

passed the exam and submitted these assurances, the Exchange will establish appropriate systems access

for the individual. In November 2012, the Exchange hired a Navigator Training Manager/Specialist to lead

the efforts around Navigator training.


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The lead organization will be responsible for reviewing and approving Navigator applications from

Navigator Organizations. Lead organizations will be expected to manage all training-related logistics

(location, schedule, enrollment and completion records) and for providing technical assistance and

subject matter expertise to Navigators (and Assisters). Lead organizations will also be expected to

mentor Navigators and provide training evaluations.

This train-the-trainer model creates a strong knowledge base and consumer support at a field level, while

ensuring the Exchange is responsible for the development and delivery of a uniform training program.

The NTAC and Consumer Workgroup are teaming to organize an ad hoc work group to work on

development of the training planning efforts and the certification process. These workgroup members

will have experience with training programs and will be able to suggest best practices related to

protecting privacy and safeguarding confidential information, ensuring the delivery of impartial services,

and other components of a comprehensive curriculum. A sample overview of the curriculum is shown

below in Exhibit 1.

Ensuring that Navigators are properly certified and trained, and that their work is impartial, effective and

efficient are critical Exchange priorities both from the standpoint of consumer protection and program

integrity, but also from the standpoint of financial management and fiscal stewardship.

NAVIGATOR CURRICULUM SAMPLE OVERVIEW

Exhibit 1: Washington Navigator Curriculum – Sample Overview Module 1: Navigator Certification Process

Role and Responsibilities of the Navigator Impartiality

Application and Exam Acceptance Process (and Appeals)

Conflict of Interest Restrictions Navigator Healthplanfinder Portal

Confidentiality/HIPAA Navigator Support

Module 2: Navigator Program Overview Key External Partnerships (OIC; HCA; DSHS;

AI/AN)

In-Person Assister Services Key Internal Partnerships

Role of Lead Organizations Navigator Tools and Technology

Needs of Underserved and Vulnerable Populations

Data Collection and Reporting Requirements

Cultural and Linguistic Needs; Disabilities Compensation

Module 3: ACA Requirements ACA Background/National Health Reform ACA State-based Individual Exchange

Specific Requirements/Full Overview

Module 4: Washington Health Benefit Exchange Vision, Mission, Objectives View of the WA State Marketplace

Module 5: Tax Credits and Cost Sharing Subsidies Individual Exchange: APTC and CSRs Federal Data Hub

Eligibility WA State-Specific Data Sources

Web Site Calculator Reconciliation

Module 6: Medicaid and Apple Health for Kids


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Eligibility “No Wrong Door”

Enrollment Medicaid Benefits and Limitations

Module 7: Qualified Health Plans (QHPs) and QHP Issuers Essential Health Benefits QHP Issuer Snapshots

QHP Metal Tiers (Platinum/Gold/Silver/Bronze)

QHP Issuer Network(s)

Individual Exchange: o Plan offerings/benefit coverage o Selecting a plan o Rating and rates o Enrollment dates o Consumer rights/inquiries/grievances/appeals

SHOP Exchange (Overview of plans/rates/dates)

Module 8: Working with the Washington Health Benefit Exchange Overview of Exchange Leadership and Governance

Overview of Key Departments o Finance/Billing/Enrollment Operations/Call Center Management/Marketing &

Outreach/PR & Media Relations/Navigator Manager/Program Oversight/Broker Relations/Appeals Management/SHOP Exchange

Module 9: Healthplanfinder Website for Public Browsing, Education and Enrollment


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NAVIGATOR PROGRAM METRICS As shown in Exhibit 2 below, the Washington Healthplanfinder offers multiple data collection

opportunities for tracking and reporting on key performance measures. This information and data will

provide the Exchange with valuable metrics that can be used to understand and improve systems and

processes that facilitate enrollment and make it easier for customers to enroll and stay insured.

Enrollment data can be tracked and reported by numerous measures, such as number of applications,

number of enrollments, number of enrollments by metal tier or by Medicaid, and the number of dis-

enrollments. The system will also allow the Exchange to measure the average time it takes to complete

various actions (i.e., average number of days/hours from application completion to enrollment, or

average number of days/hours from first Navigator action to enrollment). Data from at-risk groups will

be collected and analyzed (i.e., applications and/or enrollments by income level; primary language other

than English, and homeless status at time of application).

For data that cannot be tracked in the Healthplanfinder systematically, Navigators and lead organizations

will be asked to assist with data collection and reporting. This type of data might include: the number of

public education/awareness events per month by lead organization and/or location (including a

description of the target audience); and such demographics as education level, the number of times an

individual has moved in the last 12 months, the number of months/years since last enrolled in health care

coverage; any current coverage (direct pay coverage for individual or household; employer sponsored or

public program) and how the consumer receives care today (primary care physician; community health

center or clinic; ER; or have not received care in the last 12 months).

The Exchange will develop a “dashboard” or “scorecard” tool to use for internal and external

communication that combines several key Navigator performance indicators in a single, easy to visual.

Program metrics will be collected at the Navigator/In-Person Assister level, Navigator organization level,

lead organization level and statewide to ensure that all those involved in the program are aware of key

outcome measures and to enable the Exchange to compare performance across different metrics and

organizations. Program metrics will be assigned separately from the outcome-based compensation

targets.


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Exhibit 2

Washington Healthplanfinder: Data Fields for Tracking Navigator Metrics

Application-Enrollment Data At-Risk Data

# Pings to Navigator # Applications by Income level

# Applications # Enrollments by Income level

# Enrollments % Applications by Income level

# Enrollment Households % Enrollments by Income level

# Enrollments - QHP # Applications by Primary language other than English

# Enrollments – QHP Platinum # Enrollments by Primary language other than English

# Enrollments – QHP Gold % Applications by Primary language other than English

# Enrollments – QHP Silver % Enrollments by Primary language other than English

# Enrollments – QHP Bronze # Enrollments by Homeless status at application

# Enrollments - Catastrophic % Enrollments by Homeless status at application

# Enrollments with APTC Average Time to Complete Action Data

# Enrollments - Medicaid Average # days/hours from “ping” to Navigator action

# Enrollments – Mixed (Medicaid & QHP) Average # of days/hours from first Navigator system action to Application Completion

# Applications Resulting in Enrollment Average # of days/hours from Application Completion to Enrollment Completion

Enrollment Rate: Percentage of Applications that Result in Enrollment

Disenrollment Rate: Percentage of Enrollments with Subsequent Disenrollment


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KEY STATE AGENCY AND TRIBAL PARTNERSHIPS The Exchange expects that that there are at least four key partnerships that must be recognized in the

day to day operation of the Exchange, as well as in the development and implementation of the

Navigator Program. These four partners include: (1) Office of the Insurance Commissioner (OIC); (2)

Health Care Authority (HCA); (3) Department of Social and Health Services (DSHS), including the Economic

Services Administration; and (4) American Indian and Native Alaska (AI/AN) stakeholders and

representatives in state government. Exchange and Medicaid enrollees will benefit most from a spirit of

close collaboration and cooperation between the Exchange and its Navigator Program and these partners

who are all integral to the success of Exchange itself as well as the expanded Medicaid program.

“We’re here to protect insurance consumers.” The motto of the Office of the Insurance Commissioner

confirms the need for a close working relationship between the Exchange and the OIC. The key functions

of the OIC impacting Exchange operations include: licensure of insurances companies and agents and

brokers, oversight of rate requests and filings, collection/investigation/tracking of consumer complaints

against insurers, agents and brokers, management of the SHIBA program and general assistance to the

public in finding affordable health care coverage. Representation from OIC on the Exchange technical

advisory committees for both Navigators and Agent/Brokers (NTAC and Agent-Broker TAC) has been

instrumental in helping to shape the Navigator Program over the last several months. OIC is also

committed to sharing SHIBA program knowledge and resources with the Navigator Program’s Training

Manager/Specialist to ensure that Navigators benefit from the SHIBA learning experience over the last

several years. Given the long running success of the SHIBA program in connecting Washingtonians with

affordable health care, the support is expected to make a considerable impact in the development of the

Exchange Navigator training program.

“Shaping the Future of Health Care.” The title of the Health Care Authority’s July 2012 annual report on

health care purchasing in Washington State speaks to the partnership that exists between the Exchange

and the HCA, Washington State’s primary health care purchasing agency for Medicaid (including Apple

Health for Kids). Today, HCA serves more than 1.2 million Medicaid and medical assistance clients with

an agency projection of more than 325,000 new clients under the 2014 Medicaid expansion program.

Together, the Medicaid expansion program and availability of affordable coverage through the Exchange

are expected to significantly reduce Washington’s uninsured population. With the ACA’s “no wrong

door” vision and the expectation that many individuals eligible for Medicaid will be assisted by

Navigators, it behooves the Exchange and HCA to work closely together on outreach, operational and

policy considerations jointly impacting both entities. The alignment between the Exchange and HCA will

be demonstrated further when all current Medicaid enrollees are transitioned to the Exchange through

the completion of a single application in Washington Healthplanfinder, a major undertaking for both

parties. HCA has worked hand-in-hand with the Exchange to ensure that the Healthplanfinder can

accommodate all Medicaid eligibility, enrollment and renewal requirements. The shared platform will

closely link HCA and the Exchange together for the long term and both parties stand to benefit from one

another’s success.

“Transforming Lives.” The Department of Social and Health Services (DSHS) is an integrated organization

with multiple programs working in partnership to help transform the lives of Washingtonians, with a


20

mission to improve the safety and health of individuals and families. Of primary importance, DSHS

Community Service Offices (CSOs) currently perform Medicaid medical determinations, and will

implement use of the Healthplanfinder as a technology solution in 2013. DSHS staff will need to

understand how to help individuals they encounter who may not be eligible for Medicaid, but are eligible

for other subsidized or unsubsidized insurance options. The Exchange is involving DSHS in system design

and training discussions to ensure they have the information they need to continue performing Medicaid

medical determinations and to connect those not eligible to the right Exchange customer support

resource.

AMERICAN INDIANS AND ALASKA NATIVES (AI/AN) With the sixth largest American Indian and Alaska Native (AI/AN) population in the country, Washington

has a pronounced need to meet its obligations under the ACA to provide for the unique Exchange and

Navigator Program needs of the state’s estimated 192,000 AI/ANs (representing almost three percent of

the total state population).3 The ACA requires that states adhere to a number of provisions specific to

AI/AN people, intended to the improve the health of this vulnerable population as well as to support the

Indian health system’s participation in the Washington Health Benefit Exchange and the 2014 Medicaid

expansion. With almost one in four (23.1 percent) AI/ANs in Washington uninsured (a rate that is almost

double the statewide rate of 13.4 percent), the Exchange has paid particular attention to the stakeholder

voices of this population. In early 2012, the Exchange commissioned a Tribal analysis report to identify

how the Exchange and the Navigator Program could best accommodate the ACA requirements.4

The Tribal analysis report outlined in detail the state’s obligations under the ACA and we list only some of

the more relevant provisions impacting the Navigator Program here:

AI/AN cost sharing exemption: Unlike the general population, AI/AN people with incomes up to

300 percent of the Federal Poverty Level (FPL) are exempted from any cost-sharing

requirements in the Exchange’s individual market.

Tribal Program cost sharing provisions: Qualified health plans (QHPs) may not reduce payments

to providers to offset the cost of the AI/AN cost sharing exemption.

Health insurance penalty exemptions: While most citizens will be required to enroll in health

insurance or pay a penalty, members of an Indian tribe are exempt from this penalty.

AI/AN enrollment periods differ: The ACA permits AI/AN enrollees to be eligible for special

monthly enrollment periods to facilitate prompt enrollment in Exchange programs.

Coupled with the cultural differences of AI/AN people, the ACA provisions suggest that enrollment

facilitation of AI/ANs is best placed within the Tribes, where members are more likely to trust an

“insider’s” assistance with enrollment needs. For all of these reasons, a Navigator Program unique to

AI/ANs will be established outside the larger program design. This recommendation for establishing an

3 Tribal Analysis for Washington State Health Benefit Exchange & Health Care Authority. American Indian Health

Commission for Washington State. April 1, 2012. 4 Tribal Analysis for Washington State Health Benefit Exchange & Health Care Authority. American Indian Health

Commission for Washington State. April 1, 2012.


21

independent program is supported by Tribal members who are represented on the NTAC and Advisory

Council. (Tribal members could choose to receive services from a non-Tribal Navigator Organization or

from the Tribal Navigator Program.) Additional collaboration between the Exchange staff and the lead

Tribal agency will be needed to ensure that AI/ANs who elect to contact a Navigator entity outside the

Tribal Program or the Call Center are provided with accurate information consistent with the special

provisions in the ACA. These provisions also have direct impacts to the design of the web portal and data

systems (for example, both will need to allow AI/ANs to self-identify in order to fully benefit from all ACA

provisions intended to support this vulnerable population5). The Exchange is currently recruiting a Tribal

Liaison to work closely with the Tribes to establish and implement services that reflect their needs and

customs, and Exchange operational staff will monitor AI/AN requirements to ensure ongoing compliance.

For all of these reasons, it is important for the Exchange to continue to partner and consult with

appropriate representatives of AI/AN people.

KEY INTERNAL EXCHANGE COLLABORATIONS While Navigators are a crucial source of outreach, education and enrollment assistance, they are not the

only means of assistance available to prospective enrollees and the general public. The Exchange Call

Center team will play a significant role in facilitating enrollment and helping callers with whatever

inquiries they might have regarding the Exchange. In fact, The Call Center team will assist far more

members with enrollment and ongoing support needs than the Navigator Program, which the ACA

envisions as an added source of assistance for the most vulnerable and at-risk prospective members.

While Navigators will assist many of their enrollees on a face-to-face basis, Call Center staff will interact

with enrollees over the phone, by mail and by co-browsing sessions on the Exchange’s website. In

general, the Navigator contacts are likely to be more time-consuming and more sensitized to the cultural

and linguistic needs of the enrollee. Nonetheless, both teams need to work together in order to ensure

the needs of the enrollee are fully met in the most effective and cost efficient manner, with minimal

duplication of effort and no contradictory information. Both groups will need to know when it is best to

refer enrollees to the other. For example, if a prospective enrollee contacts the Call Center and asks for

face-to-face assistance in a convenient location, the Call Center representative will need to know what

Navigator entity is best able to assist the enrollee given his or her location, cultural, linguistic and/or

other unique needs. (The Healthplanfinder has a search tool that makes it easy to locate a Navigator

near the individual and identifies those Navigators with language fluencies.) Similarly, if a Navigator is in

the field assisting the enrollee and s/he has benefited from the encounter but is unlikely to need or want

continued Navigator assistance to complete the enrollment, the Navigator might encourage the enrollee

to contact the Call Center. The training program will emphasize collaboration and collegial respect for

the type of support each team brings to the table.

Similarly, Navigators will be in the community along with agents and brokers, and the Exchange will want

to ensure that the two parties do not compete with one another to the detriment of the consumer. To

this end, the Exchange intends to provide guidance to ensure that both groups present a united,

5 Kris Locke and Mim Dixon. Tribal Planning for Health insurance Exchanges Begins Now. Prepared for the Tribal

Self-Governance Advisory Committee. April 13, 2011.


22

collaborative approach. As an example, if an enrollee has an existing relationship with a broker, then a

Navigator should encourage him or her to continue that relationship barring any circumstances that

suggest otherwise. Similarly, a broker may need to consider the cultural or linguistic needs of an

individual and refer him or her to a Navigator that is better suited to put the enrollee at ease and

facilitate the enrollment in a trusted environment. A Navigator will also be trained to refer a consumer

to an agent or broker when the consumer is looking for a specific recommendation on their plan

selection. For consumers who prefer to work with an agent or broker, the Healthplanfinder will have the

capacity to allow consumers to search for agents and brokers in their area.

Last, Navigators and Small Business Health Options Program (SHOP) staff will need to know when to call

on each other to better support an enrollee. For example, an individual might be currently enrolled in or

eligible for coverage in an employer-sponsored insurance plan but may be eligible for either Medicaid or

subsidized coverage in an Exchange coverage option. If this individual is unsure as to what is in his or her

best interests, the SHOP should put the individual in touch with a Navigator with the knowledge and

expertise to better support the individual.

In all of the scenarios above, a spirit of cooperation, collaboration and efficiency between Exchange

customer support representatives should prevail and the Navigator training approach will highlight how

these opportunities can be leveraged to the benefit of the enrollee.


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SECTION II

NAVIGATOR NETWORK APPROACH: LEAD ORGANIZATION MODEL The intent of the Navigator Program is to create a Navigator presence in community organizations and

locations where people typically gather to do business, to enjoy free time, to participate in community

events, or to seek services or assistance. The Exchange envisions a Navigator Network that is visible to a

diverse population of individuals who make up the uninsured and underinsured in Washington State.

The network must also conduct outreach to connect with consumers who will be harder-to-reach or

unlikely to initiate contact on their own for any number of reasons. They may have cultural or linguistic

differences that make them hesitant to ask for conventional assistance, or they may be unfamiliar with

how to access affordable health insurance simply because they have not had coverage for a very long

time. Perhaps they have a disability or are simply fearful of asking for governmental assistance or the

help of a stranger.

For all of these reasons, and undoubtedly many more, a Navigator designated to serve at risk populations

or groups with unique needs must have the knowledge and skills to be perceived as credible, trustworthy

and approachable by consumers. The likelihood of this happening is greatest if Navigators are rooted in

the same community that the consumer is most comfortable in, finds the easiest to relate to, or perhaps

simply calls home. For these reasons, the Exchange has decided to establish a lead organization model in

establishing its Navigator Program.

In most instances, a lead organization (either private or a governmental agency) will be designated for

each county, or for very small counties, for a grouping of counties (sometimes the county borders will be

contiguous and sometimes not). In some areas, more than one lead organization may be designated –

perhaps because the county is very large or because there may be distinctly different populations within

the geographic area whose cultural or linguistic needs are better served by different lead organizations.

The lead organization centric model will have sufficient flexibility to ensure that a lead organization can

elect to serve either a geographic area or a designated community-defined population, and that more

than one lead organization may be selected when appropriate. Once contracted, the lead organization

will select, train, and oversee the delivery of all Navigator and In-Person Assistance services to consumers

in the given geographic or community-defined area.

The lead organization centric model is depicted below:


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Note: The number of participating agencies, organizations/individuals and representatives may vary.

There has already been significant interest from organizations and associations throughout the state

interested in serving as lead organizations. In consultation with the Navigator TAC, the Exchange is

drafting organizational qualifications as well as selection criteria to be used in procuring contracts with

lead organizations. Procurement will be initiated through a Request for Proposal (RFP) and substantial

input from the TAC and other stakeholders has been integral to the development of lead organization

requirements and responsibilities.

Once Board approval for the Navigator Program is secured, the Exchange will publish the RFP for

interested Navigator lead organizations (February/March). Lead organizations will be and the contracting

process will be initiated. The Exchange will work with lead organizations to help identify the community-

based organizations that will make up the Navigator network.


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LEAD ORGANIZATION SELECTION CRITERIA The RFP is expected to be finalized in February-March 2013. Evaluation and selection criteria for

successful lead organizations will be developed from the organizational requirements included in the RFP

and organized into the following categories: Organization Profile; Organizational Experience and

Organizational Resources. Key elements for each of these sections are provided below.

Lead Organization Profile:

Organization purpose and programs administered

Proposed county/counties to be managed and/or target population to be served

If proposing to serve as lead organization for a segment of the population, estimated number of

individuals who will be served through this contract

Demonstrate that the organization has existing relationships or the ability to establish relationships, with potential users of the Exchange (i.e., uninsured, low income, Medicaid-eligible, military, AI/AN, disabled, linguistic and cultural needs, etc.)

Length of time in operation in the county/region and/or serving the target population.

Organization provides health insurance/health benefit counseling as a primary service.

Organization currently determines a consumer’s eligibility and/or completes enrollment for public health care services or benefits.

Organization staff is experienced and skilled using computer applications

Organization’s staff reflects the diversity of the population served.

Organizational Experience

Similar projects/efforts successfully managed in the past 3 years

Experience overseeing other collaborative efforts involving community organizations that deliver

navigator-like services in the past 3 years

Experience, resources, approach and/or methods for assuring the delivery of Navigator services that

meet:

o The cultural and/or language needs of consumers

o Accessibility needs of people with disabilities

Communication approach with community-based partners for disseminating information and

announcing changes that impact community members.

Experience developing outreach efforts in the past 3 years to meet target or at-risk populations.

Include the nature of the outreach, population(s) targeted and a description of methods/approaches

used.

Experience communicating complex programs in terms and languages suited to target populations.

Approach the lead organization will use to ensure Navigators and consumers have a way to provide

input and make suggestions on process improvements.

Methods used by the organization to engage the community and solicit input on community

initiatives during the previous 12 months


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Organizational Resources

Number and position titles of staff the Navigator lead organization will assign to perform the work

under the contract. Identify for each position title:

o Number of existing staff in the position with expertise and experience in health care coverage

plans and programs, including Medicaid Programs and number of staff expected to be hired

to perform this function (if any);

o Number of existing staff in the position with experience delivering training and number of

staff expected to be hired to perform this function (if any);

o Number of existing staff in the position who will conduct outreach and education activities

and number of staff expected to be hired to perform this function (if any);

o Number of existing staff in the position with responsibility for management and oversight of

the activities in the Statement of Work and number of staff expected to be hired to perform

this function (if any).

LEAD ORGANIZATION RESPONSIBILITIES Lead organizations will provide Navigator and In-Person Assistance services in a specified geographic area

and/or for a designated community-defined population. Lead organizations will develop and oversee a

network of community-based organizations that will deliver one-on-one consumer assistance needed by

individuals to access insurance options available under the Washington Health Benefit Exchange.

The lead organizations will be responsible for developing an Outreach Plan that identifies target

populations and strategies for reaching these target groups. The lead organization will then be

responsible for recruiting, evaluating and selecting the community-based organizations best suited to

accomplish this work. As explained in Section I, lead organizations will coordinate with the Exchange on

training and certification of Navigators and organization staff. Training will be executed through a “train-

the trainer” model. In addition, lead organizations will direct outreach efforts for the overall service

area/population and coordinate public education and outreach efforts. Lead organizations will be

responsible for monitoring the performance of Navigators and In-Person Assisters as well as the

Navigator organization and reporting the results to the Exchange. Lead organizations have the flexibility

to engage individual Navigators (not affiliated with a Navigator organization) at their discretion based on

community needs and the lead organization’s capacity to administer and oversee individual agreements.

Individual Navigators must meet the same training and certification criteria as Navigators who work for a

Navigator organization.

Specific lead organization responsibilities to be outlined in the draft RFP include but are not limited to the

following:

Identify community organizations most qualified to meet Navigator organization and Navigator representative responsibilities, when services are to be provided by other than lead organization.

Assure the service delivery network provides access to the broadest population possible, particularly for Exchange target populations and other hard-to-reach populations.


27

Assure a variety of methods are used to conduct outreach that reflects the cultural, language or other needs of the target population.

Establish agreements with organizations that meet organizational requirements and responsibilities as set out by the Exchange in order to serve as Navigator organizations.

Assist Navigator organizations with infrastructure, technology and staffing assistance, as needed.

Coordinate with the Exchange for the delivery of training to Navigator organization staff (the Exchange will utilize a “train-the-trainer” approach).

Coordinate with the Exchange to assure that staff meets all training and certification requirements.

Provide mentoring and technical assistance to Navigator organization staff.

Submit required reports to the Exchange at specified intervals.

Ensure consumers are provided easy access to consumer rating tools as outlined by the Exchange to evaluate service quality and effectiveness.

Ensure each Navigator organization has consumer processes in place to address: o Collecting and reporting consumer suggestions or other feedback about Navigator activities

or processes to the lead organizations and to the Exchange. o A complaint resolution process that provides for resolution at the lowest level possible and

provides consumers the option of contacting the lead organization or the Exchange for assistance if an issue cannot be resolved satisfactorily.

o Review and resolution for situations in which a Navigator error or omission results in an adverse financial or other impact to a consumer.


28

SECTION III

THE GOAL: LOCAL , COMMUNITY-ORIENTED NAVIGATOR NETWORKS The expectation and goal of the lead organization contracts is the development of a network of multiple

community-based organizations within various geographic areas around the state. These organizations

should serve or interact with various segments of the community so that the network broadens its reach

to as many people likely to benefit from Exchange plans and programs as possible. The Navigator

Network should include, but not be limited to, community-based organizations that target services to

members of the community who have been uninsured, underinsured or who have experienced health

disparities due to lack of affordable health care options. For example, the ACA requires states to select

Navigators from at least two types of entities; one must be a community and consumer-focused non-

profit group. The second type of entity may be from any of the following other categories: trade,

industry, and professional associations; commercial fishing industry organizations, ranching and farming

organizations; chambers of commerce; unions; resource partners for the Small Business Administration;

licensed agents and brokers; Indian tribes, Tribal organizations, urban Indian organizations, and state or

local human service agencies.

Exchange stakeholders and NTAC members have provided substantial input about the characteristics and

qualities that organizations serving in the Navigator role will need in order to deliver high quality,

effective services to consumers. The Exchange will strongly encourage lead organizations to use these

criteria as evaluation guidelines and/or criteria in their selection process.

ESTIMATING THE SIZE OF THE NAVIGATOR PROGRAM AND IN-PERSON

ASSISTANCE BUDGET To project the needed size of the Navigator Program and expected costs for In-Person Assistance for July

1, 2013 through December 31, 2014, estimates on the number of Washington consumers “likely to take

up” coverage in either an Exchange QHP or Medicaid/CHIP were utilized. Manatt Health Solutions

estimates that approximately 672,000 individuals could enroll for health care coverage (QHPs or

Medicaid) through the Exchange by the end of 2014. While anyone can request Navigator/In-Person

Assistance services, those most likely to use a Navigator/In-Person Assister include: individuals with

complex care needs who are new to the insurance market: at-risk individuals, low income and/or limited

education households; people with cultural or linguistic differences; individuals with disabilities; and

members of certain target groups, such as individuals who have not had access to health coverage in the

past. Such consumers are estimated to represent 20-25% of those eligible for coverage or 168,000

individuals (25 percent of 672,000).


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Post-Implementation Coverage in Washington State6

Since Washington has designed an integrated, online application process for both Medicaid and QHPs,

the number of individuals becoming eligible for Medicaid will likely increase the need for In-Person

Assistance during the initial open enrollment period.

BUDGET PROJECTION The Exchange estimates that a single application will take approximately one hour to complete with

Navigator or In-Person Assistance, including the time it will take to explain information and answer

consumer questions. This totals 168,000 hours to complete applications and facilitate enrollment through

2014 for the population likely to take up coverage and who are also expected to need Navigator/In-

Person Assistance. This translates to approximately 170 people working six hours per day statewide for

all days during open enrollment periods through 2014. Additional time will be spent training individuals

to perform these services, traveling to community and other remote locations, education, outreach,

coordination with other programs, ongoing plan changes, assistance accessing plan services, and other

related functions. The estimated cost of providing Navigator and In-Person Assister services based on

these factors is nine million for the 18 month period of July, 1, 2013 through December 31, 2014. Of this

amount, one million will be allocated to statewide efforts and two million will be held for any needed

reallocations to Navigator lead organizations in 2014, either because of unforeseen circumstances or

because lead organizations experience higher than projected demand. The balance of the budget, or six

million, represents the initial 18 month allocation to lead organizations for Navigator and In-Person

6 Source: Washington State: Health Care Reform Update, prepared by Manatt, September 2012.

2

0

1

4

2014


30

Assistance services as well as lead organization program costs. The proposed compensation approach to

lead organizations is outlined below, following the discussion of how the Exchange might allocate and

distribute funding by geographic area.

This budget reflects the Exchange’s best efforts to mitigate costs by leveraging navigator-like

organizations that already serve Exchange-eligible populations and deliver similar services. Some

organizations already deliver similar services without Exchange funding; however their capacity to

efficiently meet peak demand would be wholly inadequate. Recruiting existing, community-based entities

engaged in this work and providing resources to expand their capacity will save money and time spent

developing entirely new programs. This also reinforces Washington State’s “no wrong door” approach by

expanding the ways in which individuals can access the Exchange.

The Exchange will need three additional staff positions to implement and administer the In-Person

Assistance Program. These Exchange positions will be established on a project basis to reflect the time-

limited nature of In-Person Assistance. These positions will assist with training and certification,

contract/grant management and monitoring, performance reporting, system administration for

Navigators/In-Person Assisters, and other administrative functions. Level Two grant funding is being used

to fund the operational component of the Navigator program at a level that reflects the estimated

ongoing, long term needs.

Barring notice of continued federal support for In-Person Assister services after 2014, organizations will

phase-out all In-Person Assister project workers and transition all duties to Navigators by January 1, 2015.


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In-Person Assistance Phase Out by 2015

ASSESSMENT OF LIKELY EXCHANGE-ELIGIBLE POPULATION AND ALLOCATION

OF RESOURCES METHODOLOGY To help determine how the Navigator Program might geographically focus resources and allocate

funding, Wakely Consulting analyzed the population of Washington to assess likely candidates for

Navigator and In-Person Assistance support (the full report is provided as Attachment B). This analysis

looked at population, household income level, the number of uninsured, and a few additional factors to

project the portion of Washington’s Navigator and In-Person Assistance resources that a given county

might receive.

Unless noted otherwise, the primary source of information used to conduct this analysis was the 2010

American Community Survey (ACS) 5-year estimate. The ACS is administered by the U.S. Census Bureau.

FEDERAL POVERTY LEVEL (FPL) Household income data for Washington and the state’s 39 counties were derived from the 2010

American Community Survey (ACS) 5-year estimate. Wakely examined three significant Federal Poverty

Levels (FPL): 138% FPL, 250% FPL, and 400% FPL. These particular levels were chosen based on their

potential relevance to Navigator and In-Person Assistance programs. Because Navigators will serve both

Medicaid/CHIP eligible and Exchange individuals, these categories can provide insight into the level of


32

assistance needed. Wakely’s analysis assumes that individuals who apply for Cost-Sharing Reductions

(from 100-250% FPL) will need more assistance than individuals whose income is above 250% FPL. It

further assumes that those individuals who qualify for premium assistance (under 401% FPL) will require

more assistance from Navigators and In-Person Assisters than those who are above 400% FPL.

Due to the fact that the ACS provides household income levels based on survey results from 2006-2010,

Wakely based the analysis on 2010 Federal Poverty Levels. The following table shows different FPLs

based on number of people in a family, sourced from the Department of Health and Human Services.

(Source: http://aspe.hhs.gov/poverty/10poverty.shtml)

The ACS household income data do not distinguish size of household. While it is acknowledged that this

lack of distinction means that the actual number of households categorized by FPL group would differ

from the numbers presented in the analysis, it is also reasonable to assume that the relative numbers of

households in each FPL category across counties and regions in Washington would most likely be very

close to the numbers presented. The ACS notes that the average Washington household has 2.5 people

and that the average family in Washington consists of 3.1 people. Using this information, Wakely

conservatively assumed that all Washington households contained 3 people and calculated FPL

accordingly. The HHS poverty guideline information listed above indicates the FPL for 3 individuals is

$18,310. Wakely assumed 138% of FPL to be $25,000, 250% of FPL to be $50,000, and 400% of FPL to be

$75,000. While these can be viewed as rough assumptions, the ACS provides income data by county for

specific income brackets. The analysis focuses on proportions and these assumptions will not affect

outcomes.

UNINSURED The number of individuals in each county that do not have health insurance was derived from the 2010

American Community Survey 3-year estimate. The ACS did not begin collecting health insurance coverage

information until 2008, and therefore the 2010 3-year estimate was used.

http://aspe.hhs.gov/poverty/10poverty.shtml


33

Unfortunately, health insurance coverage data was only available for 30 of Washington’s 39 counties, due

to small sample sizes in the 9 least populous counties. However, an estimate for the total number of

uninsured in Washington was presented, and Wakely calculated the estimated number of uninsured for

the 9 counties in total. These 9 counties were analyzed as a group and labeled “Remaining 9 Counties.”

The nine counties include Adams, Columbia, Ferry, Garfield, Lincoln, Pend Oreille, San Juan, Skamania,

and Wahkiakum.

Wakely created two indices to help analyze whether Navigator and In-Person Assistance resources should

be distributed to counties simply based on population or whether additional measures should be used to

determine resource allocation.

SIMPLE NEEDS-BASED INDEX A Simple Needs-Based Index provides a measure of the Washington population that likely requires the

most attention from Navigators and In-Person Assisters. For this index, Wakely used what might be

considered to be the two strongest indicators of need for education and outreach about the new

coverage programs available under ACA and for help in applying for eligibility and enrolling in health

plans. This index is calculated by applying an equal weighted average of the population count below

251% FPL and uninsured population:

Component Weight Definition

1. Population below 251% FPL 50% Household population below 251% FPL in county

2. Uninsured 50% Population that is uninsured

The Simple Needs-Based Index for each county is calculated in the following manner:

(Population below 251% FPL * 50%) + (Uninsured * 50%)

(WA Population below 251% FPL * 50%) + (WA Uninsured * 50%)

X 100


34

BROAD NEEDS-BASED INDEX The Broad Needs-Based Index is an expanded measure of the need for Navigators and In-Person

Assistance. The following three components and weights are used to calculate the index:

Component Weight Definition

1. Population 20% Household population in county

2. Population below 401% FPL 40% Household population below 401% FPL in county

3. Uninsured 40% Population in county that is uninsured

Based on the above weights, the Broad Needs-Based Index for each county is calculated in the following

manner:

(Population * 20%) + (Population below 401% FPL * 40%) + (Uninsured * 40%) X 100

(WA Population * 20%) + (WA Population below 401% FPL * 40%) + (WA Uninsured * 40%)


35

Table 1: Summary of Index Components


36

Table 2: Population and Indices Results by County

County

Portion of WA

Population

Simple Needs

Based Index

Broad Needs

Based Index

King 30.3% 25.4 27.4

Pierce 11.5% 11.3 11.5

Snohomish 10.2% 9.2 9.8

Spokane 7.2% 7.7 7.5

Clark 6.0% 5.8 6.0

Thurston 3.8% 3.3 3.6

Kitsap 3.7% 3.4 3.6

Yakima 3.1% 5.4 4.3

Whatcom 3.0% 3.2 3.1

Benton 2.4% 2.4 2.4

Skagit 1.8% 1.9 1.9

Cowlitz 1.5% 1.8 1.7

Island 1.3% 1.0 1.2

Clallam 1.2% 1.3 1.3

Grant 1.1% 1.7 1.5

Lewis 1.1% 1.3 1.2

Grays Harbor 1.1% 1.4 1.3

Chelan 1.0% 1.4 1.2

Mason 0.8% 1.0 0.9

Franklin 0.8% 1.3 1.1

Walla Walla 0.8% 1.0 0.9

Stevens 0.7% 0.8 0.7


37

Kittitas 0.6% 0.8 0.7

Okanogan 0.6% 1.0 0.8

Whitman 0.6% 0.7 0.6

Jefferson 0.6% 0.6 0.6

Douglas 0.5% 0.7 0.6

Pacific 0.4% 0.4 0.4

Asotin 0.3% 0.4 0.4

Klickitat 0.3% 0.4 0.4

Remaining 9 Counties 1.4% 1.6 1.5

Overall, the portion of the state population in each county does not vary much from the measures in the

indices. However, several counties in the tables above have been highlighted in red because they may

present notable variances between overall population in the county and the FPL rate and/or uninsured

rate. For example, King county has about 30 percent of the state population, but about 25 percent of the

state population in the selected FPL categories and about 25 percent of the state’s uninsured population.

Another county that stands out is Yakima, which has 3.1 percent of the state’s population, but 7.2

percent of the state’s uninsured. Yakima’s population of uninsured people is significantly higher relative

to the county’s overall population.

In determining a methodology to allocate Navigator and In-Person Assistance resources to each county,

the Exchange has decided that the differences between the population data alone and the two indices

suggests that it would be most equitable to use the broad needs-based index to distribute funding and

resource allocations. As explained above, the proposed budget for the 18 month period of July 1, 2013-

December 31, 2014 targets six million* for a first round of resource allocations to lead organizations.

Based on this amount, projected funding allocations or distributions by counties are shown below.

Following the table, the proposed compensation approach for lead organizations is reviewed in detail.


County

Broad Needs

Based Index

Estimated $

Allocation

Funding Base:

$6 million*

King 27.4 $1,644,000


38

Pierce 11.5 $690,000

Snohomish 9.8 $588,000

Spokane 7.5 $450,000

Clark 6.0 $360,000

Thurston 3.6 $216,000

Kitsap 3.6 $216,000

Yakima 4.3 $258,000

Whatcom 3.1 $186,000

Benton 2.4 $144,000

Skagit 1.9 $114,000

Cowlitz 1.7 102,000

Island 1.2 $72,000

Clallam 1.3 $78,000

Grant 1.5 $90,000

Lewis 1.2 $72,000

Grays Harbor 1.3 $78,000

Chelan 1.2 $72,000

Mason 0.9 $54,000

Franklin 1.1 $66,000

Walla Walla 0.9 $54,000

Stevens 0.7 $42,000

Kittitas 0.7 $42,000

Okanogan 0.8 $48,000

Whitman 0.6 $36,000


39

Jefferson 0.6 $36,000

Douglas 0.6 $36,000

Pacific 0.4 $24,000

Asotin 0.4 $24,000

Klickitat 0.4 $24,000

Remaining 9 Counties 1.5 $90,000

COMPENSATION APPROACH FOR LEAD ORGANIZATIONS (STILL UNDER

DEVELOPMENT) Lead organizations will be responsible for compensating Navigator organizations (and where utilized,

individual Navigators not affiliated with an organization). In addition to serving as a funding agent for the

Exchange, lead organizations will be compensated for their primary responsibilities, including: initial

development of the Navigator and In-Person Assistance Network for their region or community,

coordinating outreach and education efforts, training Navigator staff, monitoring performance and

service quality, resolving consumer complaints and problems, and submitting required Exchange data

and reports. To encourage a results-oriented Navigator Program, the Exchange is recommending a 50/50

compensation approach under which lead organizations will be paid 50 percent of the compensation for

performance-based activities and 50 percent for achieving outcome-based performance goals tied to the

number of enrollments facilitated. The 50/50 approach was selected after considering a number of

alternative approaches, including a 100 percent outcome-based model to a series of different

performance to outcome-based payment ratios (i.e., 25/75 and 75/25 splits).

The performance-based compensation is expected to cover the lead organizations’ expenses for

navigator training and certification; all outreach activities, educational presentations, information and

assistance, and all “application through enrollment” facilitation (in other words, all lead organization

requirements as specified in the Statement of Work section of their contract with the Exchange).

Performance pay would be paid out in eighteen equal monthly installments. To support the Exchange’s

overall goal to achieve 280,000 enrollments by December 31, 2014, the Navigator Program plans to

adopt outcome-based compensation pegged to enrollment-based performance measures. Lead

organizations could earn partial payments if performance goals are even partially met. The partial

payment provision has been included to ensure that lead organizations are not unduly penalized for

failing to meet 100 percent of their target enrollment measures. Lead organizations would be entitled to

invoice the Exchange for an outcome-based payment when a target is achieved. Partial payments would

be based on the proportion of the target completed.


40

For example, if a lead organization has been granted a $360,000 contract, half of the funding will be

allocated to the monthly performance payments ($10,000 per month X 18 months), and $180,000 would

be available for the outcome-based measures. In this example, we will assume that the organization has

been charged with completing 4,200 enrollment facilitations, with the first target set at 1,400; the second

at 2,800 and the third at 4,200. Some stakeholders raised concerns that organizations might avoid

serving at-risk or hard to reach populations under this model. To incent serving target populations, the

model provides a 25 percent differential in payment level for serving a majority (51 percent or more)

from a target population. Target populations will be identified in an Outreach Plan completed by each

Lead Organization. Once a lead organization has met the first target of 1,400 enrollment facilitations, the

organization can request payment for the first outcome-based payment. This example is depicted in the

exhibit below:

COMPENSATION APPROACH FOR NAVIGATOR ORGANIZATIONS Navigator lead organizations will adopt a similar approach for compensating Navigator organizations so as to assure all parties are incented for meeting facilitated enrollment goals and to assure consistent compensation statewide.

TIMELINE The proposed Navigator Program network structure, compensation model and performance metrics

received Board approval on January 9, 2013. In order to meet the aggressive schedule that allows the

Exchange to be fully operational on October 1, 2013, the Navigator Manager will continue to provide

regular program updates to the Board and Board Policy Committee. By March 15, 2013, the Navigator

Manager expects to release the RFP to identify interested lead organizations. Organizations will have 30-


41

45 days to respond to the RFP, and the Exchange projects awarding lead organization contracts beginning

in May 2013. Organizations will be awarded lead organization status on a rolling basis in order to have

sufficient resources to negotiate all contracts, and priority is expected to be given to the larger counties

and/or community-based areas. Lead organizations will be expected to finalize selection of their

Navigator and In-Person Assistance entities and to execute contracts in the May and June timeframe.

Education and outreach efforts will likely begin in July 2013.

Training and certification of Navigators will take place in August and September. During this same time

frame, process flows and hand offs for external and internal partners will be finalized. The statewide

outreach and education campaign will commence in the spring and localized outreach campaigns will kick

off shortly thereafter. Adhering to this timeline will allow the Navigator Program to assist consumers

with online enrollments as of October 1, 2013 as required by the ACA.

1 Adopted 11/8/12

Washington Health Benefit Exchange

Consumer Assistance Program – Navigator Function

Guiding Principles

Background

The intent of the Navigator provisions in the Affordable Care Act (ACA) is to support an

Exchange that provides consumers with a “no wrong door” access point to affordable health

plans and public health programs. The Exchange is designed as a resource for all

consumers, regardless of income or eligibility for public programs, subsidized coverage, or

non-subsidized coverage.

Purpose

An objective of the Exchange is to increase the public’s awareness of the ACA and provisions

that take effect on January 1, 2014. To be successful, Washington must establish a

Consumer Assistance Program under the Exchange that uses multiple approaches to make

information widely available to consumers.

The Exchange has the opportunity to utilize the flexibility granted in the ACA to develop a

Consumer Assistance Program that includes a full spectrum of functions, including outreach,

Navigators, health literacy, and the resolution of grievances. The Consumer Assistance

Program must be designed to provide consumers with objective, accurate information to

compare the options available through the Exchange. Plans available on the Exchange will

include those for children, families, adults and small businesses (including self-employment).

One of the most critical components of the Exchange’s Consumer Assistance Program is the

Navigator Program. Navigators have the potential to ensure Washingtonians can make

informed decisions about health care coverage based on their needs and financial resources.

To achieve this outcome, Navigators must have knowledge and skills that promote

competency as well as credibility.

Navigator Functions

As outlined in the ACA, organizations serving as Navigators for the Exchange must meet the following requirements:

Navigator organizations must meet the qualifications and criteria established and published by the Exchange to perform Navigator activities.

Navigator organizations must assure that the provision of Navigator services does not represent a conflict of interest for the organization or any representative(s) of the organization.

Navigator organizations must ensure that all Navigator representatives who work for the organization complete initial and continuing certification requirements and that

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2 Adopted 11/8/12

representatives demonstrate the expertise needed to provide consumers with information that is complete, accurate, impartial, and culturally competent.

To increase consumer access to services, Navigator organizations must have or be able to create collaborative relationships with other community organizations that have a role in providing health care services and coverage. Such a network will include, but not be limited to: employers and employer organizations, community-based social service or health providers, Chambers of Commerce, unions, Small Business Administrations, insurance agencies or brokers, government agencies, and other organizations or individuals capable of supporting Navigator organizations in carrying out Navigator duties.

The principles outlined below represent Guiding Principles for HBE staff, committee

members, Navigator organizations and representatives in providing consumer assistance

services under the Exchange.

3 Adopted 11/8/12

Washington Health Benefit Exchange

Consumer Assistance Program – Navigator Function

Guiding Principles

1. Duty to the Consumer

Navigator organizations and representatives have a duty to put the health care coverage

needs of each consumer first. Navigator representatives explain a consumer’s options

and provide information about those options that help a consumer select the best plan for

the consumer and the consumer’s family. They must perform their Navigator duties

impartially within professionally accepted ethical standards. This includes:

Providing all consumers with a clear and concise description of the services a

Navigator can perform and how they are paid for those services.

Presenting all information and options objectively, always refraining from “steering”

a consumer toward or away from any particular plan or from facilitating the

selection of a QHP that is not in the consumer’s best interest.

Accepting no financial or other benefit from a consumer’s enrollment in a particular

qualified health plan.

Avoiding actual conflicts of interest and the appearance of conflicts of interest.

Handling protected health information in accordance with applicable privacy laws.

Informing consumers that they may select a different navigator or navigator

organization at any time.

2. Community and Consumer Trust

Navigator organizations must be trusted resources in the communities they serve.

Navigator representatives must demonstrate expertise and cultural competency in

assisting those they serve, including communities of color and vulnerable populations,

low-income families, individuals who are not functionally literate or have low-English

literacy, families or individuals with special health care needs, individuals with physical or

mental disabilities, and individuals with substance-abuse issues. This is optimally

achieved by:

Having an established presence within the communities served, with an

understanding of the communities’ strengths and needs.

Being recognized by community members as credible and reputable voices.

Referring consumers when appropriate to entities that assist with grievances,

complaints, or questions about health plans, coverage, or eligibility determinations.

Implementing procedures to ensure Navigator representatives are accountable.

4 Adopted 11/8/12

3. Promoting Health Equity

One of the HBE’s overall objectives is to increase access to health care, particularly for

populations that have not had this access in the past. The Navigator program is of paramount

importance to promoting access to coverage for members of communities who have

historically had the greatest barriers to care, including lack of insurance. Therefore the

network of Navigator organizations must:

Help address disproportionate access to coverage and improve health outcomes for

groups who have been underinsured or uninsured.

Demonstrate the ability to identify and facilitate enrollment for those who experience

the greatest barriers to coverage and care and who have historically suffered from

health disparities.

Build or sustain capacity to effectively serve these populations, such as targeted

outreach, expanded locations and hours, and ability to provide services in languages

other than English.

4. Knowledge and Skills

Navigator representatives must possess the necessary knowledge and skills to deliver

high quality services. This includes knowledge of qualified health plans and other public

health programs and the competency to accurately explain relevant benefits, enrollment

processes, and eligibility requirements. Navigator representatives must:

Fulfill training and certification requirements established by HBE.

Demonstrate cultural sensitivity and linguistic competence (including the use of

qualified interpreters and translators) that reflects the communities served and

promotes services to hard-to-reach populations.

Demonstrate detailed, up-to-date knowledge of qualified health plans and public

health programs, enrollment and eligibility processes, and tax credits and subsidies

that are available through the Exchange.

Refer consumers when appropriate to local, state and federal agencies that can

offer assistance not available through the Exchange.

5. Timeliness and Accuracy

Navigator organizations must provide accurate and up to date information for consumers.

Navigator organizations must be able to nimbly and effectively inform communities and

community members about changes that may have an impact on their health coverage.

6. Enduring Relationships

A trusted Navigator organization remains a resource to community members after the

initial enrollment, including:

5 Adopted 11/8/12

Helping consumers with a family understand the options available for covering all

family members.

Helping newly enrolled family members establish ongoing relationships with

primary care providers.

Promoting continued insurance coverage by helping consumers evaluate options if

their financial circumstances change in a way that impacts continued coverage.

Helping families interpret the complex language and systems of health care.

Providing assistance to consumers about how to use the health care services

available under a selected plan, including prevention and wellness services.

Connecting consumers to other resources within the health care system.

7. Seamlessness

Navigator organizations may be part of a larger system of outreach that incorporates the

full continuum of available health care plans. A highly functioning Navigator organization

helps consumers traverse the health care system in a seamless fashion by:

Partnering with state agencies and other public and private programs.

Connecting consumers to services that fall within the full continuum of outreach

and assistance, including the Ombudsman entities for health insurance in

Washington State.

Incorporating education about plans, enrollment procedures, and grievances.

Increasing health literacy by helping consumers understand how to use their

health care benefits.

Communicating and coordinating among all Navigator organizations to ensure

high quality, consistent services across the state.

08 Fall

O n e C o n s t i t u t i o n C e n t e r * S u i t e 1 0 0 * B o s t o n , M A * 0 2 1 2 9

Wakely Consulting Group December 2012

Washington State Navigator Resource Allocation Assessment

Wakely Consulting Group

Attachment B

Washington State Navigator Resource Allocation Assessment 2

Wakely Consulting Group, Inc.

Washington Navigators: Resource Allocation Assessment The purpose of this report is to analyze the population of Washington residents who are likely candidates for Navigator assistance. This analysis can help determine how Navigator programs should geographically focus their efforts and allocate resources or funding.

Methodology Unless noted otherwise, the primary source of information used to conduct this analysis was the 2010 American Community Survey (ACS) 5-year estimate. The ACS is administered by the U.S. Census Bureau, and we believe it is the most reliable and relevant source of information by county for our Navigator resource allocation assessment. Federal Poverty Level (FPL) Household income data for Washington and the state’s 39 counties were derived from the 2010 American Community Survey (ACS) 5-year estimate. We examine three significant Federal Poverty Levels (FPL): 138% FPL, 250% FPL, and 400% FPL. These particular levels were chosen based on their potential relevance to Navigator programs. Assuming that Navigators will serve both Medicaid/CHIP eligible and Exchange individuals, these categories can give us insight into the level of assistance needed. We are making an assumption that individuals who apply for Cost-Sharing Reductions (from 100-250% FPL) will need more assistance than individuals whose income is above 250% FPL. We are also assuming that those who qualify for premium assistance (under 401% FPL) will require more assistance from Navigators than those who are above 400% FPL. Due to the fact that the ACS provides household income levels based on survey results from 2006-2010, we based our analysis on 2010 Federal Poverty Levels. The following table shows different FPLs based on number of people in a family, sourced from the Department of Health and Human Services.



(source: http://aspe.hhs.gov/poverty/10poverty.shtml)

The ACS household income data do not distinguish size of household. While we acknowledge that this lack of distinction means that the actual number of households categorized by FPL group would differ from the numbers presented in our analysis, we believe that the relative numbers of households in each FPL category across counties and regions in Washington would most likely be very close to the numbers we present here. The ACS notes that the average Washington household has 2.5 people and that the average family in Washington consists of 3.1 people. Using this information, we conservatively assumed that all Washington households contained 3 people and calculated FPL accordingly. The HHS poverty guideline information listed above indicates the FPL for 3 individuals is $18,310. We assumed 138% of FPL to be $25,000, 250% of FPL to be $50,000, and 400% of FPL to be $75,000. While these can be viewed as rough assumptions, the ACS provides income data by county for specific income brackets. Our analysis focuses on proportions and these assumptions will not affect outcomes. Uninsured The number of individuals in each county that do not have health insurance was derived from the 2010 American Community Survey 3-year estimate. The ACS did not begin collecting health insurance coverage information until 2008, and therefore the 2010 3-year estimate was used. Unfortunately, health insurance coverage data was only available for 30 of Washington’s 39 counties, due to small sample sizes in the 9 least populous counties. However, an estimate for the total number of uninsured in Washington was presented, and therefore through subtraction we were able to determine the estimated number of uninsured for the 9 counties in total. We analyzed these 9 counties as a group labeled “Remaining 9 Counties”, which includes Adams, Columbia, Ferry, Garfield, Lincoln, Pend Oreille, San Juan, Skamania, and Wahkiakum counties.

http://aspe.hhs.gov/poverty/10poverty.shtml



Analysis An analysis of population, household income level, the number of uninsured, and additional factors may help determine the portion of Washington’s Navigator resources that a county should receive. It can be argued that population is the most basic measure, that it can be measured by readily available data, and therefore Navigator resources can be allocated based simply on a county’s portion of the State’s population. We have created two indices to help analyze whether Navigator resources should be distributed to counties simply based on population or whether additional measures should be used to determine resource allocation. Simple Needs-Based Index A Simple Needs-Based Index provides a measure of the Washington population that likely requires the most Navigator assistance. For this index, we used what we consider to be the two strongest indicators of need for education and outreach about the new coverage programs available under ACA and for help in applying for eligibility and enrolling in health plans. This index is calculated by applying an equal weighted average of population count below 251% FPL and uninsured population: Component Weight Definition 1. Population below 251% FPL 50% Household population below 251% FPL in

county 2. Uninsured 50% Population that is uninsured

The Simple Needs-Based Index for each county is calculated in the following manner:

(Population below 251% FPL * 50%) + (Uninsured * 50%) X 100 (WA Population below 251% FPL * 50%) + (WA Uninsured * 50%)

Broad Needs-Based Index The Broad Needs-Based Index is an expanded measure of the need for Navigators. The following three components and weights are used to calculate the index: Component Weight Definition 1. Population 20% Household population in county

2. Population below 401% FPL 40% Household population below 401% FPL in

county 3. Uninsured 40% Population in county that is uninsured



Based on the above weights, the Broad Needs-Based Index for each county is calculated in the following manner:

(Population * 20%) + (Population below 401% FPL * 40%) + (Uninsured * 40%) X 100 (WA Population * 20%) + (WA Population below 401% FPL * 40%) + (WA Uninsured * 40%)


County

Portion of WA Total

Population

Portion of WA Population

Below 251% FPL

Portion of WA Population

Below 401% FPL

Portion of WA Uninsured

King 30.3% 25.4% 26.1% 25.3%

Pierce 11.5% 11.4% 11.6% 11.2%

Snohomish 10.2% 8.5% 9.2% 10.0%

Spokane 7.2% 8.7% 8.2% 6.5%

Clark 6.0% 5.8% 6.0% 5.9%

Thurston 3.8% 3.6% 3.7% 2.9%

Kitsap 3.7% 3.5% 3.7% 3.4%

Yakima 3.1% 4.0% 3.7% 7.2%

Whatcom 3.0% 3.5% 3.4% 2.9%

Benton 2.4% 2.4% 2.4% 2.5%

Skagit 1.8% 1.8% 1.9% 2.0%

Cowlitz 1.5% 1.9% 1.8% 1.8%

Island 1.3% 1.2% 1.3% 0.7%

Clallam 1.2% 1.5% 1.4% 1.1%

Grant 1.1% 1.5% 1.4% 2.0%

Lewis 1.1% 1.5% 1.4% 1.1%

Grays Harbor 1.1% 1.5% 1.3% 1.3%

Chelan 1.0% 1.2% 1.2% 1.6%

Mason 0.8% 1.0% 1.0% 1.0%

Franklin 0.8% 1.0% 1.0% 1.8%

Walla Walla 0.8% 1.0% 1.0% 0.9%

Stevens 0.7% 0.9% 0.8% 0.7%

Kittitas 0.6% 0.8% 0.8% 0.7%

Okanogan 0.6% 0.9% 0.8% 1.1%

Whitman 0.6% 0.8% 0.7% 0.5%

Jefferson 0.6% 0.7% 0.6% 0.5%

Douglas 0.5% 0.6% 0.6% 0.8%

Pacific 0.4% 0.5% 0.5% 0.3%

Asotin 0.3% 0.5% 0.4% 0.3%



Klickitat 0.3% 0.5% 0.4% 0.4%

Remaining 9 Counties 1.4% 1.8% 1.7% 1.5%

Table 2: Indices Analysis - Measure of Washington Navigator Needs by County

County

Portion of WA

Population

Simple Needs-Based

Index Broad-Needs Based Index

King 30.3% 25.4 27.4

Pierce 11.5% 11.3 11.5

Snohomish 10.2% 9.2 9.8

Spokane 7.2% 7.7 7.5

Clark 6.0% 5.8 6.0

Thurston 3.8% 3.3 3.6

Kitsap 3.7% 3.4 3.6

Yakima 3.1% 5.4 4.3

Whatcom 3.0% 3.2 3.1

Benton 2.4% 2.4 2.4

Skagit 1.8% 1.9 1.9

Cowlitz 1.5% 1.8 1.7

Island 1.3% 1.0 1.2

Clallam 1.2% 1.3 1.3

Grant 1.1% 1.7 1.5

Lewis 1.1% 1.3 1.2

Grays Harbor 1.1% 1.4 1.3

Chelan 1.0% 1.4 1.2

Mason 0.8% 1.0 0.9

Franklin 0.8% 1.3 1.1

Walla Walla 0.8% 1.0 0.9

Stevens 0.7% 0.8 0.7

Kittitas 0.6% 0.8 0.7

Okanogan 0.6% 1.0 0.8

Whitman 0.6% 0.7 0.6

Jefferson 0.6% 0.6 0.6

Douglas 0.5% 0.7 0.6

Pacific 0.4% 0.4 0.4

Asotin 0.3% 0.4 0.4

Klickitat 0.3% 0.4 0.4

Remaining 9 Counties 1.4% 1.6 1.5



Preliminary Conclusions Overall, the portion of the state population in each county does not vary much from the measures in the indices. However, we have highlighted in red several counties in the tables above that may present notable differences between overall population and the different measures. For example, King county has about 30% of the State’s population, but about 25% of the state’s population in the selected FPL categories and about 25% of the state’s uninsured population. Washington may wish to allocate King county 25% of the state’s Navigator resources and funding, instead of allocating 30% based on population. Another county that stands out is Yakima, which has 3.1% of the state’s population, but 7.2% of the state’s uninsured. Yakima’s population of uninsured people is significantly higher relative to the county’s overall population. When allocating Navigator resources to Yakima, Washington may wish to take this difference into consideration. In determining a methodology to allocate Navigator resources to each county, Washington should decide whether allocating simply based on overall population distribution is the most logical approach, or whether the differences shown in our indices and measures justify a different methodology or county specific adjustments.

Additional Measures The following section includes data used to calculate the indices and examines additional measures which may be relevant to Navigator resource allocation decisions:

Household Population by Federal Poverty Level Table 3: Household Population by Federal Poverty Level

County Total

Households

% of State's Total

Households Households 0 - 138% FPL

% of State Households 0 - 138% FPL

Households 139 - 250%

FPL

% of State Households 139 - 250%

FPL


FPL

Percent of State


FPL

King 781,977 30.34% 128,300 25.17% 157,315 25.63% 138,336 27.58%

Pierce 295,554 11.47% 55,178 10.82% 72,613 11.83% 60,216 12.01%

Snohomish 263,931 10.24% 39,095 7.67% 56,850 9.26% 53,889 10.75%

Spokane 184,590 7.16% 46,255 9.07% 51,014 8.31% 36,457 7.27%

Clark 155,042 6.02% 27,074 5.31% 37,679 6.14% 33,533 6.69%

Thurston 98,491 3.82% 17,796 3.49% 22,391 3.65% 20,481 4.08%

Kitsap 95,758 3.72% 16,150 3.17% 23,226 3.78% 20,200 4.03%

Yakima 79,075 3.07% 22,354 4.38% 22,943 3.74% 15,266 3.04%

Whatcom 78,186 3.03% 19,625 3.85% 20,072 3.27% 15,398 3.07%



Benton 62,038 2.41% 12,337 2.42% 14,885 2.42% 11,030 2.20%

Skagit 45,253 1.76% 9,034 1.77% 11,175 1.82% 10,439 2.08%

Cowlitz 39,441 1.53% 10,140 1.99% 11,342 1.85% 7,673 1.53%

Island 32,976 1.28% 5,865 1.15% 8,177 1.33% 7,276 1.45%

Clallam 30,987 1.20% 8,207 1.61% 9,014 1.47% 6,269 1.25%

Grant 29,427 1.14% 8,291 1.63% 8,397 1.37% 5,907 1.18%

Lewis 29,290 1.14% 7,962 1.56% 8,369 1.36% 6,114 1.22%

Grays Harbor 28,191 1.09% 7,801 1.53% 8,740 1.42% 5,383 1.07%

Chelan 26,676 1.04% 6,040 1.18% 7,684 1.25% 5,481 1.09%

Mason 21,808 0.85% 5,619 1.10% 5,627 0.92% 4,671 0.93%

Franklin 21,422 0.83% 5,004 0.98% 6,104 0.99% 4,854 0.97%

Walla Walla 21,367 0.83% 5,641 1.11% 6,047 0.99% 3,833 0.76%

Stevens 17,404 0.68% 4,912 0.96% 5,127 0.84% 3,132 0.62%

Kittitas 16,619 0.64% 5,230 1.03% 4,200 0.68% 2,857 0.57%

Okanogan 15,747 0.61% 5,394 1.06% 4,458 0.73% 2,857 0.57%

Whitman 15,717 0.61% 6,105 1.20% 3,446 0.56% 2,535 0.51%

Jefferson 14,194 0.55% 3,794 0.74% 3,991 0.65% 2,632 0.52%

Douglas 13,802 0.54% 2,882 0.57% 4,187 0.68% 2,867 0.57%

Pacific 9,667 0.38% 2,844 0.56% 3,059 0.50% 1,771 0.35%

Asotin 8,977 0.35% 2,368 0.46% 2,897 0.47% 1,917 0.38%

Klickitat 8,405 0.33% 2,761 0.54% 2,574 0.42% 1,362 0.27%

San Juan 7,986 0.31% 1,805 0.35% 2,118 0.35% 1,768 0.35%

Adams 5,599 0.22% 1,579 0.31% 1,824 0.30% 1,059 0.21%

Pend Oreille 5,511 0.21% 1,970 0.39% 1,477 0.24% 831 0.17%

Lincoln 4,649 0.18% 1,133 0.22% 1,446 0.24% 954 0.19%

Skamania 4,514 0.18% 1,024 0.20% 1,289 0.21% 991 0.20%

Ferry 2,706 0.10% 1,003 0.20% 763 0.12% 483 0.10%

Wahkiakum 1,763 0.07% 420 0.08% 711 0.12% 316 0.06%

Columbia 1,732 0.07% 541 0.11% 399 0.06% 317 0.06%

Garfield 903 0.04% 270 0.05% 260 0.04% 169 0.03%

Washington State Total 2,577,375 100.00% 509,803 100.00% 613,890 100.00% 501,524 100.00%

Portion of a County’s Household Population by FPL In the previous analysis, we measured a county’s population, in each FPL category, as a percent of the State’s total population. An additional potentially important measure is to analyze the population in each FPL category of a county as a percent of the county’s total population.



Table 4: Portion of County’s Household Population by FPL

County

% of County Population in 0 - 138% FPL

% of County Population in 139 - 250%

FPL

% of County Population in 251 - 400%

FPL

% of County Population

Greater than 400% FPL Total (check)

Adams 28% 33% 19% 20% 100%

Asotin 26% 32% 21% 20% 100%

Benton 20% 24% 18% 38% 100%

Chelan 23% 29% 21% 28% 100%

Clallam 26% 29% 20% 24% 100%

Clark 17% 24% 22% 37% 100%

Columbia 31% 23% 18% 27% 100%

Cowlitz 26% 29% 19% 26% 100%

Douglas 21% 30% 21% 28% 100%

Ferry 37% 28% 18% 17% 100%

Franklin 23% 28% 23% 25% 100%

Garfield 30% 29% 19% 23% 100%

Grant 28% 29% 20% 23% 100%

Grays Harbor 28% 31% 19% 22% 100%

Island 18% 25% 22% 35% 100%

Jefferson 27% 28% 19% 27% 100%

King 16% 20% 18% 46% 100%

Kitsap 17% 24% 21% 38% 100%

Kittitas 31% 25% 17% 26% 100%

Klickitat 33% 31% 16% 20% 100%

Lewis 27% 29% 21% 23% 100%

Lincoln 24% 31% 21% 24% 100%

Mason 26% 26% 21% 27% 100%

Okanogan 34% 28% 18% 19% 100%

Pacific 29% 32% 18% 21% 100%

Pend Oreille 36% 27% 15% 22% 100%

Pierce 19% 25% 20% 36% 100%

San Juan 23% 27% 22% 29% 100%

Skagit 20% 25% 23% 32% 100%

Skamania 23% 29% 22% 27% 100%

Snohomish 15% 22% 20% 43% 100%

Spokane 25% 28% 20% 28% 100%

Stevens 28% 29% 18% 24% 100%

Thurston 18% 23% 21% 38% 100%

Wahkiakum 24% 40% 18% 18% 100%



Walla Walla 26% 28% 18% 27% 100%

Whatcom 25% 26% 20% 30% 100%

Whitman 39% 22% 16% 23% 100%

Yakima 28% 29% 19% 23% 100%

Washington State

20% 24% 19% 37% 100%

Uninsured Table 5: Uninsured Population

County % of State

Households Number of Uninsured

Percent of Washington State

Uninsured

King 30.34% 221,843 25.30%

Pierce 11.47% 98,542 11.24%

Snohomish 10.24% 87,949 10.03%

Yakima 3.07% 63,151 7.20%

Spokane 7.16% 56,724 6.47%

Clark 6.02% 51,937 5.92%

Kitsap 3.72% 29,408 3.35%

Thurston 3.82% 25,618 2.92%

Whatcom 3.03% 25,202 2.87%

Benton 2.41% 21,660 2.47%

Grant 1.14% 17,822 2.03%

Skagit 1.76% 17,184 1.96%

Franklin 0.83% 15,893 1.81%

Cowlitz 1.53% 15,483 1.77%

Chelan 1.04% 14,129 1.61%

Grays Harbor 1.09% 11,494 1.31%

Clallam 1.20% 9,771 1.11%

Lewis 1.14% 9,733 1.11%

Okanogan 0.61% 9,412 1.07%

Mason 0.85% 9,143 1.04%

Walla Walla 0.83% 8,167 0.93%

Douglas 0.54% 6,708 0.77%

Island 1.28% 6,472 0.74%

Stevens 0.68% 6,352 0.72%

Kittitas 0.64% 6,083 0.69%

Whitman 0.61% 4,482 0.51%



Jefferson 0.55% 4,263 0.49%

Klickitat 0.33% 3,120 0.36%

Pacific 0.38% 3,031 0.35%

Asotin 0.35% 3,004 0.34%

Remaining 9 Counties 1.37% 12,904 1.47%

Washington State Total 100% 876,684 100.00%

Language Navigators may require additional resources to meet the language needs of Washington residents who do not speak fluent English. We have evaluated estimates from the American Community Survey to compare the language characteristics of each Washington county. The ACS provides estimates for the number of people over five years old who speak English less than “very well” and speak one of the following languages; Spanish, other Indo-European, Asian and Pacific Islander, or Other language. We analyze this information as percent of a county’s total population and the following table presents Washington counties in order of least to greatest English-speaking capability. Table 6: Language as a Percent of County Population

% of County that speaks the following languages at home and speak English less than "Very Well"

County

% of County that Speaks

English "Very Well"

% of County that Speaks

English LESS THAN "Very

Well" Spanish

Other Indo-European

Languages

Asian and Pacific

Islander languages

Other Languages

Franklin 69.77% 30.23% 27.88% 1.26% 1.01% 0.08%

Adams 74.05% 25.95% 25.10% 0.11% 0.49% 0.25%

Yakima 81.16% 18.84% 18.27% 0.15% 0.33% 0.09%

Grant 82.89% 17.11% 15.90% 0.70% 0.50% 0.01%

Douglas 87.57% 12.43% 12.19% 0.15% 0.09% 0.00%

King 89.04% 10.96% 3.10% 1.88% 5.14% 0.84%

Chelan 89.57% 10.43% 9.84% 0.29% 0.19% 0.11%

Walla Walla 91.30% 8.70% 8.13% 0.12% 0.42% 0.03%

Benton 91.58% 8.42% 6.60% 0.65% 1.05% 0.12%

Snohomish 92.10% 7.90% 2.87% 1.48% 3.17% 0.38%

Okanogan 93.42% 6.58% 6.14% 0.35% 0.06% 0.03%

Clark 93.73% 6.27% 2.06% 2.58% 1.47% 0.17%

Skagit 93.74% 6.26% 5.17% 0.43% 0.63% 0.03%

Pierce 94.33% 5.67% 2.22% 0.90% 2.48% 0.08%

Whatcom 95.22% 4.78% 2.01% 1.62% 0.90% 0.26%

Pacific 95.44% 4.56% 3.62% 0.11% 0.81% 0.02%

Mason 96.27% 3.73% 2.94% 0.34% 0.42% 0.03%



Lewis 96.28% 3.72% 3.14% 0.25% 0.24% 0.09%

Grays Harbor 96.33% 3.67% 2.81% 0.26% 0.57% 0.04%

Whitman 96.46% 3.54% 0.42% 0.73% 2.01% 0.39%

Thurston 96.54% 3.46% 1.13% 0.31% 1.97% 0.04%

Cowlitz 96.55% 3.45% 2.19% 0.52% 0.65% 0.08%

Clallam 96.64% 3.36% 1.80% 0.80% 0.66% 0.10%

Kittitas 96.67% 3.33% 2.14% 0.28% 0.82% 0.09%

Kitsap 96.69% 3.31% 1.30% 0.38% 1.57% 0.06%

Klickitat 96.69% 3.31% 3.12% 0.03% 0.16% 0.00%

Garfield 96.87% 3.13% 2.29% 0.00% 0.28% 0.56%

Spokane 97.20% 2.80% 0.72% 1.04% 0.89% 0.15%

San Juan 97.65% 2.35% 2.04% 0.15% 0.16% 0.00%

Island 97.90% 2.10% 0.59% 0.24% 1.23% 0.04%

Jefferson 98.44% 1.56% 0.65% 0.70% 0.17% 0.05%

Ferry 98.89% 1.11% 0.44% 0.00% 0.67% 0.00%

Skamania 98.93% 1.07% 0.72% 0.10% 0.14% 0.12%

Stevens 98.93% 1.07% 0.25% 0.73% 0.01% 0.07%

Pend Oreille 99.04% 0.96% 0.36% 0.07% 0.44% 0.09%

Wahkiakum 99.16% 0.84% 0.18% 0.42% 0.00% 0.24%

Asotin 99.18% 0.82% 0.29% 0.20% 0.34% 0.00%

Columbia 99.24% 0.76% 0.76% 0.00% 0.00% 0.00%

Lincoln 99.34% 0.66% 0.45% 0.14% 0.07% 0.00%

State Total 92.14% 7.86% 3.74% 1.22% 2.57% 0.34%

Relative to other counties in Washington, Franklin will require the greatest Navigator language-specific resources. About 30% of Franklin County residents do not speak English “very well”. Spanish is the most prevalent language in Franklin of those who do not speak English, as 28% of the county speaks Spanish and does not speak English “very well”. The following table details the language population data utilized in the above analysis. Table 7: Population over 5 years old that speak the following languages and speak English less than “very well”

Population over 5 years old that Speaks the Following Languages at Home and Speak English LESS THAN "Very Well"

County

Total Population over

5 yrs old Spanish

Other Indo-European

Languages

Asian and Pacific Islander

languages Other

Languages

Adams 15,952 4,004 17 78 40

Asotin 20,133 58 40 68 0

Benton 154,897 10,230 1,011 1,622 185

Chelan 66,240 6,517 194 129 70

Clallam 67,406 1,216 538 446 66

Clark 385,641 7,926 9,949 5,660 654



Columbia 3,797 29 0 0 0

Cowlitz 94,696 2,073 496 620 79

Douglas 34,535 4,210 52 31 0

Ferry 7,033 31 0 47 0

Franklin 63,625 17,736 804 640 54

Garfield 2,138 49 0 6 12

Grant 77,490 12,320 544 384 9

Grays Harbor 67,984 1,912 175 385 25

Island 74,049 438 175 909 30

Jefferson 28,590 185 199 49 13

King 1,762,479 54,680 33,071 90,653 14,752

Kitsap 232,706 3,035 879 3,644 145

Kittitas 37,974 811 108 310 35

Klickitat 18,898 590 5 30 0

Lewis 70,222 2,204 174 172 62

Lincoln 9,983 45 14 7 0

Mason 56,140 1,652 190 238 16

Okanogan 37,585 2,309 133 21 10

Pacific 20,211 732 22 163 5

Pend Oreille 12,267 44 9 54 11

Pierce 728,649 16,158 6,543 18,037 550

San Juan 15,033 307 23 24 0

Skagit 107,789 5,569 463 679 35

Skamania 10,321 74 10 14 12

Snohomish 647,799 18,567 9,562 20,565 2,465

Spokane 431,952 3,115 4,506 3,848 641

Stevens 40,825 103 299 4 29

Thurston 229,021 2,596 721 4,523 94

Wahkiakum 3,788 7 16 0 9

Walla Walla 54,048 4,396 65 225 16

Whatcom 184,994 3,714 2,995 1,662 474

Whitman 41,895 174 305 842 163

Yakima 216,062 39,482 327 704 202

State Total 6,134,847 229,298 74,634 157,493 20,963

Race While race is not likely an important measure in determining Navigator efforts, Navigators may wish to focus attention on certain cultures, such as American Indian and Alaska Natives, to meet their needs. The following table shows population of race by county, for people considered to be one-race. Note that Washington’s total population is 6,561,297 and the total one-race population is 6,289,158.



Table 8: Population by Race for people who consider themselves “One-race”

County White

Black or African

American

American Indian and

Alaska Native Asian

Native Hawaiian and Other

Pacific Islander

Some other race

Adams 11,598 35 287 128 6 5,192

Asotin 20,044 19 223 112 3 246

Benton 138,078 2,231 1,723 4,712 167 15,918

Chelan 63,623 242 927 494 64 4,085

Clallam 62,141 616 3,660 1,154 59 1,027

Clark 359,636 7,795 2,644 16,444 2,245 9,785

Columbia 3,671 0 127 22 0 39

Cowlitz 92,429 507 1,611 1,477 208 1,526

Douglas 28,206 175 325 270 29 7,018

Ferry 5,749 58 1,310 96 31 85

Franklin 41,590 1,598 723 1,382 3 23,656

Garfield 2,111 0 0 8 0 0

Grant 61,348 1,025 1,166 877 52 18,462

Grays Harbor 62,179 708 2,858 987 124 2,371

Island 67,933 1,520 566 3,194 379 1,084

Jefferson 27,015 272 571 288 9 235

King 1,330,812 112,588 14,401 266,435 13,379 57,608

Kitsap 205,605 6,905 3,776 11,859 2,122 3,834

Kittitas 35,971 262 631 840 0 1,245

Klickitat 18,079 14 874 149 0 544

Lewis 68,110 313 723 560 7 2,008

Lincoln 9,912 56 200 27 0 137

Mason 52,147 805 2,069 730 223 1,634

Okanogan 30,027 136 4,491 304 94 4,138

Pacific 18,528 98 333 393 4 1,010

Pend Oreille 11,732 19 522 109 0 76

Pierce 596,418 54,490 9,933 45,451 9,355 20,126

San Juan 14,778 101 135 205 25 91

Skagit 98,852 897 2,117 2,113 172 7,218

Skamania 9,934 8 256 97 9 369

Snohomish 560,694 15,586 8,874 59,692 2,797 18,991

Spokane 414,507 7,948 5,501 10,244 1,616 4,960

Stevens 38,820 215 1,971 286 69 167

Thurston 203,177 6,705 3,394 13,027 1,649 4,957



Wahkiakum 3,863 0 28 11 0 0

Walla Walla 49,159 924 608 923 144 4,682

Whatcom 171,611 2,177 5,445 7,274 311 3,376

Whitman 37,574 797 331 3,298 120 346

Yakima 171,506 2,040 9,878 2,099 231 43,171

Total Washington One-race Population 5,199,167 229,885 95,212 457,771 35,706 271,417

Household Population Density Household population density can be a measure of the rural or urban environment of a county. Depending on whether Navigators are required to travel to provide in-person support, population density may be an important measure to consider. To compare the difficulties Navigators may face while traveling, we have created a scoring system, called the Navigator Travel Score, to rank Washington counties based on traveling difficulty. A Navigator Travel Score is assigned to each county which is based on two measures, population density and land area, and is calculated as follows:

Households per Square Mile Land Area

Theoretically, the lower the Navigator Travel Score the more difficult it will be for a Navigator to travel around the county to assist a given number of people. A Navigator will face the most difficulty working in a county that has low population density but high land area. The following table illustrates four different scenarios of population density and land area and a corresponding expected Navigator traveling difficulty level.

County Population Density and Land Area Characteristics

Navigator Traveling Difficulty

Population Density: Lower than Average Land Area: Higher than Average

High

Population Density: Higher than Average Land Area: Higher than Average

Medium

Population Density: Lower than Average Land Area: Lower than Average

Medium

Population Density: Higher than Average Land Area: Lower than Average

Low



In the next table we calculate the Navigator Travel Score and rank Washington counties from greatest to least in terms of Navigator traveling difficulty. To test whether the Navigator Travel Score rankings correspond to the four scenarios described above, the last two columns on the right side of the table indicate whether the county’s population density and land area is higher or lower than the state’s average. Note that the state’s average population density in a county is 50.6 households per square mile and the average land area in a county is 1,704 square miles. Table 9: County Ranking of Greatest to Least Navigator Traveling Difficulty

Rank County Households

Population Density

(households per square

mile)

Land Area

(Square Miles)

Navigator Travel Score

Population Density

compared to state average

Land Area compared

to state average

1 Ferry 2,706 1.23 2,203 0.00056 Lower Higher

2 Okanogan 15,747 2.99 5,268 0.00057 Lower Higher

3 Lincoln 4,649 2.01 2,310 0.00087 Lower Higher

4 Adams 5,599 2.91 1,925 0.00151 Lower Higher

5 Skamania 4,514 2.73 1,656 0.00165 Lower Lower

6 Garfield 903 1.27 711 0.00179 Lower Lower

7 Columbia 1,732 1.99 869 0.00230 Lower Lower

8 Klickitat 8,405 4.49 1,871 0.00240 Lower Higher

9 Pend Oreille 5,511 3.94 1,400 0.00281 Lower Lower

10 Stevens 17,404 7.02 2,478 0.00283 Lower Higher

11 Chelan 26,676 9.13 2,921 0.00313 Lower Higher

12 Kittitas 16,619 7.23 2,297 0.00315 Lower Higher

13 Whitman 15,717 7.28 2,159 0.00337 Lower Higher

14 Grant 29,427 10.98 2,680 0.00410 Lower Higher

15 Douglas 13,802 7.59 1,819 0.00417 Lower Higher

16 Yakima 79,075 18.41 4,295 0.00429 Lower Higher

17 Jefferson 14,194 7.87 1,804 0.00436 Lower Higher

18 Lewis 29,290 12.19 2,403 0.00507 Lower Higher

19 Grays Harbor 28,191 14.82 1,902 0.00779 Lower Higher

20 Clallam 30,987 17.83 1,738 0.01025 Lower Higher

21 Pacific 9,667 10.37 933 0.01111 Lower Lower

22 Walla Walla 21,367 16.82 1,270 0.01324 Lower Lower

23 Franklin 21,422 17.25 1,242 0.01388 Lower Lower

24 Skagit 45,253 26.14 1,731 0.01510 Lower Higher

25 Whatcom 78,186 37.11 2,107 0.01761 Lower Higher

26 Benton 62,038 36.48 1,700 0.02146 Lower Lower

27 Asotin 8,977 14.11 636 0.02218 Lower Lower

28 Mason 21,808 22.73 959 0.02369 Lower Lower

29 Wahkiakum 1,763 6.69 263 0.02542 Lower Lower



30 Cowlitz 39,441 34.59 1,140 0.03034 Lower Lower

31 Spokane 184,590 104.66 1,764 0.05934 Higher Higher

32 Snohomish 263,931 126.45 2,087 0.06058 Higher Higher

33 Pierce 295,554 177.03 1,670 0.10604 Higher Lower

34 King 781,977 369.63 2,116 0.17472 Higher Higher

35 Thurston 98,491 136.42 722 0.18896 Higher Lower

36 San Juan 7,986 45.92 174 0.26403 Lower Lower

37 Clark 155,042 246.49 629 0.39187 Higher Lower

38 Kitsap 95,758 242.46 395 0.61392 Higher Lower

39 Island 32,976 158.20 208 0.75893 Higher Lower

According to the Navigator Travel Score results, traveling will be the most difficult in Ferry, Okanogan, Lincoln, and Adams counties. The Navigator Travel Score rankings comport with our four expected scenarios in that counties with lower than average population density and higher than average land area rank at the top while counties with higher than average population density and lower than average land area rank at the bottom in terms of traveling difficulty. Note that the Navigator Travel Score is not a proven mathematical approach and is a methodology we have designed to develop a ranking system for comparing traveling difficulty between counties. While we believe the results serve to adequately rank and compare counties, further analysis may need to be performed to determine a more precise measurement of traveling difficulty. The following table includes data used in the above analysis and is presented in order of greatest to least population density (households per square mile). Table 10: Household Population Density

County Households Land Area

(Square Miles) Households Per

Square Mile

King 781,977 2,116 369.63

Clark 155,042 629 246.49

Kitsap 95,758 395 242.46

Pierce 295,554 1,670 177.03

Island 32,976 208 158.20

Thurston 98,491 722 136.42

Snohomish 263,931 2,087 126.45

Spokane 184,590 1,764 104.66

San Juan 7,986 174 45.92

Whatcom 78,186 2,107 37.11

Benton 62,038 1,700 36.48

Cowlitz 39,441 1,140 34.59

Skagit 45,253 1,731 26.14

Mason 21,808 959 22.73

Yakima 79,075 4,295 18.41

Clallam 30,987 1,738 17.83



Franklin 21,422 1,242 17.25

Walla Walla 21,367 1,270 16.82

Grays Harbor 28,191 1,902 14.82

Asotin 8,977 636 14.11

Lewis 29,290 2,403 12.19

Grant 29,427 2,680 10.98

Pacific 9,667 933 10.37

Chelan 26,676 2,921 9.13

Jefferson 14,194 1,804 7.87

Douglas 13,802 1,819 7.59

Whitman 15,717 2,159 7.28

Kittitas 16,619 2,297 7.23

Stevens 17,404 2,478 7.02

Wahkiakum 1,763 263 6.69

Klickitat 8,405 1,871 4.49

Pend Oreille 5,511 1,400 3.94

Okanogan 15,747 5,268 2.99

Adams 5,599 1,925 2.91

Skamania 4,514 1,656 2.73

Lincoln 4,649 2,310 2.01

Columbia 1,732 869 1.99

Garfield 903 711 1.27

Ferry 2,706 2,203 1.23

State Total 2,577,375 66,456 38.78

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