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Proposed Rules Address Navigators under Health Insurance Exchanges
Practical Law Legal Update 8-525-5723 (Approx. 5 pages)
Proposed Rules Address Navigators under Health Insurance Exchanges
by PLC Employee Benefits & Executive Compensation
| Law stated as of 08 Apr 2013 • USA (National/Federal) |
The Department of Health and Human Services (HHS) has issued proposed regulations providing training, certification and conflict of interest standards for insurance exchange navigators under the Affordable Care Act (ACA).
On April 3, 2013, HHS issued proposed regulations providing training, operating and conflict of interest standards for "navigators" who will help individuals and small employers participate in the Affordable Care Act's (ACA's) insurance exchanges (see Practice Note, Health Insurance Exchange and Related Requirements under the ACA). The ACA requires establishment of a navigator program that awards grants to navigators who are responsible for:
- Conducting public education activities to raise awareness of the availability of qualified health plans (QHPs).
- Distributing fair and impartial information about:
- enrollment in QHPs; and
- the availability of exchange-related tax credits and subsidies.
- Assisting enrollment in QHPs.
- Providing referrals to health insurance consumer assistance or ombudsman offices established under the ACA, for individuals with grievances, complaints or questions about their health plan.
- Furnishing information in a culturally and linguistically appropriate manner to populations being served by the exchanges.
Although navigators cannot choose a health insurance plan for individuals or small employers, they can assist enrollment by providing information on available health insurance options. Among other things, the proposed regulations provide standards for training, certification, conflicts of interest and accessibility. The proposed regulations generally apply to:
- Navigators and non-navigator assistance personnel (that is, support provided outside a navigator program) in federally-facilitated exchanges, including state partnership exchanges.
- Non-navigator assistance personnel in state-based exchanges funded through federal exchange establishment grants under the ACA.
The proposed regulations clarify that any navigator licensing, certification or other standards required by a state or exchange must not prevent application of requirements of Title I of the ACA, which includes exchange-related provisions. HHS seeks public comments on the proposed regulations.
Entities and Individuals Eligible to be Navigators
Under the ACA, navigators cannot be health insurers or receive consideration, directly or indirectly, from a health insurer in connection with enrollment of qualified individuals in QHPs. Prior regulations implementing this requirement provide that a navigator also cannot be either:
- A subsidiary of a health insurer.
- An association that includes members of (or lobbies on behalf of) the insurance industry.
The proposed regulations clarify that a navigator cannot:
- Be a stop loss insurer or its subsidiary.
- Receive consideration, directly or indirectly, from a stop loss insurer in connection with enrollment of individuals in a QHP or non-QHP.
Navigator Training Standards
The proposed regulations provide training standards for navigators and non-navigator assistance personnel performing consumer assistance functions. The proposed rules build on existing training standards intended to ensure navigator expertise in issues including:
- Eligibility and enrollment rules and procedures.
- QHP options and insurance affordability programs.
- The needs of underserved populations.
- Privacy and security requirements governing personally identifiable information.
The proposed regulations add specific training standards requiring up to 30 hours of training, including standards for certification and recertification.
Certification and Recertification
Under the proposed regulations, all navigators and non-navigator consumer assistance personnel must meet certain certification and recertification requirements. Before performing any consumer assistance functions, these entities must:
- Register with and obtain certification from a health insurance exchange.
- Complete an HHS-approved training (before certification).
- Be staffed by individuals who have achieved a passing score on all HHS-approved examinations.
Navigators and non-navigator consumer assistance personnel must also:
- Obtain continuing education and be certified or recertified at least annually.
- Be prepared to serve both the individual exchanges and small business health option (SHOP) exchanges (see Practice Note, Health Insurance Exchange and Related Requirements under the ACA).
Training Module Content
The proposed regulations would require navigators and non-navigator assistance personnel to receive training in a variety of subjects, including:
- How QHPs operate, including metal levels, benefits covered, payment processes, appeals rights and procedures and how to contact individual plans.
- Insurance affordability programs (for example, Medicaid and the Children's Health Insurance Program (CHIP)).
- The tax implications of enrollment decisions.
- Eligibility requirements for tax credits and subsidies, and the impact of receiving a tax credit on premium cost.
- Contact information for federal, state and local agencies for consumers seeking additional information about specific coverage options not offered through an exchange.
- Basic concepts about health insurance and the exchanges, the benefits of having health insurance and enrolling through an exchange, and the individual responsibility to have health insurance.
- Eligibility and enrollment rules and procedures, including how to appeal an eligibility determination.
- Providing culturally and linguistically appropriate services.
- Ensuring physical and other accessibility for individuals with a full range of disabilities.
- Privacy and security standards for handling and safeguarding individuals' personally identifiable information.
- Working with individuals having limited English proficiency, individuals with a full range of disabilities, and rural and underserved populations.
- Customer service standards and outreach methods.
Conflict of Interest Standards
The proposed regulations also include conflict of interest rules for navigators and non-navigator assistance personnel. Navigators would be required to submit to an exchange:
- A written attestation that the navigator and its staff do not have any prohibited conflicts of interest (for example, certain prohibited relationships with insurers or the insurance industry).
- A written plan to remain free of conflicts of interest during the navigator's term.
Navigators would need to provide information to individuals about the full range of QHP options and insurance affordability programs (for example, exchange-related tax credits and subsidies).
To mitigate conflicts of interest, navigators must also disclose certain information to an exchange and its participants (for example, any lines of insurance business, other than health or stop loss insurance) that the navigator intends to sell while serving as a navigator). Agents and brokers would be permitted to serve as navigators in an HHS-operated exchange, provided that the agent or broker satisfies all standards applicable to navigators in the exchange (for example, receiving consideration, directly or indirectly, from a health insurer in connection with enrolling individuals in QHPs or non-QHPs).
The proposed regulations provide that non-navigator assistance personnel carrying out consumer assistance functions must comply with similar conflict of interest requirements (for example, not having disqualifying conflicts from being a health or stop loss insurer).
Accessibility Standards
The proposed regulations also establish accessibility standards for individuals with disabilities and include standards for providing services in a culturally and linguistically appropriate manner.