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'Navigators' will guide Americans through the ACA exchanges

Feds release final rule outlining eligibility and training for the navigators

Topics: Health Care Reform, Market Trends, Strategy, Payer and Regulatory Policy, Reimbursement, Finance, Payer Relations

April 05, 2013

HHS on Wednesday released a proposed rule defining the eligibility, standards, and training of "navigators," who are tasked with providing guidance to people enrolling in the federal health exchanges under the Affordable Care Act (ACA).

  • Need a refresher on the state health exchanges? We've got you covered with a quick review of the ACA marketplaces, including when they're rolling out, how they work, and what it means for you.

Under the ACA, each exchange must have two certified as navigators, one of which must be not-for-profit. The navigators are expected to provide "fair, impartial, and accurate information that assists consumers with submitting the eligibility application, clarifying distinctions about [qualified health plans], and helping qualified individuals make informed decisions during the health plan selection process." They will also provide additional assistance to consumers who are disabled, do not speak English, or who are unfamiliar with health insurance.

The proposed guidelines specify that while navigators do not have to be licensed insurance agents or brokers, they: 

  • Cannot be employed by an insurer;
  • Cannot receive compensation or rewards from carriers;
  • Must disclose what other lines of insurance they intended to sell during their work;
  • Must disclose any prior employment with health insurers in the previous five years; and
  • Must certify that they will abide by conflict of interest and impartiality standards developed by HHS.

The proposed rule also states that navigators cannot select a plan for their clients, and that they are not tasked with determining whether a client is eligible for a subsidy through the ACA.

Further, the proposed rule states, "The navigator must not have a personal interest in the coverage choices made by individuals or employers who receive the navigator's assistance," adding, "More specifically, with respect to the assistance offered by a navigator to a small employer, a navigator should not have a personal interest in whether a small employer choose to self-insure its employees, or chooses to enroll in fully-insured coverage inside or outside the exchange."

Navigators in state-run exchanges do not have to abide by the same conflict-of-interest standards as those in federal and federal-state partnered exchanges. However, HHS suggested that state exchanges use the proposed rule as a model for developing their own guidelines (Block, Modern Healthcare, 4/3 [subscription required]; Baker, "Healthwatch," The Hill, 4/3).

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