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Institute for Workplace Studies----------------- Professor Samuel B. Bacharach

School of Industrial & Labor Relations-------- Director, Institute for Workplace Studies

Cornell University

16 East 34th Street, 4th floor---------------------- Stuart Basefsky

New York, NY 10016 -------------------------------Director, IWS News Bureau

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Congressional Research Service (CRS)

 

Health Insurance Exchanges: Health Insurance “Navigators” and In-Person Assistance

Suzanne M. Kirchhoff, Analyst in Health Care Financing

September 25, 2013

http://www.fas.org/sgp/crs/misc/R43243.pdf

[full-text, 32 pages]

 

Summary

The 2010 Patient Protection and Affordable Care Act (ACA, P.L. 111-148) allows certain

individuals and small businesses to buy health insurance through state exchanges, beginning on

October 1, 2013. The exchanges are not themselves insurers, but rather are special marketplaces

where insurance firms may sell health policies that meet set, federal guidelines. As of September

2013, 16 states and the District of Columbia had secured Department of Health and Human

Services (HHS) approval to create their own exchanges, 7 to enter into partnership exchanges, 26

to have federally facilitated exchanges, and 1 to have a state-based Small Business Health

Options Program (SHOP)/federally facilitated individual exchange. An estimated 24 million

individuals are expected to secure coverage through the exchanges by 2022.

 

The ACA requires exchanges to perform outreach to help consumers and small businesses make

informed decisions about their insurance options, including the creation of “navigator” programs.

Navigators are to carry out public education activities; provide information to prospective

enrollees about insurance options and federal assistance; and examine enrollees’ eligibility for

other federal or state health care programs, such as Medicaid. Navigators may assist consumers in

comparing insurance plans, but may not determine their eligibility for subsidies or enroll them in

plans—functions that are left to the exchanges. A variety of organizations may become

navigators, including labor unions, trade associations, chambers of commerce, and other entities.

Navigators may not be health insurers or take compensation from insurers for selling health

policies. Navigators will be required to have 20-30 hours of training on consumer privacy,

exchanged-based insurance offerings, and other issues. HHS in August 2013 allocated $67

million in 12-month grants for navigators at federally facilitated and partnership exchanges. In

addition, HHS has determined that state-based exchanges may use ACA exchange establishment

funds to create parallel, in-person, or non-navigator, assistance programs that perform the same

function as navigators. Exchanges must also certify “certified application counselors” to help

with outreach and enrollment, though no new ACA funds are available for such programs.

 

Consumers and small businesses may continue to use insurance brokers and agents, including

web-based brokers, to compare and buy coverage, both on and off the exchanges. Brokers and

agents are licensed by the states, and are generally paid on a commission basis by insurance

companies. While brokers and agents may choose to become navigators, they may not accept

compensation from health insurance companies in that role. Consumers may also purchase

policies directly from health insurers. Outside non-profit groups and businesses, such as insurers,

are launching their own separate efforts to educate consumers about the ACA and the process of

applying for qualified health plans (QHP) and other programs.

 

Some lawmakers, agents, and brokers have raised questions about the navigator and other

assistance programs. Issues include whether navigators will have sufficient training and whether

HHS regulations provide sufficiently stringent consumer and privacy safeguards. A number of

states have passed legislation to further regulate navigators, including requiring navigators to be

licensed and to be liable for financial losses due to their advice. HHS has determined that the

ACA gives states authority to set additional standards, so long as they do not prevent

implementation of Title I of the law, which includes the exchanges and navigator program. This

report describes exchange outreach programs, the role of brokers, agents and insurers, and

emerging issues regarding consumer outreach assistance.

 

Contents

Introduction ...................................................................................................................................... 1

Consumer Assistance Programs ....................................................................................................... 2

Navigator Program .................................................................................................................... 4

Eligibility to Become a Navigator ....................................................................................... 5

Navigator Application Process ............................................................................................ 6

Non-navigator Programs ........................................................................................................... 7

Certified Application Counselors .............................................................................................. 8

Conflict-of-Interest Rules .......................................................................................................... 9

Training and Certification........................................................................................................ 10

Navigator and Non-navigator Training ............................................................................. 10

Certified Application Counselor Training ......................................................................... 11

Privacy Protections .................................................................................................................. 12

State and Exchange Licensing and Certification ..................................................................... 13

Navigator and Non-navigator Funding .................................................................................... 14

Brokers and Agents ........................................................................................................................ 16

Licensing ........................................................................................................................... 16

Exchange Requirements ................................................................................................................ 17

Federally Facilitated and Partnership Exchanges .................................................................... 17

State-Based Exchanges ............................................................................................................ 19

Web-Based Brokerages ............................................................................................................ 19

Direct Enrollment Through Insurers ........................................................................................ 20

Previous Insurance Education and Outreach Efforts ..................................................................... 20

Medicare Part D ................................................................................................................ 21

State Health Insurance and Assistance Programs (SHIP) .................................................. 22

Children’s Health Insurance Program ............................................................................... 23

Outstanding Issues ......................................................................................................................... 24

Funding .................................................................................................................................... 24

Adequacy of Privacy Protections ............................................................................................ 25

 

Tables

Table 1. Types of Consumer Assistance Available at Exchanges .................................................... 7

Table 2. 2013 Federal Navigator Grants to Top 10 States with Highest Uninsured ...................... 15

 

Appendixes

Appendix. CMS Exchange Privacy Requirements ........................................................................ 27

 

 

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