Role of Navigators and Other ACA Public Outreach Organizations Examined by CRS

Navigators, non-navigators, application counselors, as well as insurance brokers and agents, will be used to help people make decisions about the various qualified health plans (QHPs) from which they may choose to obtain insurance from the health insurance exchanges beginning on October 1, 2014. The Congressional Research Service (CRS) reported on the various functions, sources of funding, and training provided to each of these types of consumer assistance groups. The Affordable Care Act (ACA) (P.L. 111-148 and 111-152) requires exchanges to perform outreach activities to help consumers and small business make informed decisions about their insurance options.

As of September 2013, 16 states and the District of Columbia will be running their own exchanges. Seven states have entered into a partnership with the federal government to run an exchange and 26 states are leaving it up to the federal government to operate an exchange in their state. An estimated 29 million people are expected to obtain insurance through an exchange by 2023. An exchange is not an insurer, but rather, a marketplace where insurance firms may sell their products and customers may obtain federal subsidies help purchase insurance.

Navigators

Sec. 1311 of the ACA required the use of navigators for exchanges being run by federal government, which can carry out public education activities; provide information to prospective enrollees about insurance options and federal assistance; and examine enrollee’s eligibility for subsidies or enroll them in plans. According to the ACA, navigators can be labor unions, trade associations, chambers of commerce and other entities. HHS received 830 letters of intent from organizations that sought to become navigators. On August 15, 2013, CMS awarded $67 million in funding to 105 organizations to be navigators at federally run exchanges. The grantees included food banks, county commissioners, hospitals and health systems, universities, and legal aid societies. The only limitation on navigators is that they do not receive any money from the insurers operating on the exchange as a commission or incentive for selling their product.

Non-Navigators

Non-navigator organizations fill the same role as navigators, but they are used by state-funded exchanges. While no money was provided in the ACA for non-navigators, states can use grant money they received to set up their exchanges for non-navigator programs. While this money cannot be awarded to a non-navigator as a grant, it can be used to cover the exchange’s cost of administering the non-navigator program, including training, management and oversight.

Brokers and Agents

Insurance brokers and agents can sell insurance policies that are available on the exchange to people. However, there are limitations on what they can do and the money they can receive. Brokers and agents will have to register with the exchange in their state and complete exchange specific training. If the agent or broker will be selling a policy that is on the exchange, they will be directed to the exchange’s website. At that time the purchaser will see not only the policy the broker is selling but all the policies available on the exchange.

Application Counselors

CMS regulations require state exchanges to have certified application counselor programs to help facilitate enrollment in QHPs. These counselors are to provide information on QHPs offered at the exchange. They, too, will be required to go through training, but since their role does not include outreach functions, their training is not as rigorous.

Training

Training requirements for navigators and non-navigators is similar. They must complete 30 hours of HHS-approved trainings and receive a passing score on an exam. The training is to include (1) eligibility and enrollment rules and process; (2) the full range of QHPs offered at an exchange; (3) the range of insurance options including Medicaid and CHIP and other public programs; (4) eligibility requirements for government assistance; (5) the tax implications of enrollment decisions; (6) privacy and security requirements; (7) appeals processes; (8) outreach methods; and (9) knowledge about the racial, ethnic and cultural groups in the exchange’s service area including knowledge about the variety of languages spoken.