ACA Marketplace Consumer Assistance Still a Work in Progress

The Robert Wood Johnson Foundation (Foundation) discussed in a health policy brief the state of navigators and assisters employed to help and educate the public about the health insurance exchanges, or Marketplace, under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Both navigators and assisters are employed to help individuals with purchasing a health plan in the Marketplace. According to the Foundation, navigators are not a new concept; a similar program is the State Health Insurance Assistance Program (SHIP) provided for Medicare beneficiaries.

Categories of ACA Assistance

Funded by federal or state grants, navigators are individuals or community-based organizations utilized to guide consumers in the Marketplaces, assist with subsidy applications, and enroll in health plans. Funded by separate grants or contracts administered at the state level, assisters function in a similar role. A third form of assistance, enrollment assisters, help consumers fill out applications and compare health plans; these assisters, however, do not receive federal funding.

Although navigators and assisters perform similar functions, differences do exist. States are permitted to use Marketplace establishment grant money to plan and administer a navigator program. However, navigators cannot be paid out of these grants. Instead, navigators must be paid out of the operational budget of the Marketplace, which in most states is funded by an assessment on premiums for health plans sold in the Marketplace. The Foundation noted that as a result, state Marketplaces will not have a funding stream for navigators until insurance coverage begins in January 2014. Conversely, assisters can be funded out of the establishment grants.


Navigators are required to: (1) perform public education and outreach activities; (2) distribute enrollment information on health plans and federal subsidies; (3) facilitate enrollment in health plans; (4) provide referrals for consumer grievances or complaints; and (5) provide information that is appropriate for consumer understanding. Additionally, navigators may not receive benefits directly or indirectly from an insurance company, including a stop-loss insurer. Assisters are bound by similar education, training, and conflict-of-interest standards.

Unequal Funding

Thirty-four states passed on setting up their own state-based Marketplace and the demand on the federal government’s navigator program outpaced its funding. HHS will be operating a Marketplace that accounts for nearly two-thirds of the uninsured. As a result, states that provided their own Marketplace had more money available for consumer assistance than states that passed on operating a Marketplace, because they could rely upon establishment grants. For instance, Maryland had $24 million to spend on consumer assistance for 700,000 uninsured residents, whereas Texas will only have $8 million available to spend on its 6.4 million uninsured residents.

Conflict with State Laws

In a letter earlier this year, 13 states via their attorney generals raised concerns about privacy protections and inadequate training of navigators and assisters. The letter contended that navigators would be exposed to sensitive information, such as consumers’ Social Security numbers and tax returns, while helping a consumer find a plan.

Moreover, agents and brokers for insurance companies have been lobbying state legislatures to pass laws imposing additional requirements on navigators. Currently, 17 states have passed navigator laws that place additional requirements on navigators and assisters. The brief noted that most of the states that have passed legislation are states in which HHS is operating the Marketplace, making the additional requirements appear to be politically motivated.

In its Final Rule on navigators, HHS noted that while states could require additional licensing or certification for navigators, these additional requirements could not prevent navigators from fulfilling duties under ACA.

Future of Programs

With the troubling launch of the Marketplace online, the brief noted that navigators and assisters would be extremely important for consumers. The Foundation stated that HHS would likely need to issue clearer guidance on when federal law preempted state laws that could potentially prohibit navigators from fulfilling responsibilities.