What is a Health Insurance Navigator?

The Affordable Care Act requires state health insurance marketplaces to establish a “navigator” program (Section 1311(i)) that will help individuals who are eligible to purchase coverage through a health insurance marketplace learn about their new coverage options and enroll. States can award grants to entities that will provide these services. This articles explains how navigators are different from brokers and agents.

What is a health insurance navigator?

Under current law, navigators have the following five duties:

1. To conduct public education about the availability of qualified health plans. 

2. To distribute fair, impartial information about enrollment in qualified plans and about the availability of premium tax credits and cost-sharing assistance in the exchange.

3. To facilitate enrollment in qualified plans.

4. To refer people who need help resolving a problem with their health plan or with their premium assistance to a consumer assistance or ombudsman program or to another appropriate agency that can help with a grievance or appeal.

5. To provide information in a culturally and linguistically appropriate manner to the population being served by an exchange.

Who can become a health insurance navigator?

The law lists a number of different kinds of entities that could become navigators, including:

• community- and consumer-focused nonprofits; 

• trade, industry, and professional associations; 

• commercial fishing, ranching, and farming organizations; 

• chambers of commerce; 

• unions; 

• Small Business Administration resource partners; 

• licensed insurance agents and brokers; and 

• other entities.

To be eligible to receive navigator grants, an entity must meet the following criteria:

1. Relationships

The entity must already have relationships, or be readily able to establish relationships, with one or more of the following that qualify to enroll in exchange plans:

• employers and employees;

• consumers, including uninsured and underinsured consumers; and

• self-employed individuals.

2. Capabilities

The entity must be capable of performing the duties of a navigator, described above.

3. Meet standards established by the Secretary of HHS

These standards will ensure that navigators are qualified and “licensed if appropriate” and that they avoid conflicts of interest. The law requires that navigators cannot be health insurers. Nor can they receive direct or indirect compensation from an insurer in connection with enrollment of any exchange-eligible individuals or employers in a qualified health plan.

4. Deliver fair and impartial information

The Secretary and states will develop standards to ensure that navigators deliver fair, impartial, and accurate information.

Can a health insurance agent or broker be a navigator?

Yes. According to ACA Section 1312(e), the Secretary will establish procedures under which states may allow agents or brokers to:

1. Enroll individuals and small employers in qualified health plans, and 

2. Assist individuals in applying for premium tax credits and cost-sharing reductions in exchanges.

Insurers are not prohibited from paying agents and brokers for their services. While the yet-to-be-issued procedures will clarify how this will work, it appears that agents and brokers can be paid by insurers for enrollments (as they are now) or can be paid a fee by the exchange, but when they are paid by insurers, they cannot simultaneously get grants to act as navigators.

Note: This should not be taken as legal or tax advice.