On Wednesday, April 3, 2013 the U.S. Department of Health and Human Services (HHS) released proposed rules on Navigators in the state health insurance exchanges. The much-anticipated release clarifies standards for Navigator eligibility, conflict of interest, training, and service delivery.
Proposed Rules for Navigators - Highlights
Key highlights from the proposed rules include:
Navigators cannot be employed by health insurers, and cannot be issuers of stop-loss insurance for self-funded plans (or their subsidiaries), although Navigators would be permitted to sell other forms of insurance, such as life and disability plans.
Navigators, as individuals or organizations, would be required to make several conflict of interest disclosures to the exchanges and consumers, listing any lines of non-health or stop-loss insurance business and any employment with health or stop-loss insurers during the last five years.
Insurance agents and brokers would be able to serve as Navigators, absent of financial ties to health insurers. However, states could not require Navigators to be licensed brokers or to carry professional liability insurance. In other words, any individual or entity could be a Navigator if they meet the exchange's requirements and standards.
- Agents and brokers will have a choice to operate either as a traditional producer (selling individual and small group health insurance policies on and off the exchange), or change their business model and serve as a Navigator. Further rules will be released on producers registering and selling with the exchanges, and may vary by state.
1. Proposed Rules for Navigators - Eligibility
These eligibility standards would apply to Navigators in all state health insurance exchanges, including Federal Exchanges, Partnership Exchanges and State-based Exchanges.The proposed rule clarifies Navigators (entity or individual) must meet any licensing, certification or other standard prescribed by the state or Exchange (if applicable), as long as such standards do not prevent the application of the provisions of title I of the Affordable Care Act. In other words, a Navigator does not need to be licensed as a broker or agent.
2. Proposed Rules for Navigators - Conflict of Interest
The following proposed rules would be applicable to Navigators, and and non-Navigator assisters ("in-person assisters") in the Federal Exchange, Partnership Exchanges, and State-based Exchanges federally funded through 1311(a) Exchange Establishments grants.
Conflict of Interest: The proposed rules provide further details on conflict of interest standards.The conflict of interest prohibition found in the original rule is expanded. Under existing rules Navigators may not be health insurance issuers, subsidiaries of issuers, associations of insurers or insurer lobbyists, or receive direct or indirect consideration for insurers, including trailer commissions for past sales. The proposed rule expands prohibited relationships to include relationships with stop loss issuers or subsidiaries of stop loss issuers, or consideration from stop loss issuers.
Individual vs. Entity Navigator: The same conflict of interest rules would apply to individuals as to entities awarded a Navigator grant. If an entity or organization is awarded a Navigator grant, the entity as a whole is considered to be a Navigator. While a Navigator could retain staff members who serve as agents and brokers, those staff members—and the organization itself—could not receive compensation from health insurance or stop loss insurance issuers for enrolling individuals or employees in QHPs or health insurance plans outside of the exchange. Such staff members, however, could continue to be compensated for selling other insurance products (for example, auto, life, and homeowners' policies).
3. Proposed Rules for Navigators - Training Standards
The proposed rules establish training standards for Navigators. HHS had earlier proposed that Navigators and non-Navigator assisters “be trained regarding QHP options, insurance affordability programs, eligibility, and benefits rules and regulations governing all insurance affordability programs operated in the state, as implemented in the state, prior to providing such assistance.”
The proposed rule clarifies that Navigators and non-Navigator assisters in federal exchanges (and federally-funded non-Navigator assisters in state exchanges) must receive up to 30 hours of training. Additionally, they must register with the exchange, be certified as having received the necessary training, and pass an HHS-approved exam.
The rule details the topics required in the training program, including privacy and security issues. Navigators must receive continuing education and be recertified at least annually. Navigator and non-Navigator assisters must be trained to assist with SHOP exchange as well as individual exchange issues, although in general a Navigator may refer a consumer to other exchange resources where an issue arises beyond the Navigator’s competence.
4. Proposed Rules for Navigators - Culturally and Linguistically Appropriate Services, and Access for Persons with Disabilities
The final sections of the proposed rules address requirements for providing culturally and linguistically appropriate services, as well as accessible services to persons with disabilities. The proposed rule would require Navigators to (among other activities):
Be familiar with the racial, ethnic, and cultural groups in their area
Have access to oral interpretation and written translations of appropriate documents in non-English languages
Have access to telephone interpretive services
Inform Non-English speakers of the availability of these services
Proposed Rules for Navigators - Public Comments Until May 6
HHS is accepting comments on the proposed rules until 5:00 PM EDT on May 6, 2013.