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CMS Issues Proposed ACA Navigator Rules

affordable care actOn April 3, the Centers for Medicare & Medicaid Services (CMS) issued proposed rules to govern navigators and non-navigator consumer assistance personnel. These are people health insurance exchanges will make available to help consumers choose and purchase their qualified health insurance. The navigator/non-navigator consumer assistance function was created in the Affordable Care Act (ACA), but is not intended to replace professional health insurance agents and brokers.

The proposed rules (CMS-9955-P) set standards for navigator training, certification, and conflict of interest. They apply to navigators dealing with health insurance provided within a federal exchange, to federal-state partnership exchanges, and to non-navigator assistance personnel working through state-based exchanges that received federal funding.

Conflict of Interest Rules: CMS-9955-P sets out a number of rules aimed at preventing conflicts of interest. Among them are:

  • Any state requirements for licensing or certifying navigators or non-navigator assistance personnel may not conflict with the rules set out in the health reform law
  • No person or entity connected with a stop-loss insurance issuer may serve as a navigator
  • Navigators will have to submit, in writing, assurances that they (and their staff) are not connected in any way with (including receiving payment from or being affiliated with) any health insurance issuer (including issuers or stop-loss insurance), and that they are not an association that includes members, or lobbies on behalf of any health insurance issuer in connection with enrolling individuals or employees in an exchange-offered health plan
  • Navigators (companies and individuals) must disclose any employment arrangements—existing and those within the preceding five years—with health insurance issuers. The disclosure must also cover navigators’ (and their employees’) spouses and domestic partners

Training: The proposed rule does not require that navigators and non-navigator assistance personnel be licensed, but does impose training and certification requirements. The requirements include completion of (and passing) a training course approved by the Department of Health and Human Services (HHS) and annual recertification. The rule requires navigators and non-navigator assistance personnel to demonstrate competency in both small business (including SHOP [Small Business Health Options]) and individual coverage.

Approved training must include qualified health insurance coverage levels (and how they operate), including benefits covered, payment processes, and appeals. It must also educate navigators on insurance for the poor, including Medicaid and the Children’s Health Insurance Program (CHIP). Also to be included in the training is information on the tax implications of the coverage a prospective enrollee selects, eligibility for federal subsidies, and contact information for federal and state agencies that can provide consumers with additional assistance on coverage options.

Access/Information Reporting: The proposed rule also requires that navigators and non-navigator assistance personnel collect and maintain demographic information on the populations served by the exchange for which they work. This information is designed to help assure that low-income and diverse (racially and culturally) populations have access to the assistance provided by navigators, the proposed rule states. Accordingly, navigators must also be able to provide or obtain, “appropriate translation services” where needed. The rule also requires that navigators make consumer education materials accessible to people with disabilities.

Next Steps: CMS will accept comments on this proposed rule, which was published in the Federal Register on April 5, through May 6. The proposed rule emphasizes that a navigator is inherently different from a professional agent/broker. For example, the rules state a navigator must be proficient in public coverage options (particularly with respect to the poor) and thus requires different expertise than that required of a licensed agent/broker. Navigators will also be responsible for data collection that is not normally part of an agent’s/broker’s activity.

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