By Maggie Dunham

Last month, the Department of Health and Human Services released final regulations on the minimum standards states must meet in establishing health insurance exchanges.  The regulations include Navigator program standards for both the individual exchange and the SHOP (45 CFR Section 155.210).  The purpose of a Navigators program is to help consumers access health insurance within the Exchange.  Even with the new regulations, individual states must still make several decisions about how to set up a Navigator program within their Exchange.

Navigators are Exchange grant-funded entities or individuals who will educate consumers about available health plan coverage through the Exchange.  Navigators must be culturally and linguistically competent in order to support diverse populations in accessing the Exchange and understanding health plan options.  They must distribute fair and impartial information concerning the availability of premium tax credits, and may help facilitate enrollment in qualified health plans, though according to the regulations, Navigators are prohibited from marketing health insurance products.

The final regulations identify which individuals and organizations can become Navigators.  Navigators must be someone with existing relationships with employers and employees, as well as uninsured or underinsured individual consumers.  Navigators may be community and consumer-focused nonprofit groups, chambers of commerce, unions or even licensed agents or brokers.  The regulations also clarified that there must be at least two types of Exchange Navigators, one of which must be a community-based organization or a consumer-focused nonprofit.   Ultimately, it is ideal to have Navigators come from a broad array of backgrounds in order to meet the needs of a diverse consumer population. 

An important component addressed in the regulations is the prohibition of Navigators having conflicts of interest.  One way the rules address this issue is by excluding Navigators from receiving compensation from insurers for enrolling individuals, although they are not exempt from receiving grants for activities unrelated to enrollment.  The regulations  require states to set conflict of interest and training standards for Navigators.  However, HHS explained that states or exchanges should not be able to stipulate that Navigators hold an agent or broker license as that would mean all Navigators would be agents and brokers which would violate the standard in the final rule that at least two types of entities serve as Navigators. 

HHS has recognized that standards in the final rule are likely not sufficient, and is encouraging states to develop a robust set of conflict of interest standards for Navigators. Navigators will inevitably play an essential role in guiding consumers to available health plan options within the Exchange.  The implications of how Navigators will ultimately be defined will undoubtedly impact how consumers access the Exchange.

Maggie Dunham is a Policy Intern at CCHI and a Master of Social Work Candidate with the University of Denver’s Graduate School of Social Work.

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