Health Plan Payment and Reimbursement

Fact Sheet: Standards for Consumer Assistance Programs for Healthcare Insurance Exchanges

August 9, 2013 3:26 pm


The Centers for Medicare & Medicaid Services (CMS) has released a final rule outlining the various training requirements applicable to navigators, non-navigators assistance program personnel, and certified application counselors in healthcare insurance exchanges—also called health insurance marketplaces—mandated under the Affordable Care Act (ACA). The final rule also creates conflict-of-interest, training and certification, and meaningful access standards, and clarifies that any licensing, certification, or other standards prescribed by a state or exchange must not prevent application of the provisions of title I of the ACA.


Beginning October 1, 2013, individuals, families, and small businesses will be able to purchase private health insurance through the affordable insurance exchanges, with coverage becoming effective as early as January 14, 2014. The exchanges will provide competitive marketplaces where individuals and small employers can compare available private health insurance options on the basis of price, quality, and other factors. The exchanges will help enhance competition in the health insurance market, improve choice of affordable health insurance, and give small businesses the same purchasing power as large businesses.

On January 22, 2013, CMS issued a rule that proposed standards to ensure the availability of certified application counselors in the exchanges and to clarify the training requirements that govern the consumer-assistance functions of the exchanges. Certified application counselors were proposed as a type of assistance personnel to help individuals in each exchange apply for enrollment in a qualified health plan (QHP) and in insurance affordability programs, which include Medicaid, Children’s Health Insurance Program (CHIP), and advance payments of the premium tax credit and cost-sharing reductions in connection with QHPs offered through an exchange. On April 5, 2013, CMS issued a related proposed rule to create conflict-of-interest, training and certification, as well as meaningful access standards applicable to Navigators and non-Navigator assistance personnel in federally facilitated exchanges, including state partnership exchanges, and to non-navigator assistance personnel in state exchanges that are funded through federal exchange establishment grants.  

Major Provisions of the Final Rule

Each exchange must conduct consumer-assistance activities and conduct outreach and education activities to inform consumers about the exchange and insurance affordability programs to encourage participation. Consumer assistance is provided through three programs involving navigators, non-navigator assistance personnel, and certified application counselors.

Consumer-Assistance Programs

Navigator and Non-Navigator Assistance Personnel

Federal and/or state funds are allocated for conducting public education activities to raise awareness about the exchanges. The purpose of these personnel is to educate consumers about health insurance, QHPs, and insurance affordability programs; to facilitate QHP enrollment; to provide enrollees with referrals for help with grievances, complaints, or questions about their health plan or coverage; and to provide information in a manner that is accessible to and culturally and linguistically appropriate for persons with disabilities. Navigators play a role in all three types of marketplaces (i.e., federally facilitated, state-partnership, and state-based). However, non-navigator assisters play a role only in state-based and some state-partnership marketplaces.

Certified Application Counselors

Every exchange is responsible for establishing its own certified application counselor program. The scope can vary based on each exchange’s needs and market features. These counselors focus primarily on helping consumers identify coverage and premium assistance options, select plans, and enroll in the plans. Certified application counselors are encouraged but not required to conduct community outreach activities or handle complaints. Although many of the program requirements are the same, certified application counselor requirements are tailored to the functions that they perform. They play a role in all three types of marketplaces.

Individuals and entities providing application and enrollment assistance related to health insurance or insurance affordability programs are not required to be certified application counselors—whether by the exchanges, state Medicaid, or CHIP agencies—or to be organizations designated by the exchanges to continue providing those services or communicating with consumers. The certified application counselor program is not designed to limit existing or potential application assistance programs. Rather, the certification of an individual as a certified application counselor provides an assurance to consumers that they are receiving assistance from persons trained by the exchange and overseen by organizations that protect personally identifiable information.

Training and Certification

Navigators and non-navigator assistance personnel in federally facilitated exchanges and state partnership Exchanges will be required to have up to 30 hours of training. Training will be offered on CMS’s website through content-specific training modules, which are expected to be available by the end of August. Training courses for certified application counselors will not be as broad as those for navigators and non-navigators. Each exchange may either designate organizations to certify their staff members and volunteers as application counselors or certify individual application counselors directly, or they may do both.

CMS expects that federally facilitated exchanges will designate organizations to certify application counselors. Each organization designated by an exchange to certify application counselors must maintain a registration process and method to track the performance of certified application counselors. Further, certified application counselors will enter into agreements with the certifying entity, whether they are certified directly by a state exchange or by an organization designated by the exchange, agreeing to comply with the standards and requirements for certified application counselors. Certified organizations must oversee compliance by their employees or volunteers.

Conflict of Interest/Reporting

All Exchanges are required to develop and publicly disseminate conflict-of-interest standards for navigators. Neither navigators nor non-navigator assistance personnel are permitted to be health insurance issuers or their subsidiaries, issuers of stop-loss insurance or their subsidiaries, associations that include members of the insurance industry or that lobby on behalf of the industry, or recipients of any direct or indirect consideration from any health insurance issuer or issuer of stop-loss insurance in connection with the enrollment of any individuals or employees in a QHP or non-QHP.

Navigators in federally facilitated marketplaces must submit a written attestation that they have no conflicts of interest, will remain free from conflicts of interest, and will provide information to consumers about the full range of QHP options and insurance affordability programs for which the consumers are eligible. Hospitals and other providers that perform navigator functions will not be prevented from receiving payment for medical services or grants for unrelated purposes. However, hospitals will need to disclose these payments to the marketplaces and to consumers receiving application assistance.

Some inherent potential conflicts of interest exist that must be disclosed to marketplaces and to consumers receiving application assistance by navigators in a federally facilitated marketplace. Examples include the sale of lines of insurance other than health or stop loss (for agents who are navigators); employment relationships with insurers, stop loss insurers, or their subsidiaries within the previous five years; and employment relationships among an insurer, stop-loss insurer, or subsidiary, and the navigator or staff member’s spouse or domestic partners.

Hospitals or health systems with health plans within their corporate structure are not prohibited from participating as certified application counselors as long as employees of the health plan are not involved and they disclose the conflict of interest to the marketplace and potential enrollees.

Providing Culturally and Linguistically Appropriate Services

Navigator entities have a duty to provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by an exchange or exchanges. CMS recognizes that the National CLAS Standards provide guidance for best practices in providing culturally and linguistically appropriate services and encourages all entities providing outreach and enrollment assistance to refer to that document as a resource, as well as to the accompanying Blueprint for Advancing and Sustaining CLAS Policy and Practice, a new guidance document for the National CLAS Standards that discusses implementation strategies for each standard.

Ensuring Access by Persons with Disabilities

Navigators and non-navigator assistance personnel must ensure that persons with disabilities can access and use navigator and non-navigator assistance services in accordance with the Americans with Disabilities Act and section 504 of the Rehabilitation Act. Navigators and non-navigator assistance personnel should have sufficient knowledge to be able to refer individuals with disabilities to additional personnel to facilitate consumer access to additional services.  

More Information

Read the final rule published in the July 17, 2013, Federal Register. 

Other Resources

Read HFMA’s FAQ titled, What the Navigator Rule Means for Providers .



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