Healthcare Reform

At a Glance: What the Final Health Insurance Exchange Navigator Rule Means for Providers

July 31, 2013 1:55 pm

At a Glance: What the Final Health Insurance Exchange Navigator Rule Means for Providers 


CMS’s final navigator rule opens the door for hospitals and health systems to play a role in educating patients about the health insurance marketplaces—either by offering assistance services themselves or by referring patients to appropriate services. Here’s what you need to know.


On July 12, the Centers for Medicare & Medicaid Services (CMS) issued its final rule for the various types of assisters that will help consumers enroll in the health insurance marketplaces, beginning this October. Below are some key take-aways from the final rule:a

What’s the difference between navigators, non-navigator assistance personnel, and a certified application counselor (CAC)? The final rule spells out three main distinctions among these three types of consumer assisters:

o Funding

? Navigators and non-navigator assistance personnel can be funded with grants—either federal or state grants, depending on what type of exchange is running in your state.

• The Department of Health & Human Services’ fact sheet includes a table that lays out this funding information .

? CACs are not eligible to receive funding/grants through the federal or state exchanges.

o Training/outreach

? Both navigators and non-navigators will be required to take 30 hours of training to be certified, and both will be responsible for the whole range of exchange enrollment activities—from public outreach and education to helping individuals enroll and sign up for premium subsidies.

? By contrast, the CACs will have to take some training (which will be left to the discretion of the states), but CMS insinuates through the final rule that the amount of training could be less than what is required of navigators and non-navigators.

? CACs are only required to provide assistance with activities related to enrollment; however, they are not precluded from conducting community outreach.

o Conflicts of interest/reporting

? Navigators and non-navigators may not be health insurers or stop-loss insurers, subsidiaries of insurers, or associations that represent insurers; nor can they receive consideration from health insurers in connection with the enrollment of individuals in qualified health plans.

? Navigators and non-navigators must attest that they have no existing conflict of interests, will provide information to consumers on the full range of qualified health plans and insurance affordability programs, and provide a written plan to remain free of conflicts.

? Some potential conflicts of interest do not preclude an individual or organization from being either a navigator or non-navigator; however, they must be disclosed to both the health insurance marketplace and consumers.

• These 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; or employment relationships between an insurer, stop-loss insurer, or subsidiary, and the navigator or staff member’s spouse or domestic partner.

? Organizations with conflicted interests, like insurers or their agents and brokers, are explicitly not prohibited from serving as CACs.

• However, CACs must disclose any conflicts of interest to consumers they serve and to the exchanges that certify them or, if they are individuals certified by an organization, to the organization.

? For navigators, non-navigators, and CACs, only the employees or volunteers acting in an assister capacity need to be free of conflicts of interest.

What roles can hospitals and provider organizations play? It appears that hospitals and other provider organizations can serve as any type of exchange assister. The section of the final rule discussing CACs explicitly states “healthcare providers” when listing types of organizations that would qualify.

The navigator/non-navigator is less explicit; however, page 42832 of the final rule discusses whether or not a healthcare provider’s contract with a payer to provide medical services to members would constitute a conflict of interest. It clarifies that while the provider may have to disclose the relationship, it would not serve as a bar. This seems to suggest that providers can be navigators/non-navigators.

Can providers who have insurance plans under their corporate umbrella act as navigators, non-navigators, or CACs? Yes, as long as the individuals performing the assister function don’t have any existing conflicts of interest and have no reporting relationships with the entity that sells insurance.

Do provider organizations have to be certified to provide assistance enrolling individuals in exchange products? No. Only individuals who represent themselves to the public as “certified application counselors” need to be certified.

As detailed on page 42843 of the final rule, individuals and entities providing application and enrollment assistance related are not required to be certified application counselors, whether by the exchange, state Medicaid, or CHIP agencies. Nor are they required to be organizations designated by the exchange in order 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.

CMS plans to make the training material for the certified application counselor program publicly available once it is developed. Anyone will be able to access that training material, regardless of whether you intend to become certified.


Chad Mulvany is director, healthcare finance policy, strategy and development, HFMA. [email protected]

This summary was based, in part, on a special members-only bulletin from the American Hospital Association and a recent Health Affairs blog piece by Timothy Jost.

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