Health Exchange Navigators - Agents in Health Insurance Exchanges

Health Exchange Navigators

Navigators are individuals or agencies that assist consumers with purchasing qualified health plans through an Exchange. As many as 30 million Americans are currently uninsured and will need to purchase healthcare by 2014 or face a tax penalty. . Given the number of people in this population who have little to no experience with health insurance, Navigator programs target consumers needing to “navigate” an Exchange’s insurance marketplace in order to find the right health plan for their needs and determine if they are eligible for a subsidy. It is expected that Navigator employees will also help filing insurance applications and notifying consumers when their coverage changes.

Individual Exchanges are required to establish a grant program to fund Navigators. Exchanges must select a minimum of two types of entities to be Navigators. At least one of these entities must be a community or consumer-focused non-profit organization. Exchanges must also develop training standards for Navigators so that they can provide the appropriate guidance for consumers.

Navigators, in turn, are expected to:

  • Maintain expertise in health insurance eligibility and enrollment
  • Conduct public education activities to raise awareness about the Exchange
  • Provide information and services in a fair, accurate, and unbiased manner
  • Facilitate the selection of a qualified health plan
  • Provide referrals for consumers with questions, complaints, and/or grievances to any applicable office of health insurance consumer assistance, health insurance ombudsman, or any other appropriate state agency
  • Provide information in a culturally and linguistically appropriate manner, including to persons with limited English proficiency
  • Ensure accessibility and usability of Navigator tools and functions for disabled persons

States may impose additional requirements on Navigators so long as those requirements do not interfere with the federal requirements.

Navigators are prohibited from either direct or indirect compensation from insurance companies for enrolling individuals in qualified health plans or health plans offered outside of the Exchange. Accordingly, the following entities are prohibited from being Navigators:

  • Health insurance company or subsidiary
  • Insurance company or subsidiary providing stop-loss insurance
  • Associations who lobby on behalf of the insurance industry or include insurance industry members

Policing Bias

Towards this end, Exchanges are expected to develop policies to prevent conflict of interests among Navigators. All Navigator employees will be required to provide neutral information regarding the qualified health plans and they will be prohibited from steering consumers towards purchasing from insurance companies they prefer. Some states are considering requiring specific licensing programs for their Navigator employees. The Health Exchange Navigator programs are still in the development process since open enrollment doesn’t begin until October 1, 2013.

Staffing Up for Open Enrollment

In order to reach the over 30 million Americans who are expected to purchase health insurance between October of 2013 and March of 2014, Navigator agencies will need to hire and train tens of thousands of workers. Between 30 and 40 states, however, are expected to let the federal government operate their Navigators. Federally-run Navigators will most likely be run by contractors funded by the government. States that choose to create their own programs are still exploring their options. Some exchanges will manage their Navigators while others will contract with a third party to manage Navigators.

Monitoring Navigator Performance

State are not unified on how they will monitor and evaluate Navigator performance. Evaluation methods and metrics vary by state. One of the key areas of concern for states are the number of enrollments they facilitate.

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