Reform Alert - News from the Blues' Office of National Health Reform

Navigator and Certified Application Counselor Final Rule Issued July 17

July 30, 2013

The July 17 rule finalizes provisions from two proposed rules: consumer assistance provisions contained within the broad Medicaid, CHIP, and Marketplace proposed rule issued January 22, 2013, and the Navigators proposed rule issued April 3, 2013.

The final rule requires all Health Insurance Marketplaces to have a consumer assistance function, including a Navigator program. It also establishes general requirements for consumer assistance including basic training and a grievance process for enrollees who have a complaint or question.

The rule creates conflict-of-interest training and certification and accessibility standards. Federally-facilitated Marketplaces (FFMs), such as Michigan, will not have non-Navigator assistance programs.

The final rule includes two amendments to existing regulation applicable to all Navigators:

  • Any Navigator licensing, certification or other standards required by the state or Marketplace must not prevent the application of the provisions of title I of the ACA; and
  • Those entities with relationships to issuers of stop-loss insurance, including those who are compensated directly or indirectly by the issuers of stop-loss insurance, are not eligible to act as Navigators.

The final rule also adds a new section that requires Marketplaces to have a certified application counselor program. In addition, it creates requirements for those programs and describes the role of certified application counselors (CACs). In a change from the proposed rule, the final rule allows Marketplaces to designate organizations to certify their own staff members and volunteers as CACs. The training, conflict-of-interest and accessibility standards imposed on CACs are less stringent than those imposed on Navigators, since CAC duties are more limited.

Categories of Consumer Assistance Personnel

Navigators include individuals whose functions are funded through federal grants. They must be free from conflicts of interest and certified to perform the following duties:

  • Maintain expertise and conduct public education activities about the Marketplace;
  • Provide information and services in a fair, accurate and impartial manner;
  • Facilitate selection of a qualified health plan (QHP);
  • Provide referrals for enrollees with a grievance, complaint or question; and
  • Provide information in a manner that is culturally and linguistically (CLAS) appropriate, and ensure accessibility for individuals with disabilities.

Each Marketplace is required to have a Navigator program.

Non-Navigator Assistance Personnel are individuals who provide consumer assistance other than through a Navigator program. This includes programs that provide assistance, education and outreach functions for the Marketplace, including in-person consumer support, to as broad a range of consumers as possible. Most of the same standards that apply to Navigators also apply to non-Navigator assistance personnel who are in state Marketplaces funded through Marketplace grants, and those in state partnerships. However, Federally-facilitated Marketplaces will not have non-Navigator assistance programs, so this category will not apply in Michigan.

Certified Application Counselors are individuals who are certified to perform the following duties:

  • Provide information to consumers about QHP options and insurance affordability programs;
  • Assist consumers in applying for coverage in a QHP and insurance affordability programs; and
  • Help facilitate enrollment of eligible individuals in QHPs and insurance affordability programs.

Each Marketplace is required to have a CAC program.

Major differences among these roles include:

  • The goal of Navigators and non-Navigator assistance personnel is to provide information and services in a fair, accurate and impartial manner, while the goal of certified application counselors is to act in the best interest of the applicants they assist.
  • Navigators and non-Navigator assistance personnel are required to perform public outreach, provide referrals, comply with stringent conflict-of-interest standards and eligibility requirements, and comply with CLAS and disability access standards. These requirements do not apply to CACs.
  • The required training for Navigators is more extensive than the training required for CACs.

Where can I find more information?

More information can be found here.

The information in this document is based on preliminary review of the national health care reform legislation and is not intended to impart legal advice. The federal government continues to issue guidance on how the provisions of national health reform should be interpreted and applied. The impact of these reforms on individual situations may vary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. As required by US Treasury Regulations, we also inform you that any tax information contained in this communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenue Code.