CMS Finalizes Certification Standards For Health Insurance Exchange Navigators, Certified Application Counselors

The Centers for Medicare and Medicaid Services (CMS) has issued a final rule, which provides standards for navigators, which are organizations authorized by the Patient Protection and Affordable Care Act (ACA) to provide unbiased information to consumers about coverage options in the health insurance exchanges. The rule also finalizes the requirement that exchanges must have a certified application counselor program. The final rule was published in the July 17 Federal Register.

Under the ACA, states are required to establish exchanges to facilitate the purchase of qualified health plans in the individual and small group markets beginning in 2014. Navigators will assist consumers with selecting coverage under these new exchanges and must remain impartial and accessible. Open enrollment in the exchanges is set to begin on October 1, with coverage to begin Jan. 1, 2014.

The CMS issued proposed rules in April 2013. The final rule does the following: creates conflict-of-interest, training and certification, and meaningful access standards; clarifies that any licensing, certification, or other standards prescribed by a state or exchange must not prevent individuals from applying; adds entities with relationships to issuers of stop loss insurance to the list of entities that are ineligible to become Navigators; and clarifies that the same ineligibility criteria that apply to Navigators apply to certain non-Navigator assistance personnel. The final rule also directs that each exchange designate organizations which will then certify their staff members and volunteers to be application counselors that assist consumers and facilitate enrollment in qualified health plans and insurance affordability programs, and provides standards for that designation.

Certified application counselors. In conjunction with the final rule, the CMS also issued guidance on the certified application counselor (CAC) program. The CAC program uses community-based organizations, including community health centers and hospitals, to help enroll eligible consumers in qualified health plans and insurance affordability programs. Each exchange is required to offer CAC services.

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