CMS Releases Proposed Certification Standards For Health Insurance Exchange Navigators

The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule adding to previously adopted 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. Non-navigator assistance programs and personnel also would be affected by the proposed rule. Included in the rule are standards for training and certification, conflict of interest, and culturally and linguistically appropriate services. Funding for navigators that operate in states with federally facilitated exchanges and state partnership exchanges will be handled by the federal government. The proposed rule was published in the April 5 Federal Register.

Under 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. The Department of Health and Human Services (HHS) will create and operate a federally facilitated exchange (FFE) for states that do not create their own exchange. Navigators will assist consumers with selecting coverage under these new exchanges and must remain impartial and accessible.

Affected parties. Navigators in states with a FFE and state partnership exchanges (SPE) and any in-person assisters that are funded by ACA exchange establishment grants in states with state-based exchanges (SBE) and SPEs are covered by the proposed rule. Navigators in SBE states may adopt the rule and adapt the standards; however it is not required. A list of entities prohibited from becoming navigators also is included in the proposed rule.

The CMS is requesting comments on whether the standards should apply to certified application counselors, a new category of assisters proposed in ACA-related rules issued in January 2013. Comments may be submitted through May 6, 2013 through, or mailed to CMS, HHS, Attention: CMS-9955-P, P.O. Box 8010, Baltimore, MD 21244-1850.

Certification standards. According to the proposed rule, navigators must meet any licensing, certification or other standards set by each state, so long as such standards do not interfere with ACA provisions. Navigators are required to provide fair and impartial information and must not have a personal interest in the coverage choices made by individuals or small businesses. Issuers of stop loss insurance and their affiliates are prohibited from serving as navigators. Navigators may not receive consideration directly or indirectly from insurers, including stop loss insurers. They also may not receive consideration directly or indirectly from an insurer for enrollment in a QHP or non-QHP, including receiving “trailer commissions,” which are commissions received for renewals of coverage even after an agent or broker is no longer actively selling the product.

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