Filed Under:Health Insurance, Individual Health

HHS: States can license navigators

Kathleen Sebelius (AP Photo/Charles Dharapak)
Kathleen Sebelius (AP Photo/Charles Dharapak)

States cannot require health insurance exchange "navigators" to be licensed as insurance producers, but states certainly can license the navigators.

Officials at the Centers for Medicare & Medicaid Services (CMS) -- the arm of the U.S. Department of Health and Human Services (HHS) that's in charge of HHS efforts to implement much of the Patient Protection and Affordable Care Act of 2010 (PPACA) -- talk about navigator licensing in a list of answers to frequently asked questions (FAQs) about the PPACA exchange program.

PPACA calls for state and federal regulators to set up exchanges, or Web-based health insurance supermarkets, for individuals and small groups by October 2013.

States can run their own state-based exchanges, work to set up "partnership" exchanges with HHS, or let HHS provide exchange services for their residents through "federally facilitated exchanges" (FFEs).

Entities or individuals called "navigators" are supposed to help individual consumers use the new the new exchange. PPACA seems to assume that the navigators will mostly be staffers at consumer advocacy groups, charitable group volunteers, or the like.

Supporters of the navigators program have argued that many of the exchange users will be unsophisticated, poorly educated, low-income people who have been shut out of government health insurance programs as well as commercial health insurance programs and have no idea how health insurance works.

Health insurance agents have worried that the navigators program could put consumers with complicated situations at the mercy of untrained workers who know little more about health insurance and government health programs than the consumers themselves.

HHS officials startled Nevada insurance regulators this summer by rebuffing state efforts to license navigators as producers.

In the new batch of FAQ answers, CMS officials said HHS will be training, testing and licensing the PPACA exchange navigators itself.

"States may impose navigator-specific licensing or certification requirements upon individuals and entities seeking to operate as navigators," officials said.

States cannot require the navigators to have producers, simply because PPACA seems to require that each state offer multiple types of navigators, officials said.

If all navigators in a state were producers, that would violate the PPACA rule requiring an exchange to offer consumers a choice of two different types of navigator, officials said.

Officials seemed to be implying that licensing requirements for navigators could be similar to the licensing requirements for insurance producers, as long as the navigators are not called navigators, a health policy observer who requested anonymity said.

CMS posted the FAQ answers as HHS was announcing a move to grant early approval to six states that want to set up exchange programs.

The states -- Colorado, Connecticut, Maryland, Massachusetts, Oregon and Washington -- "are on track to meet all exchange deadlines," HHS Secretary Kathleen Sebelius said in a blog entry.

Some states, such as New Jersey, have refused to set up exchanges. Officials in those states have argued that HHS regulations are giving states too little flexibility for the states to run their exchanges how they see fit.

Sebelius said in her blog entry that HHS is trying to be flexible.

"If states decide they want to play a larger role in running the new marketplace in their state in 2015, 2016 and beyond, we will work with them so they can have the opportunity to take on that role," Sebelius said.

In the FAQ answers, HHS tried to reassure states that states will not have to pay dearly to get the data they need to run state exchange eligibility programs, or to feed their own Medicaid data or other data to the federal exchanges.

"HHS is establishing a federally managed data services hub," CMS officials said.

The hub will support information exchanges between states exchanges, state Medicaid programs and state children's health insurance plans and the relevant federal agencies, officials said.

In some cases, HHS will help states pay for the systems needed to send data to the federal exchanges, officials said.

Officials noted that, in addition to PPACA requiring exchanges to offer consumers access to navigators, PPACA requires exchanges to offer consumers access to "in-person assistance."

The in-person assistance program will be separate from the navigators program, and HHS will provide separate grant money to help fund the in-person assistance program, officials said.

Elsewhere in the FAQ answers, officials said they expect the PPACA federal Pre-Existing Condition Insurance Plan (PCIP) program to end Jan. 1, 2014.

PPACA drafters created the PCIP program to serve as a temporary coverage option for people with health problems that make buying commercial health coverage difficult.

PCIP makes coverage available at standard commercial rates for people with health problems who have been uninsured for at least 6 months.

Enrollment has been lower than officials expected and claims have been much higher.

When PPACA takes effect, it will require all major medical carriers to offer health coverage on a guaranteed-issue basis, without using personal health information other than wellness program information to set rates.

Once the PPACA underwriting rules take effect in 2014, "all individuals will be able to access coverage without any pre-existing condition exclusions in the individual market," and PCIP coverage will no longer be necessary, officials said.

HHS is looking into the possibility of letting states continuing to operate their own existing high-risk-pool programs beyond 2014, officials said.

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