The Centers for Medicare & Medicaid Services (CMS) talk about who can and cannot be health insurance exchange "navigators" in a new batch of proposed regulations.
In the proposed regulations, "Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel" (CMS-9955-P) (RIN 0938-AR75), CMS officials also talk about the rules that will govern "non-navigator consumer assistance programs," such as "in-person assister" programs.
Officials at CMS -- an arm of the U.S. Department of Health and Human Services -- said HHS eventually might require every Patient Protection and Affordable Care Act (PPACA) exchange to set up a "certified application counselor program" to complement its navigator program.
Officials said in the proposed regulations that:
- HHS wants to let agents and brokers serve as navigators, as long as the producers are not getting any consideration, including trailing commissions, from health insurers.
- Health insurers and their subsidiaries could not be navigators.
- Issuers of stop-loss insurance -- insurance for self-insured health plans -- and the stop-loss issuers' subsidiaries could not be navigators.
- The same compensation rules that apply to producers who sell health insurance would apply to producers who sell stop-loss insurance.
- Agents and brokers who sell products other than health insurance or stop-loss insurance could be navigators and also continue to collect compensation from the providers of those other lines of insurance products.
CMS officials said they want to let producers serve as navigators because they recognize that producers have traditionally helped consumers buy health insurance.
"We anticipate that agents and brokers will continue to be an important source of assistance for many consumers seeking access to health insurance coverage through an exchange, including those who own and/or are employed by small business," officials said.
In other documents, CMS officials and the officials in charge of most state-based exchanges have said that they expect commercial health insurance agents and brokers to continue to sell coverage to customers, and for the brokers to negotiate commission rates directly with the insurers, without the exchanges being directly involved in setting the rates.
Officials have said that exchanges would pay the navigators. The Washington Health Benefit Exchange, for example, has posted a hypothetical example of a navigator contract summary that shows that the navigator might get about $85 per application.
The proposed regulations are set to appear in the Federal Register Friday. Comments will be due 30 days after the official Federal Register publication date.
PPACA requires HHS to work with states to set up exchanges, or Web-based health insurance supermarkets, in every state and the District of Columbia by Oct. 1. The exchanges will sell "qualified health plans" (QHPs), or plans that cover a minimum level of the actuarial value of a standardized "essential health benefits" (EHB) package.
To help exchanges get poor and uninsured people who might not be used to health insurance into health plans, PPACA drafters required exchanges to offer "navigators," or ombudsmen not paid by any health insurer, to help consumers use the exchanges.
CMS officials believe that the PPACA navigator sections -- PPACA Section 1311(d)(4)(K) and Section 1311(i) -- require that each exchange offer consumers a choice of at least two different types of navigators.
If an exchange required each navigator to hold a producer license, that would conflict with the need for the exchange to offer two different types of navigators, officials said.
PPACA also requires that a navigator not be a health insurance issuer, a subsidiary of a health insurance issuer, an insurance industry trade group, or any entity that receives "any consideration, directly or indirectly, from any health insurance issuer in connection with the enrollment of any individuals or employees in a QHP or non-QHP," officials said.
The proposed regulations do set minimum standards for navigators and "non-navigator assistance personnel" in both the "federally facilitated exchanges" (FFEs) that HHS will run directly and the "state partnership exchanges" that will be run by HHS-state government alliances.
"We also propose that these standards would apply to non-navigator assistance programs and personnel in state-based exchanges" that are funded through federal exchange grants, officials said.
Both navigator personnel and non-navigator personnel would have to register, get training, and pass HHS-approved certification exams, officials said.
States that used their own money to set up their own exchanges would not have to meet the same navigator and non-navigator assistance program standards, but those states might find the proposed standards to be useful examples, officials said.
A state could require a navigator to "meet any licensing, certification or other standard by the state or exchange, if applicable," as long as the state or exchange was not requiring the navigator to be an agent, a broker or a holder of errors and commissions (E&O) coverage, officials said.
Stop-loss insurance reps
Officials said they want to bar stop-loss insurers, stop-loss issuer subsidiaries, and producers getting compensation from stop-loss entities from serving as navigators because they believe that a navigator "should not have a personal interest in whether a small employer chooses to self-insure its employees, or chooses to enroll in fully insured coverage inside or outside the exchange."
Non-navigator consumer assistance programs
A non-navigator consumer assistance program is a program that would help an exchange provide "outreach, education and assistance," officials said.
A state-based exchange must offer a navigator program, but it can choose whether to offer a non-navigator assistance program, officials added.
The officials suggested that one type of non-navigator program could give consumers in-person support.
Officials observed that some have recommended that HHS require every exchange to offer "certified application counselors" as an additional source of help.
CMS is asking for comments on whether the navigator and non-navigator standards should apply to the certified application counselors, in case HHS eventually requires all exchanges to offer access to certified application counselors, officials said.
What people are worth
Officials give estimates of how much they think various types of personnel are paid in a regulatory burden analysis.
Officials assume that both navigator and non-navigator project leads earn $29 per hour, and that senior executives earn $48 per hour.
The time of ordinary navigator and non-navigator personnel could cost about $20 per hour, officials said.
CORRECTION: An earlier version of this article described the proposed rules on compensation for agents and brokers working as navigators incorrectly. A producer working as a navigator could not get compensation from a health insurer.
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