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CMS Releases Final Rule for Affordable Care Act’s ‘Navigator’ Program

Individuals who work in the Affordable Care Act's "navigator" program for the law's health insurance exchanges must be affiliated with certain community organizations, such as churches, according to a final rule released Friday that outlines selection criteria and training and certification requirements for the program's workers, The Hill's "Healthwatch" reports (Baker, "Healthwatch," The Hill, 7/12).

In addition, the workers must undergo at least 30 hours of training to before they can be qualified as a "certified application counselor," the rule issued by CMS states (Reichard, CQ HealthBeat, 7/12).

Background on the Navigator Program

Under the ACA, exchanges that will be operated solely by or in partnership with the federal government are required to have at least two certified navigator entities, one of which must be a not-for-profit. HHS has allocated $54 million in funding grants to train and pay navigators in the 37 states with federally run exchanges.

Navigator workers must provide "fair, impartial and accurate information that assists consumers with submitting the eligibility application, clarifying distinctions among [qualified health plans] and helping qualified individuals make informed decisions during the health plan selection process." They also must provide additional assistance to:

  • Consumers with disabilities, limited proficiency in English; or
  • Consumers who are unfamiliar with health insurance.

Lawmakers in recent months have raised concerns about the workers' level of training and access to consumers' personal and potentially sensitive data. In particular, some GOP leaders have stepped up their scrutiny of the navigator program and a separate "in-person assisters" program in states that will operate their own exchanges. The ACA prohibits federal funding for the assisters program because it does not have to meet the same criteria as the navigators program (California Healthline, 6/21).

More Details of Final Rule

Under the final rule, traditional insurance agents cannot be selected and trained as navigator workers, who must not be affiliated with the insurance industry ("Healthwatch," The Hill, 7/12). Navigator workers and in-person assisters can provide information only about specific topics, such as:

  • The exchanges' qualified health plans and insurance affordability programs;
  • The tax implications of enrollment decisions;
  • Eligibility for premium tax credits; and
  • Cost-sharing reductions.

States with their own exchanges can establish more rigorous selection and training requirements for in-person assisters. For example, Maryland requires such workers to undergo at least 120 hours of training, CQ HealthBeat reports (CQ HealthBeat, 7/12).

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