Table of Contents

Endnotes

Tool Kit PDF

Background

1. What are the federal requirements for navigator programs?²  

Navigator programs are a required component of exchange consumer assistance. Exchanges must comply with federal minimum standards in establishing and operating these programs, including the development of state-specific standards and requirements.

Duties

1. At a minimum, each entity that is selected to be a navigator must do the following:
2. Maintain expertise in and conduct outreach and public education on the health coverage options and financial assistance that are provided through the exchange. 
3. Distribute fair, accurate, and impartial information about the full range of health coverage options that are available through the exchange, including public programs. 
4. Facilitate enrollment in qualified health plans (QHPs) through the exchange.
5. Make referrals to health insurance consumer assistance or ombudsman programs and to state agencies for help with grievances, complaints, appeals, and questions about using coverage.
6. Provide information and services in a manner that is culturally and linguistically appropriate and accessible to people with disabilities.

Selecting Navigators

The entities that exchanges select to become navigators must include at least one community-based and consumer-focused nonprofit and at least one other type of public or private entity. These entities cannot be health insurers or have affiliations with health insurers, as this may create a conflict of interest. Each of the entities selected must be able to perform all of the required navigator duties and must demonstrate that it has existing relationships (or the ability to readily establish relationships) with the populations that are likely to be eligible for exchange coverage. Federal guidance states that exchanges should plan to have a sufficient number of navigators to provide assistance to individuals and employers in all of the geographic areas served by the exchange.

Standards of Conduct

Navigators must comply with the privacy and security standards for exchanges. Each exchange must also establish standards to prevent, minimize, and mitigate conflicts of interest among navigator entities. Federal guidance encourages states to develop methods to ensure that navigators meet these standards and operate with integrity, such as requirements to disclose existing financial and non-financial relationships with other entities, to monitor enrollment patterns, and to impose penalties if standards are violated. The Department of Health and Human Services (HHS) plans to release model conflict of interest standards in forthcoming guidance.

Training

Navigators must have expertise in all of the following areas:

• the needs of underserved and vulnerable populations
• exchange eligibility and enrollment procedures
• the range of qualified health plans and insurance affordability programs (premium tax credits and cost-sharing reductions) that are available through the exchange
• their state’s Medicaid, CHIP, and Basic Health programs
• privacy and security standards for consumer information

Exchanges will develop training and certification requirements for navigators, but exchanges are prohibited from requiring navigators to obtain a producer license or to purchase errors and omissions insurance (a type of liability coverage that provides financial protection for an entity in cases of negligence). HHS plans to issue model training standards, including standards for cultural and linguistic competency, in forthcoming guidance.

Funding

Navigator programs must be funded through grants from the operating budget that is used to run an exchange. However, federal exchange planning and establishment grants that are available through 2014 can be used for activities involved in establishing navigator programs, such as conducting needs assessments, developing training curricula, obtaining technology, and conducting public education to lay the groundwork for navigator outreach.

Navigator entities will also be eligible to receive administrative matching funds for assistance that is provided to individuals who are eligible to enroll in Medicaid and CHIP. Federal guidance states that exchanges should make sure that their navigator programs have sufficient funds to ensure that all potential enrollees have access to assistance.

2. How will navigator programs operate in the different exchange models?  

States have three options for structuring exchanges, each of which affects implementation of the navigator program:

1. States may run their own exchange and implement all consumer assistance functions, including the navigator program.
2. States may have a federally facilitated exchange in which the federal government is responsible for implementing all consumer assistance functions, including the navigator program.
3. States may have a federally facilitated exchange but partner with the federal government to operate specific exchange functions, including in-person assistance. This is called a partnership exchange. In a consumer assistance partnership exchange, states will administer the navigator program, including monitoring and providing support to navigators. The federal government will select and award grants to navigator entities, establish standards of conduct, and provide training for navigators. States may provide additional state-specific training.³ 

3. What are in-person assistance programs?  

In its Blueprint for Approval of Affordable State-Based and State Partnership Insurance Exchanges,⁴ CMS provided a new option for states to receive exchange grant funding to establish and operate "in-person assistance programs" (also know as "assisters") to supplement and fill gaps in the assistance that is provided by navigators (which may target their services only to specific populations). All states that partner with the federal government to provide consumer assistance must develop and implement in-person assistance programs. States that operate their own exchanges can decide whether to use assisters in addition to navigators. States that have a federally run exchange (including those that partner with the federal government only for health plan management) will not have in-person assistance programs.

This new funding opportunity will be particularly helpful for expanding assistance capacity during the first open enrollment period for exchanges, which begins on October 1, 2013, before exchanges are able to generate sufficient funding to run their navigator program at full capacity.⁵ The recommendations and tips that follow, while focused on navigator programs, also pertain to in-person assister programs.

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