Obamacare Navigator Confusion

Obamacare Navigators: What Are Their Qualifications And Who Are They?

With the individual Obamacare mandate looming into our near future questions about enrollment procedures persist.  This mandate is a major concern for those retiring prior to their Medicare eligibility date or those already retired.   We will  soon be within 60 days of the required enrollment period and no one has seen a demo of the ACA Insurance Exchange.  Reassurances  are out there instructing us  not to worry because there will trained navigators hired  to assist.

Without a working demo of the Health Exchange how will the navigators be trained?  There is no concrete answer  yet.

Since these navigators will have unlimited access to all of our personal data including financial records and personal identifying information. Will the Navigators  be subject to any kind of background check?  On the Federal level this is unclear.  At the state level at least in Wisconsin Navigators will be required to pass a criminal background check as well the organization they work for and attend training in order to become licensed by the State of Wisconsin.

Wisconsin Office of the Commissioner of Insurance pursuant to s. 628.92, Wis. Stat: In addition to federal required training.

  • Navigators must be licensed
  • Complete 16 hours of pre-license training
  • Successfully pass a written examination
  • Must possess the requisite character, competency and trustworthiness
  • Navigators will need to submit fingerprints  and complete a criminal background investigation consistent with requirements for insurance intermediaries.
  •  Navigators who are not affiliated with a navigator entity must furnish and maintain a minimum bond no less than $100,000 from an authorized insurer or provide other evidence of financial responsibility capable of protecting all persons against the wrongful acts, misrepresentations, errors or omissions, or the negligence of the navigator.
  •  Once licensed, navigators will need to complete at least 8 hours of approved training annually.

Permitted Navigator Activities:

  • Conduct public education activities to raise awareness of available Qualified Health Plans (QHP) within the  federal Exchange.
  • Distribute fair and impartial information concerning enrollment in a QHP through the federal Exchange and the availability of premium tax credits and cost-sharing reductions that may be available.
  • Explain that consumers may purchase health plans through the federal Exchange or off the Exchange.
  • Make consumers aware that plans are available in the outside market and that they may want to talk with a licensed health insurance agent about health insurance options.
  • Facilitate enrollment in a QHP through the federal Exchange.
  • Outline information that a consumer will need to have available when applying for coverage through the federal Exchange.
  •  Provide information that will allow the consumer to access the federal Exchange either at their home or a computer terminal provided by the navigator.
  • Explain to the consumer the following information: potential eligibility for public/governmental programs, and how the federal health insurance premium tax credit and cost-sharing reductions work and potential risks, if any, for use of the federal health insurance premium tax credit.
  • Describe the features and benefits of health coverage in general terms, including cost-sharing mechanisms like deductibles, co-pays or co-insurance and how these work or affect the consumer.
  • Describe what a summary of benefits document is and where to locate a summary of benefits and relevant cost-sharing provisions within the information from QHPs. Explain how to find information about provider networks.
  • Describe the different metal tiers (i.e., bronze, silver, gold and platinum) and how the benefits may change at different metal tiers based upon the consumer’s income.
  • Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the federal Exchange.
  • Provide a referral for an individual to an appropriate state or federal agency who has a grievance, complaint or question regarding their health plan, coverage, or a determination under such plan or coverage.

Prohibited Navigator Activities:

  • Receive compensation from an insurer, stop-loss insurance or a third-party administrator.
  • Receive compensation that is dependent upon, in whole or in part, whether an individual enrolls in or renews coverage in a health benefit plan.
  • Provide any information related to enrollment or other insurance products not offered in the federal Exchange.
  • Make or cause to be made false or misleading statements. Provide advice comparing health benefit plans that may be better or worse for the consumer or employer.
  • Recommend a particular health benefit plan or insurer or advise consumers or employers regarding a particular insurer or health benefit plan selection.
  • Engage in any fraudulent, deceptive or dishonest acts or unfair methods of competition. Receive consideration directly or indirectly from any health insurance issuer in connection with the enrollment of individuals or employees into a QHP.

Who else can help navigate the health insurance exchange?

Professional health insurance agents.  They have already been background checked, licensed and in many cases have years of experience.  They can help someone find the right coverage with or without the federal subsidy on or off the Healthy Insurance Exchange.  Visit with your agent now to see if you have a “grandfathered” plan or will you likely have steep premium increases in 2014 and if so, what can you do about them.

-Tim Barton, ChFC