ACA Insurance Exchanges - Navigators or In-Person

Helping Americans Choose Their Health Insurance Plans

Mid adult couple talking with insurance agent in office, smiling
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The bulk of the new Affordable Care Act, also known as Obamacare, went into effect on January 1, 2014, at which time Americans were required to fulfill the "individual mandate." That is, the requirement to be covered by a health insurance plan or be fined for not doing so.

State and federal health insurance exchanges (also called "marketplaces") are set up to help those American citizens who need to purchase individual insurance, and the small businesses that must provide their employees with health insurance.

These marketplaces are a central source for the information needed: the available insurance plans they may choose from, guidance for choosing the best insurance plan for themselves and enrollment support.

Individuals in Need of Coverage

Of course, those individuals who have not been previously covered, and those who must find new coverage, may find the choices and necessary decision-making to be confusing. To help allay the confusion, each exchange provides "navigators" or "in-person assisters" who will be prepared to help individuals make their choices.

Health insurance exchange / marketplace navigators are not individuals - they are organizations, described as follows: "trade, industry, and professional associations, commercial fishing industry organizations, ranching and farming organizations, community and consumer-focused nonprofit groups, chambers of commerce, unions, resource partners of the Small Business Administration, other licensed insurance agents and brokers, and others."

(Please note: While Obamacare has labeled this role as "navigator", these navigators are not the same as advocate-navigators who help patients on their journey through their health care and decision-making. You can learn more about advocate-navigators here.)

Exchange or Marketplace Navigators and In-Person Assisters have five functions:

  1. Conduct public education about the availability of qualified health plans (QHPs),
  2. Provide impartial, objective information about enrolling in different QHPs to the individuals and small businesses that need the information,
  3. Help individuals and small businesses get enrolled in the best plan for their needs,
  4. Provide or refer individuals who encounter problems with their health plans to an appropriate grievance or appeal body or system, and
  5. Provide all these services consistently regardless of culture or language of the population being served.

"In-person assisters" is another title being used for both individuals and organizations who will be available to provide these kinds of support. The differences between navigators and in-person assisters is found mostly in how they are funded. From the consumer's point of view, they will serve very similiar functions.

Navigator Systems

For many years, states have implemented State Health Insurance Programs (called SHIPs) which help guide Medicare patients in their plan choices, and Children's Health Insurance Programs (CHIPs) which function similarly.

Each state has a different name for its SHIP and CHIP programs, and each state has the option of creating its own name for insurance navigators.

Here are some decisions that have been made and publicized to date:

  • Navigators may not work for a health insurance provider.
  • Navigators do not have to be licensed to sell insurance.
  • Navigators will not be paid based on the advice they give. In no way can payment for their services be tied to the decisions made by the people they advise. Put another way, no navigator will be paid a commission, finder's fee, or any other form of compensation because someone they worked with made any specific choice of insurance plans.
  • Navigators will not make decisions for the people they advise. They will simply walk their advisees through a series of questions and decision-making tools to help those people make their own insurance plan choices.
  • Navigators will not be able or be expected to qualify the people they advise for any specific plan.

Navigator Training

Organizations that wish to be designated as navigators will be required to undergo training in order to fulfill their duties. The requirements and possibility for certification will vary by state. They will likely need to go through an approval or certification process as well.

The training will focus on five areas:

  • Providing for the needs of underserved and vulnerable populations
  • Understanding marketplace eligibility and health insurance enrollment procedures
  • Familiarity with the range of QHPs and subsidy programs (such as tax credits and cost-sharing reductions) available through the exchange
  • Each state’s Medicaid, CHIP, and Basic Health programs (government options)
  • State and federal privacy and security standards for consumer information

It is then expected that once a navigator program is established, the individuals who work within that navigator organization will also need to undergo training.

Funding and Payment

The federal government provided some grant funding to support training for navigators through the end of 2014. The first round of funding was announced on April 9, 2013 and was designated for those the self-employed or for profit businesses.

Here is information about this navigator funding from Grants.gov.

Find additional information about establishing navigator programs:

• From the government (CMS): Navigators and In-Person Assisters

• From Families USA

• From Georgetown University

• HHS is partnering with Enroll America which stays updated on Marketplace Navigators information: Enroll America

FAQ on the Marketplace can be found here

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