Publication Date

9-25-2013

Abstract

The 2010 Patient Protection and Affordable Care Act (ACA, P.L. 111-148) allows certain individuals and small businesses to buy health insurance through state exchanges, beginning on October 1, 2013. The exchanges are not themselves insurers, but rather are special marketplaces where insurance firms may sell health policies that meet set, federal guidelines. As of September 2013, 16 states and the District of Columbia had secured Department of Health and Human Services (HHS) approval to create their own exchanges, 7 to enter into partnership exchanges, 26 to have federally facilitated exchanges, and 1 to have a state-based Small Business Health Options Program (SHOP)/federally facilitated individual exchange. An estimated 24 million individuals are expected to secure coverage through the exchanges by 2022.

The ACA requires exchanges to perform outreach to help consumers and small businesses make informed decisions about their insurance options, including the creation of “navigator” programs. Navigators are to carry out public education activities; provide information to prospective enrollees about insurance options and federal assistance; and examine enrollees’ eligibility for other federal or state health care programs, such as Medicaid. Navigators may assist consumers in comparing insurance plans, but may not determine their eligibility for subsidies or enroll them in plans—functions that are left to the exchanges. A variety of organizations may become navigators, including labor unions, trade associations, chambers of commerce, and other entities. Navigators may not be health insurers or take compensation from insurers for selling health policies. Navigators will be required to have 20-30 hours of training on consumer privacy, exchanged-based insurance offerings, and other issues. HHS in August 2013 allocated $67 million in 12-month grants for navigators at federally facilitated and partnership exchanges. In addition, HHS has determined that state-based exchanges may use ACA exchange establishment funds to create parallel, in-person, or non-navigator, assistance programs that perform the same function as navigators. Exchanges must also certify “certified application counselors” to help with outreach and enrollment, though no new ACA funds are available for such programs.

Consumers and small businesses may continue to use insurance brokers and agents, including web-based brokers, to compare and buy coverage, both on and off the exchanges. Brokers and agents are licensed by the states, and are generally paid on a commission basis by insurance companies. While brokers and agents may choose to become navigators, they may not accept compensation from health insurance companies in that role. Consumers may also purchase policies directly from health insurers. Outside non-profit groups and businesses, such as insurers, are launching their own separate efforts to educate consumers about the ACA and the process of applying for qualified health plans (QHP) and other programs.

Some lawmakers, agents, and brokers have raised questions about the navigator and other assistance programs. Issues include whether navigators will have sufficient training and whether HHS regulations provide sufficiently stringent consumer and privacy safeguards. A number of states have passed legislation to further regulate navigators, including requiring navigators to be licensed and to be liable for financial losses due to their advice. HHS has determined that the ACA gives states authority to set additional standards, so long as they do not prevent implementation of Title I of the law, which includes the exchanges and navigator program. This report describes exchange outreach programs, the role of brokers, agents and insurers, and emerging issues regarding consumer outreach assistance.

Comments

Suggested Citation
Kirchhoff, S. M. (2013). Health insurance exchanges: Health insurance “navigators” and in-person assistance. Washington, DC: Congressional Research Service.

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