(Updated April 2013)
If you are interested in staying up to date on the implementation of the ACA (Affordable Care Act, also called Obamacare) insurance exchange navigator and in-person assister programs, please bookmark this page and sign up for the weekly patient empowerment newsletter. We will keep this article updated as additional information becomes available.
The bulk of the new Affordable Care Act, known as Obamacare, will go into effect January 1, 2014 when Americans will be 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 being 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 will be one 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.
[Note - not all states are creating exchanges. Find the status of your state here.]
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 will provide "navigators" and/ 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 will have five functions:
- Conduct public education about the availability of qualified health plans (QHPs),
- Provide impartial, objective information about enrolling in different QHPs to the individuals and small businesses that need the information,
- Help individuals and small businesses get enrolled in the best plan for their needs,
- Provide or refer individuals who encounter problems with their health plans to an appropriate grievance or appeal body or system, and
- 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.
As of this update, we don't have a lot of information yet about how the role of navigator or in-person assister will be implemented. These decisions and guidelines are being developed by the US Department of Health and Human Services and will be executed differently within each state that has an exchange. Most decisions have not yet been made, nor have any exchanges begun providing insurance navigation.
We do have models for how navigator systems will work, however. 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.
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 subsity 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 will provide some grant funding to support training for navigators through the end of 2014.
The first round of funding was announced April 9, 2013 and is designated for those who are 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