Starting Oct. 1, individuals and small businesses will have the chance to shop for and purchase private insurance through the new health insurance exchanges, but they are likely to have plenty of questions about the products and the process for enrollment. With that in mind, the Affordable Care Act (ACA) also mandates that the exchanges award grants to "navigators" and other personnel to provide impartial information to consumers about health plans, eligibility, and their potential to qualify for financial subsidies.
The Health and Human Services department recently issued regulations outlining the roles, training, and certifications required of navigators. Shelly Ten Napel, an expert on state health care coverage issues, explained what these navigators will do and how physicians may be affected.
Shelly Ten Napel
Question: Who can be a navigator under the HHS regulations?
Ms. Ten Napel: It may be helpful to think in these terms: "navigator entities" are organizations that have existing relationships with the target populations of the health insurance exchange. Individual navigators are people who work for navigator entities and receive in-depth training on health coverage options under the ACA. Each health insurance exchange can set its own target population, but most will emphasize outreach to those who qualify for the tax credits (people with household incomes between 138% and 400% of the federal poverty level), the uninsured, and populations that have traditionally been underserved or hard to reach.
Federal regulations require that navigators include at least one community-based organization or consumer-focused nonprofit as well as at least one of the following: trade, industry, and professional associations; commercial fishing industry organizations; ranching and farming organizations; chambers of commerce; unions; resource partners of the Small Business Administration; licensed agents and brokers; and other public or private entities or individuals that meet the requirements of this section, such as Indian tribes, tribal organizations, and state or local human service agencies.
Navigators and "in-person assisters" cannot have a financial or nonfinancial conflict of interest. Some states may allow health care providers to serve as navigators, while others may perceive providers as having a conflict of interest because they receive payments from health plans.
Question: Has HHS included enough safeguards to ensure that the navigators don’t have financial conflicts of interest?
Ms. Ten Napel: Yes, there are strong requirements to prevent navigators from having both financial and nonfinancial conflicts of interest. Specifically, navigators cannot receive financial or nonfinancial consideration from any health insurer. States must monitor the enrollment patterns of navigators and develop civil and criminal penalties for those who fail to comply with the conflict-of-interest standards.
Question: How will the navigators help consumers?
Ms. Ten Napel: They will conduct education and outreach to help the public learn about the new health care coverage options under the ACA. Navigators will help consumers determine whether they are eligible for Medicaid or tax credits. They will walk consumers through the decision tools on the health insurance exchange websites to help individuals understand plan choices and enroll in plans. There is an emphasis on providing services in a culturally and linguistically appropriate manner.
Question: Does anything like this exist in the current insurance marketplace?
Ms. Ten Napel: There are individuals in the current market who perform similar functions. For example, Medicaid enrollment brokers and eligibility workers perform some similar functions, though they focus on the Medicaid program. Brokers or producers help people find and enroll in private health coverage. Navigators are unique in that they will be trained to help people understand the range of options across public programs and the private market in the health insurance exchanges. In addition, they will have an outreach and education function. They will be selected based on their unique ability to reach uninsured and underserved populations.
Question: Will the navigators work only with consumers or will they be in contact with physician offices?
Ms. Ten Napel: Navigators will work primarily with consumers, though providers may feel the impact of navigators in a few ways. First, new functionality in health insurance exchange websites will enable individuals to determine which plans offer in-network coverage for their providers. Thus, navigators can help patients who want to remain with their current physician select the right plan. Second, navigators will have a role in helping people understand some of the key features of health insurance, such as copayments and deductibles. The hope is that consumers will not only gain coverage but develop a better understanding of how to use that coverage. Third – and this is the exciting part of the program – if the navigators and other outreach efforts are successful, more people will gain coverage, enabling them to seek needed health care.