GOP probes ACA insurance exchange “navigator” grants

The Obama administration plans to pay $54 million to individuals and entities to help consumers find and obtain coverage from the marketplaces starting this fall.

By — Posted April 22, 2013

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House Republican lawmakers are asking the White House for more details about a proposal to establish “navigators” that are designed to provide unbiased information and assistance on coverage available through federal health insurance exchanges and exchanges operated through partnerships between states and the federal government.

The Centers for Medicare & Medicaid Services announced April 9 that the agency would provide up to $54 million for the navigators, which can be self-employed individuals or public or private organizations. Applications by interested entities for the grant money are due by June 7.

“Navigators will be an important resource for the millions of Americans who are eligible to enroll in new coverage opportunities through the marketplace starting in October of 2013,” acting CMS Administrator Marilyn Tavenner said in a statement.

The funding announcement followed the release of a CMS proposed rule outlining federal standards for the navigators. There will be at least two entities chosen for each of the 33 states that have decided to partner with the federal government on running exchanges or that will default to a federal exchange. At least one navigator in each state must be a “community and consumer-focused nonprofit organization,” CMS stated.

Navigators must meet certain conflict-of-interest requirements outlined in the proposed rule. For instance, the entities cannot issue health insurance, receive any direct or indirect consideration from companies offering coverage on the exchanges, or be associations that lobby for the insurance industry.

Grants prompt oversight questions

Republican members of the House Energy and Commerce Committee sent an April 12 letter to Health and Human Services Secretary Kathleen Sebelius requesting more details about the navigator program and its funding.

For instance, the lawmakers want to know where the money to pay for the exchange assistance is coming from, exactly how many navigators the administration plans to fund and the process the White House will use to choose the grant recipients.

The letter questioned the conflict-of-interest rules that will prohibit some entities from becoming navigators. “News reports indicate that individuals compensated by insurance companies are prohibited from becoming navigators; please describe the reasons for this and whether underwriters, who have experience in this field, are permitted to become navigators,” the letter stated.

The lawmakers also want to know what, if any, responsibilities navigators will have in states that will be running their own health insurance exchanges.

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Qualifications of an exchange “navigator”

The Centers for Medicare & Medicaid Services is looking for self-employed individuals and public and private organizations that will help consumers understand their health coverage options under the federal health insurance exchange or the marketplaces run through state-federal partnerships. CMS said successful applicants for the $54 million in total grant money available to “navigators” must demonstrate their ability to:

  • Maintain expertise in eligibility, enrollment and program specifications.
  • Conduct public education activities to raise awareness about the exchange.
  • Provide information and services in a fair, accurate and impartial manner. Such information must acknowledge other health programs (such as Medicaid and the Children’s Health Insurance Program).
  • Facilitate selection of a qualified health plan.
  • Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman or any other appropriate state agency or agencies, for any enrollee with a grievance, complaint or question regarding their health plan, coverage or a determination under such plan or coverage.
  • Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the exchange, including individuals with limited English proficiency, and ensure accessibility and usability of navigator tools, such as fact sheets, and functions for individuals with disabilities.

Source: Overview of navigator duties, Centers for Medicare & Medicaid Services (link)

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