Health Insurance Exchanges: Health Insurance 'Navigators' and In-Person Assistance [August 13, 2014]   [open pdf - 443KB]

"The 2010 Patient Protection and Affordable Care Act (ACA, P.L. 111-148) allows certain individuals and small businesses to buy qualified health insurance through state exchanges. 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 July 2014, 14 states and the District of Columbia had secured HHS [Department of Health and Human Services] approval to create and run their own exchanges, 7 to enter into partnership exchanges, 29 to have federally facilitated exchanges, and two to have statebased SHOP/federally facilitated individual exchanges. An estimated 25 million individuals are expected to secure coverage through the exchanges by 2024. The ACA requires exchanges to perform outreach to help consumers and small businesses make informed decisions about their insurance options, including the operation of 'navigator' programs. Navigators 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 must have 20 hours of training on consumer privacy, exchange-based insurance offerings, and other issues. HHS has provided about $60 million in yearly grants for navigators at federally financed and state partnership exchanges. In addition, HHS has determined that state-based exchanges may use ACA exchange establishment funds to create parallel, inperson, 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."

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CRS Report for Congress, R43243
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