The Role of Third Party Assistors in New YorksTheRoleofThirdPartyAssistorsinNewYork sExchange:OverviewofFederalRequirements

DanielleHolahan

HealthBenefitExchangeStakeholderMeetingMarch14,2012

TheBasics

UnderthePatientProtectionandAffordableCareAct(ACA):

An Exchange shall establish a Navigator programAnExchangeshallestablishaNavigatorprogram

ExchangeswouldawardNavigatorgrantstoeligibleentitiesentities

FundingfortheNavigatorprogrammustbefromExchangeoperationalfunds,notfederalfunds

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NavigatorEligibilityEntitiesthathave,orcouldreadilyestablish,relationshipswiththoselikelytobequalifiedhealthplan(QHP)eligible(employers,employees,consumers,selfemployed)

Underfinalregulations,anExchangemustincludeanentityfrom:

Communityandconsumerfocusednonprofitsy p

And anentityfromatleastoneofthefollowing:

ChambersofCommerceLicensedagentsandbrokersTrade,industry,andprofessionalassociationsCommercialfishingindustryorganizations,ranchingandfarmingorganizations

UnionsResourcepartnersoftheSmallBusinessAdministrationO h bli i i i i di id l h h d dOtherpublicorprivateentitiesorindividualsthatmeetthestandardsoutlinedinACASection1311/Regulation155.210

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NavigatorDutiesTheACArequiresNavigatorsto:

Maintainexpertiseineligibility,enrollment,andprogramspecificationsandconductpubliceducationactivitiestoraiseawarenessabouttheExchangep g

Provideinformationandservicesinafair,accurateandimpartialmanner.Informationmustacknowledgeotherhealthprograms

F ilit t l ti f QHPFacilitateselectionofaQHP

Providereferralstoconsumerassistanceoffice(s)forenrolleeswithgrievances,complaints,questionsabouttheirplan,coverage,oranyd t i tideterminations

Provideinformationthatisculturallyandlinguisticallyappropriatetotheneedsofthepopulationbeingservedandensureaccessibilityandusabilityf N i t t l f th ith di bilitiofNavigatortoolsforthosewithdisabilities

UnderthefinalExchangeregulations,StatesmayallowNavigatorstoassistith bli t Th ti iti ld b li ibl f f d l f diwithpubliccoveragetoo.Theseactivitieswouldbeeligibleforfederalfunding

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NavigatorStandards

UndertheACA,

Navigators shall not: Navigatorsshallnot:Beahealthinsuranceissuer;

Beasubsidiaryofahealthissuer;

Beanassociationthatincludesmembersof,orlobbiesonbehalfof,theinsuranceindustry;or

Receive any consideration directly or indirectly from any health insuranceReceiveanyconsiderationdirectlyorindirectlyfromanyhealthinsuranceissuerinconnectionwithenrollmentofindividuals/employeesinQHPsornonQHPs

Th E h h ll bli h N i d d i l di TheExchangeshallestablishNavigatorstandards,including:Conflictofinterestprovisions

Navigator training standardsNavigatortrainingstandards

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AgentsandBrokers

InadditiontopermittingagentsandbrokerstobeNavigators,astatemayalsochoosetopermitagentsandbrokersto:

Enrollqualifiedindividuals,employers,oremployeesintoQHPsinthe individual and SHOP exchangestheindividualandSHOPexchanges

AssistindividualsinapplyingforadvancepremiumtaxcreditsandcostsharingreductionsforQHPsg

TheExchangemayprovideinformationaboutlicensedagentsd b k it b itandbrokersonitswebsite

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NewYorkStatePolicyQuestionsNavigatorsg

WhatshouldthecriteriabeforeligibilitytoserveasaNavigator? ShouldNavigatorsprovidehelpwithpublicprograms,inadditiontoQHPs?Sh ld N i t b th th i di id l d SHOP E h ? ShouldNavigatorsserveboththeindividualandSHOPExchanges?

WhatkindoftrainingshouldberequiredofNavigators?ShoulditbethesamefortheindividualandSHOPExchanges?

Wh t h ld N i t tifi ti l k lik ? WhatshouldNavigatorcertificationlooklike?Producers,Chambers,BusinessAssociations

Whatroleshouldproducers,chambers,businessassociationsplayinenrollingindividuals and small groups in QHPs?individualsandsmallgroupsinQHPs?

ShouldtheyserveboththeindividualandSHOPExchanges? ShouldbrokersbeNavigatorsorcontinuetheirtraditionalroleasbrokers(includingbeing reimbursed directly by carriers)?beingreimburseddirectlybycarriers)?

Compensation

Whataretheoptionsforcompensatingtheseentities?N i Navigatorgrants

BrokerscanbereimbursedbytheExchange(Navigatorgrants)ordirectlybycarriers Other? 7