The federal agency responsible for administering the Affordable Care Act’s health insurance marketplaces, the Centers for Medicare and Medicaid Services (CMS), has released new proposed rules to govern health insurance companies and the marketplaces beginning in 2017. The rules cover a wide range of subjects, from the regulation of premium rates, to benefit design and provider networks. However, because we have been providing policy support to Navigators and enrollment assisters as part of a Robert Wood Johnson Foundation-funded project, we are particularly interested in provisions that affect the marketplace Navigator program. Below are a few key changes proposed by CMS:

A New Emphasis on Targeted Outreach

CMS proposes to require all Navigator grantees to provide targeted assistance to “underserved” and/or “vulnerable” populations within their service area. While Navigators are already required to have expertise in the needs of these populations, CMS will be asking Navigators to focus their efforts on these harder-to-reach populations. CMS will not, however, attempt to define the particular populations. Rather, CMS is hoping to rely on Navigator grantees to propose specific communities to target, based on local needs. For federally facilitated marketplaces, CMS may provide suggestions through future grant announcements. This provision, if finalized, would apply beginning with Navigator grant applications to be awarded in 2018.

Helping Consumers, Post-Enrollment

CMS is proposing to require Navigators to help consumers with questions or concerns about their coverage, after they’ve enrolled. To date, Navigators have only been required to provide help through enrollment. However, we know through our own work with Navigators, as well as the Kaiser Family Foundation’s national survey, that consumers often turn to Navigators later in the year when they have problems with their plan. The Navigator that helped them enroll is often the first person a consumer will turn to with questions about how to use their health insurance, what to do if a provider isn’t in network, or if their plan has denied payment for a service.

Help with Marketplace Appeals, Exemptions and APTC Reconciliation

CMS proposes to require Navigators to help consumers file appeals of their Marketplace eligibility determinations. This will include helping people understand their appeal rights and assisting them with the process of completing and submitting appeal forms. This requirement does not, however, impose a “duty” on Navigators to represent a consumer in an appeal, sign an appeal, or file an appeal on behalf of a consumer.

Navigators will also be required to help people apply for the exemptions from the individual mandate that are granted by the Marketplace (some mandate exemptions can only be granted by the IRS). CMS will expect Navigators to help consumers understand the availability of exemptions through the tax filing process, be able to explain the purpose of IRS form 8965 as well as how to access relevant tax information on the IRS website.

CMS additionally proposes to require Navigators to help consumers with the reconciliation of their advance payment of premium tax credits (APCTs). This would include ensuring that a consumer can obtain Forms 1095-A and 8962, as well as providing “general, high-level” information about the purpose of the forms. Navigators will also be expected to help consumers understand (1) how to report errors on the Form 1095-A; (2) how to find silver plan premiums using the Marketplace tool; and (3) the difference between advance payments of the premium tax credit and the premium tax credit, as well as the consequences of not filing a tax return and undergoing the reconciliation process. For both this requirement and the requirement to assist with exemptions, however, CMS is asking for comment on whether Navigators should also provide consumers with a disclaimer stating that they are not acting as tax advisors and cannot provide tax advice. CMS is also proposing that Navigators provide referrals to licensed tax advisors and preparers.

Health Insurance Literacy

CMS asserts that an overall purpose of the marketplaces’ consumer assistance programs is to help consumers become “health literate.” To that end, they propose that Navigators be required to help consumers understand basic concepts related to health coverage and how to use it, although CMS notes that the type and level of education would depend on each consumer’s “needs and goals.”

Of course, most Navigators are already helping consumers with health insurance literacy, and they’re often performing all of the duties described above – targeting vulnerable populations, helping resolve post-enrollment issues, and helping consumers apply for eligibility appeals, exemptions and reconcile APTCs. In this latest proposed rule, CMS is now formalizing these activities as requirements of the Navigator program. CMS, however, is not extending these requirements to Certified Application Counselors (CACs) or other consumer assistance personnel at this time.

For more on 2017 changes to the Navigator program, see the proposed Notice of Benefit and Payment Parameters for 2017. And stay tuned for more updates on CHIRblog.