Final Rules Make Expanded Role Official for Some Navigators in 2018

The administration officially expanded roles for Navigators beginning in 2018 when it finalized Marketplace regulations earlier this week. Much of what CHIRblog had previously described under the proposed rule published in November has been retained in the final rules.

Beginning in 2018, Navigators in all Marketplaces must target assistance to underserved or vulnerable populations as well as assist other consumers in their area. The administration declined to provide a list of underserved or vulnerable populations, reasoning that such groups vary across regions. It will, however, use the funding opportunity announcements for federally facilitated marketplaces (FFM) to identify populations that are disproportionately without access to care or at greater risk for poor health outcomes as the main criteria for measuring underserved or vulnerable populations. States with their own marketplaces (SBMs) and states using the (SBM-FPs) can apply their own criteria.

The final rules also give SBMs and SBM-FPs the discretion to further expand Navigator roles with post-enrollment issues. Navigators in FFMs, however, must help consumers with the following post-enrollment related areas:

Understand the appeals process for marketplace eligibility determinations including:

  • identifying and meeting appeal deadlines,
  • identifying determinations that can be appealed,
  • accessing relevant Marketplace resources like appeal forms and guidance,
  • providing information about free or low-cost help with filing an appeal,
  • collecting supporting documentation for an appeal.

Understand the requirement to have health insurance and available exemptions through the Marketplace.

Understand exemptions available through the tax return filing process.

Understand the consequences of not filing and reconciling premium tax credits and what available IRS resources are available for reconciling premium tax credits including:

  • accessing Form 8962 and instructions,
  • reporting errors on their Form 1095As,
  • finding silver plan premiums using the tool.

Understand basic concepts related to health coverage and how to use coverage including:

  • educating consumers about key terms in health insurance such deductible and coinsurance and how they relate to a health plan,
  • educating consumers the cost and care differences between going to the emergency department and a primary care provider,
  • identifying in-network providers and making and preparing for a medical appointment,
  • educating consumers about what to expect after an appointment like making a follow-up appointment and filling a prescription,
  • educating consumers about the availability of certain preventative health services without cost sharing.

While many Navigators already provide help with these and other post-enrollment issues, the final rules make this expanded role official for Navigators in FFMs. This allows Navigator programs to allocate funding for these required duties in 2018. In the meantime, Navigator programs in the FFM can and are authorized to use current funding for these expanded duties.

Like the proposed rule, the final rule does not expand these duties as a requirement for certified application counselors (CAC) or other consumer assisters, but does not bar CACs from taking on these duties. In the interest of consumer awareness, however, the final rule requires all Navigators, CACs and non-navigator assisters to provide a disclaimer to consumers that they are not acting as tax advisors and cannot provide tax advice.



  • Deborah Strain says:

    I hope someone there will be able to help me. I have been trying for almost a year to receive a retroactive termination from the marketplace. I have spoken with several people there and have been told different things about my marketplace termination.

    I began receiving Medicare August of 2017 My 1095-A is incorrect. The first person I spoke with put a begin date and not end date for marketplace termination.

    I need to know where to go for help. I have spoken with Social security, Medicade and both told me my 1095-A is incorrect. I am confident that i should not have to repay tax credits.

    Please help me to find agency to help me with an appeal or answers for me Thank you so much.

    • Hi there. Sorry you’re going through this bureaucratic headache! First, the fact that your Medicare enrollment began does not automatically end tax credits or Marketplace coverage. If you called the Marketplace in the summer of 2017 to direct them to terminate your Marketplace coverage effective in August, they should have done so. It sounds like there may have been a mistake. Unfortunately, neither the Social Security nor the Medicare call centers can help you with your Marketplace coverage or your 1095-A. Only the Marketplace call center can terminate your Marketplace coverage or give you information about whether or not it was terminated.

      Assuming you did call the Marketplace and request a termination in the summer of 2017, then you should call the Marketplace now and ask them to refer you to the 1095-A casework system. Those caseworkers investigate the case based on the information they can access and then can initiate a corrected 1095-A. However, if you did not call the Marketplace back in 2017, then the Marketplace call center will probably be tell you that they can’t do a retroactive termination.

      That said, if you can send me an email with your details and the narrative of what happened (including specifically saying that you called to request a termination in the summer of 2017), I can forward it to marketplace staff here in DC and ask them to put it into casework. No guarantees, but it could help move things along faster. My email address is Best,

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