Health exchanges: Where do brokers fit in?

Though the Department of Health and Human Services anticipates the agent and broker industry will play a "critical role" in health exchange plan enrollment, whether (and to what extent) agents and brokers will be able to participate in these exchanges is a decision states will have to make before 2014.  

According to new rules announced Monday, it will be left up to individual states to decide whether agents and brokers will be permitted to assist qualified individuals, employers or employees with enrolling in a qualified health plan offered in state-run health insurance exchanges.

Agents and brokers will be permitted to become exchange “navigators,” but must meet state requirements for these roles. If they choose to become a navigator, agents and brokers will not be allowed compensation from an issuer for helping an individual or small group select a specific QHP, but will receive grant money for services that go beyond enrollment (see "Navigator duties" explained on next page).

Either form of participation in health exchanges, because of compliance and regulatory requirements, likely will incur costs for agents and brokers, according to HHS.

HHS has determined agents and brokers also will be among a list of stakeholders, with which exchanges must consult on an ongoing basis.

Enrollment assistance

Agents and brokers, who aren't acting as "navigators," will be permitted to help enroll qualified individuals, employers or employees in a health plan, if their state exchange allows for it. They also will be allowed to help individuals with applications for advance payments of the premium tax credit and cost-sharing reductions.

Under health care reform, these tax credits will be available to low- to moderate-income individuals and families to help them pay for health insurance. Tax credits will be based upon income up to 400 percent of the federal poverty level. According to a report from the Georgetown University Center for Children and Families, in 2019 about 66 percent of those who purchase health coverage through an exchange will receive some level of premium tax credit.

HHS is proposing exchanges set up websites, which could also include information about agents and brokers that are available for assistance.

Who is a Navigator?

HHS requires exchanges to include specific "entities" to act as navigators, in order to receive funding for a "Navigator grant." These can be groups ranging from consumer-focused nonprofits, licensed agents and brokers, unions, chambers of commerce and other organizations that have ties to potential, or existing, exchange plan enrollees.

Navigators will need to meet state exchange requirements for licensing or certification. HHS notes this “will allow the state or exchange to enforce existing licensure standards (such as verifying that agents who seek to be navigators are licensed), certification standards, or regulations for selling or assisting with enrollment in health plans and to establish new standards or licensing requirements tailored to navigators.”

There are also specific compensation standards for brokers and agents acting as navigators. According to HHS, navigators (whether agents, brokers or any other entity) may not receive any financial compensation from an issuer for helping an individual or small group select a specific QHP. Instead, navigators will be awarded grant money through the health insurance exchange, but HHS requires funding for these grants cannot come from federal funds used to set up the exchange. 

Navigator duties

According to HHS guidelines, a navigator must:

  • Maintain expertise in eligibility, enrollment, and program specifications and conduct public education activities to raise awareness about the health insurance exchange
  • Provide information and services in a fair, accurate and impartial manner. Such information must acknowledge other health programs
  • Facilitate enrollment in qualified health plans
  • Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health Service Act, 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 and functions for individuals with disabilities

Navigator compensation

Navigator grants will not be allowed to come from funds for establishing an exchange. To receive a navigator grant, an entity must:

  • Be capable of carrying out duties listed above
  • Demonstrate to the exchange that the entity has existing relationships, or could readily establish relationships, with employers and employees, consumers (including uninsured and underinsured consumers), or self-employed individuals likely to be eligible for enrollment in a QHP
  • Meet any licensing, certification or other standards prescribed by the state or exchange, if applicable
  • Not have a conflict of interest during the term as navigator

The full legislation can be found here.

Other health exchange coverage from BenefitsPro:


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