Marketplace Navigator roles still cause for question


Will the 34 federally-facilitated and state-partnership exchange programs be sufficient?

On October 1, the Health Insurance Marketplaces opened to millions of consumers looking for affordable coverage. Every marketplace has Bronze, Silver, Gold and Platinum levels of coverage and a variety of insurance providers and plans under each level. A big question relates to how much guidance will be available to consumers to help them understand their different coverage options, eligibility, enrollment, affordability programs, tax credits and cost sharing reductions.

One resource carved out in the Patient Protection and Affordable Care Act is “Navigators.” Federally-facilitated, state partnership and state-based marketplaces are all required to set up a Navigator program. Navigators will primarily provide in-person and impartial information to consumers about the different Qualified Health Plans, walk consumers through the selection process, and conduct public outreach and education efforts.

Navigators are required to be trained in a number of areas, including benefits that will be covered under plans, the differences between plans, payment processes, the range of affordability programs available, information about tax credits and their impact on premiums, eligibility and enrollment rules and procedures, working effectively with individuals with disabilities, English proficiency, and underserved populations.

Although the Act stipulates the availability of Navigators, it does not spell out how and when these programs will be implemented. The answer to this question is only beginning to emerge. On August 15, the U.S. Department of Health & Human Services (HHS) awarded $67 million to 105 Navigator grant applicants in the 34 federally-facilitated and state partnership marketplaces. The grant recipients can share their awards with organizations to hire and train individual Navigators or they can hire and train Navigators themselves.

While $67 million may seem like a lot to allocate toward the programs, some marketplaces received as little as $510,000 while others received millions. For example, Texas received the largest total award with $10.9 million, but more than 10 marketplaces received less than $1 million to implement a Navigator program.

However, these numbers really begin to raise questions of capability when you consider how much money state-based marketplaces are allocating towards their own programs. Maryland will be spending $24 million to dispatch more than 325 Navigators, Colorado will spend more than $17 million on 400 Navigators, and New York will spend $27 million on Navigator efforts.

These figures raise a number of questions. How many Navigators will be needed to assist consumers? Are state-based marketplaces spending too much, or will the 34 federally-facilitated and state partnership marketplace programs be insufficient? Will the Navigators be trained and available in time?

On top of this, several of the grantees were forced to respond to a Congressional inquiry that was initiated shortly after HHS announced the grants. While some have said the inquiry is nothing more than partisan politics, the inquiry appeared to divert attention away from the Navigator grantees’ necessary work-preparing for the launch of the marketplaces. With all of these questions and uncertainties, all interested parties-not just consumers-should keep an active eye on the developments of the Navigator programs.

In addition, another option that HHS views as a “critical” resource in the process is agents or brokers. HHS requires that agents or brokers wishing to work on the marketplace complete an online marketplace-specific training program and register online for a specific ID.

Marketplace agents and brokers will essentially play the same role that they do in the current insurance market. The process by which agents and brokers will assist consumers will depend on the type of pathway used. Under an Issuer-based pathway the agent or broker will use an insurance issuer’s website to work with the consumer, whereas under a marketplace pathway, the agent or broker will guide the consumer through the actual marketplace website.

Agents and brokers will continue to be hired by insurance issuers, and their compensation arrangements will be negotiated between the insurance issuer and the agent or broker.

They will not be required to provide impartial information like Navigators. HHS recognizes that they will provide consumers information specific to the plans of the insurer that hired them. However, HHS does expect agents and brokers to inform the consumer that they can directly access their marketplace’s website which lists all available Qualified Health Plans.

As is the case with Navigators, it is unclear how many marketplace brokers or agents will be needed to serve as the “critical” resource HHS expects that they will serve in the new marketplaces.

Regardless, having a strategy to stay on top of the certain-to-change marketplaces is a must, especially when it comes to Navigators and brokers and agents. Even if the strategy is a wait-and-see approach, not staying informed of new developments could be detrimental.


Williams is a partner in the Health Care & Bioscience Practice Group of Cleveland-based Walter | Haverfield, LLP.



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