Exchange Navigator Requirements Defined and "Employee Choice" Delayed for SHOP Exchanges

Employee Choice” in Federal SHOP Exchanges Delayed

On March 11, HHS announced it is delaying the “employee choice” option in the Small Business Health Options Program (SHOP) Exchanges from 2014 to 2015. This delay will impact states where the Federal government will run the Exchanges and states that are developing their Exchanges in partnership with the Federal government.

The employee choice option will allow employers to determine how much they will contribute toward the cost of employee coverage and offer their employees a choice of Exchange plans from different carriers at a certain metal level (Bronze, Silver, etc.).

In 2014, small employers in states impacted by this delay will choose an Exchange plan and their employees will decide whether or not to enroll in that plan. Employers will not be able to offer their employees a choice of plans until 2015.

Exchanges being developed by states may choose to offer employee choice in 2014, or they may choose to delay implementation of that feature until 2015. The employee choice option will be available in all SHOP Exchanges for plan years beginning on or after January 1, 2015.

On April 3, 2013, the Centers for Medicare & Medicaid Services (CMS) issued proposed regulations outlining standards for Navigators and non-Navigators (also known as "in-person assisters") for training and certification, cultural and linguistic services, disability access and conflict of interest disclosures.

Navigators are organizations and individuals that will help individuals and small employers shopping for coverage on public Exchanges through the eligibility and enrollment process.

"In-person assisters," "non-Navigator assistance programs" and "non-Navigator assistance personnel" may supplement the Navigators in some states. These roles were added to ensure that states would have enough resources to support all those who need assistance. Their responsibilities are similar to Navigators and the standards and training requirements in these proposed regulations apply to them as well.

Who Can and Cannot Be a Navigator

To ensure that Navigators are objective, CMS has proposed the following rules:

Can be a Navigator

·  Agents and brokers may be Navigators as long as they are not receiving any compensation from health insurance or Stop Loss insurance carriers for enrolling people in health coverage, either on or off the Exchange.

Note: Agents and brokers who sell products other than health insurance or Stop Loss insurance can continue to receive commissions on the sale of other types of insurance, provided they comply with the proposed disclosure requirements.

Cannot be a Navigator

·  Companies that issue health insurance and Stop Loss insurance, and their subsidiaries, cannot be Navigators.

·  Associations that include members of, or lobby on behalf of, the insurance industry cannot be Navigators.

What Navigators and In-Person Assisters Will Need to Disclose

Navigators and in-person assisters will need to disclose the following types of information to both the Exchange and to the consumers they are assisting:

·  Any current or former employment relationships over the last five years with companies that issue health insurance or Stop Loss coverage, or their subsidiaries.

·  Any other business, financial or contractual relationships with companies that issue health insurance or Stop Loss coverage, or their subsidiaries.

·  Any employment or business relationship their spouse or domestic partner has with companies that issue health insurance or Stop Loss coverage, or their subsidiaries.

Navigator and In-Person Assister Training and Certification Requirements

Navigators and in-person assisters will be required to:

·  Meet any licensing, certification or other standards prescribed by the state or Exchange.

·  Complete a training program approved by the Department of Health and Human Services (HHS) that may include up to 30 hours of training.

·  Pass an examination to be certified.

·  Obtain continuing education and be recertified at least annually.

·  Be prepared to serve both the individual and small group Exchanges.

·  Be trained to work with individuals with limited English proficiency and individuals with disabilities.