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Who should help me enroll in a health plan?

Need someone to help you wade through health coverage options? Here's how to choose between Navigators, counselors and agents.

During the ACA implementation process, state and federal governments invested millions of dollars in online exchanges to facilitate enrollment in subsidy-eligible, ACA-compliant health plans. And over the last few years, the exchanges have been refined and upgraded to make them as user-friendly as possible.
But even with a perfectly designed, glitch-free enrollment system, many people will still want or need personal assistance with the application process and with ongoing insurance utilization questions. To fill this need, there are a variety of assisters nationwide who are trained to guide people through the process of researching and enrolling in health plans, and some can provide ongoing support after the plan is purchased.
It may be clear to you that you need help choosing a plan. What isn’t clear to many potential enrollees is how the various options for assistance – Navigators, certified application counselors, brokers, agents and enrollment consultants – differ.
Here’s what you need to know before you set up an appointment.

Navigators offer impartial education about exchanges, but their funding has been slashed

The Navigator role was created for the purpose of providing impartial education and outreach about the exchanges and exchange health plans, helping applicants determine whether they qualify for subsidies or Medicaid, and assisting them in the enrollment process. Standards and regulations for the Navigator program are outlined in 45 CFR 155.210 and CFR 45 155.215.
Navigators are not permitted to recommend one plan over another or direct consumers towards a particular policy. Instead, their job is to provide general information that consumers can use to understand what’s available to them. Navigators are paid by state and federal grant programs, and they cannot be compensated by the insurance companies. But the Trump administration has drastically cut funding for Navigators, compared with what was provided under the Obama administration.
In September 2016, under the Obama administration, HHS announced $63 million in Navigator grants for 98 organizations working in 34 states with federally run or partnership exchanges. The grants are used to pay Navigators and maintain the Navigator programs at these organizations. (States that are running their own exchanges also have exchange-funded Navigator programs.)
But the Navigator funding that was provided in September 2017 was sharply reduced — about 40 percent lower than it had been the year before — and the lower funding, totaling about $36 million, was announced at the last minute, catching Navigator organizations off-guard.
And in July 2018, the Trump Administration announced yet another sharp funding cut, with just $10 million in total Navigator funding for the upcoming open enrollment period. That was down from $63 million two years earlier. Some states were particularly hard-hit, although it varies considerably from state to state: Louisiana and Indiana actually saw a slight increase in their Navigator funding, although it was still well below what they received in the 2016 grants. But in Florida, Navigator funding dropped by 81 percent, from $6.6 million to $1.25 million — and they started with $9.5 million in the 2016 funding cycle. Iowa, Montana, and New Hampshire did not receive any Navigator funding in 2018 (CMS notes that in each case, no organizations applied to serve as Navigators).
Navigator funding remained level in 2019, with another $10 million granted to 34 Navigator organizations in advance of the open enrollment period for 2020 health plans. Navigator funding again remained at $10 million when HHS announced funding recipients in August 2020, but there are only 30 Navigator organizations receiving federal funding in advance of the open enrollment period that starts in November 2020. Virginia and Maine did not receive federal Navigator funding, as they will be operating state-based exchanges that use the federal enrollment platform, which means they’ll need to fund their own Navigator programs (federal approval for Maine’s transition to an SBE-FP was still pending as of August 2020).
There aren’t as many Navigators as there used to be (HHS funded just 30 organization in August 2020, as opposed to more than 80 in 2018), and their services aren’t as readily available in states that use (states that run their own exchanges fund their own Navigators — or a similar position with a different name — and their funding isn’t affected by the Trump Administration’s decision to cut Navigator funding).
The Trump administration has defended the funding cuts by noting that Navigators don’t enroll as many people as brokers, but it has to be noted that Navigators often work with people who enroll in Medicaid or CHIP, which means they don’t get credit for the enrollment since it’s not a private plan. But their work is essential in terms of providing assistance to people who would otherwise find it quite challenging to navigate the enrollment process.
In the Benefit and Payment Parameters for 2019, HHS stopped requiring navigator organizations to have a physical presence in an area where they provide services. HHS also removed the requirement that an exchange have at least two Navigator entities (most states now have just one), including at least one community/consumer-focused non-profit entity.
In early 2016, HHS laid out enhanced requirements for Navigators —most of which took effect for 2018 — including targeted assistance for underserved and uninsured populations, as well as post-enrollment assistance (on issues such as eligibility appeals and health insurance utilization). The enhanced requirements are detailed in 45 CFR 155.210(e)(9). But in the guidelines for 2020, HHS reversed course somewhat on this, making those duties optional, rather than required, for Navigator organizations. So some Navigator organizations now provide assistance with things like subsidy reconciliation, obtaining exemptions from the requirement to maintain coverage (hardship exemptions are still necessary for catastrophic plan eligibility if you’re 30 or older, even though there’s no longer a penalty for not having coverage), and eligibility appeals. But they are no longer be required to offer these services.
So although their funding has been reduced, some Navigators continue to provide more assistance than they did prior to 2018. But the shorter open enrollment window that took effect in the fall of 2017 (and which will continue to be used for 2021 coverage), the reduced budget for Navigator organizations, and the reduction in the number of other enrollment assisters could mean that Navigator assistance is spread fairly thin in many areas. In announcing the 2018 funding cut, the Trump administration noted that “It is appropriate to scale down the Navigator program to reflect the enhanced public awareness of health coverage through the Exchanges.” The Administration reiterated this view in the final regulations for 2020, noting that “We believe it is appropriate to scale down the Navigator program and other outreach activities to reflect the enhanced public awareness of health coverage options through the Exchanges.”
But according to Kaiser Family Foundation research, there is still a considerable lack of awareness about how open enrollment works among people who are uninsured and those who buy their own health insurance. In other words, assistance with the enrollment process is still greatly needed. The individual market has always been volatile — it doesn’t tend to be the same people from one year to the next, as people cycle in and out of the market depending on their access to employer-sponsored plans. So each year, a new group of people must learn the ropes when it comes to individual market enrollment.

CACs have a more limited focus on enrollment

Certified application counselors (CACs) can also provide assistance with the enrollment process. They are similar to Navigators, but their role is more limited and their focus tends to be strictly on helping people enroll, without the more extensive assistance that some Navigators can provide.
The exchange designates local “CAC organizations” (health centers, faith-based organizations, colleges, etc.) and people who are affiliated with or employed by those organizations are eligible to serve as CACs. Navigators are funded through the exchange, but certified application counselors are not. Funding for the CAC program can come from a variety of state and federal sources though, including existing public health appropriations. And CACs themselves are often volunteering their time to help people enroll in health coverage.
Since CACs aren’t funded by the exchange, some states (Vermont is an example) have worked to boost outreach to organizations that would be well served by having a CAC on staff. CACs generally serve a more focused clientele (people who would be using the organization where the CAC is employed, such as a clinic or hospital), but relying on CACs can help a state expand the total number of people available to help with the enrollment process, without having to spend as much on the Navigator program.
During the open enrollment period for 2018 coverage, after the Trump administration’s first round of Navigator cuts, many Navigator organizations partnered with volunteer CACs who could help to handle the enrollment volume. But it’s noteworthy that even when the Navigator organization was supporting and coordinating the CACs, the Navigators couldn’t get credit for the enrollments that were facilitated by the CACs. The Trump administration cited low Navigator-facilitated enrollment volume as a reason for the further funding cuts in 2018, but Navigators would have had higher enrollment numbers if all of the enrollments conducted under their watch — including those facilitated by CACs, along with enrollments in Medicaid and CHIP — had been counted.
HHS had proposed allowing Navigators and CACs to use web broker sites to enroll people via the enhanced direct enrollment pathway. But in their final rule for 2020, they opted not to implement that change. So the enhanced direct enrollment pathway can still only be used by insurers and brokers (described below), while Navigators and CACs must use the exchange website (as opposed to an exchange-certified third-party web broker site) to help consumers enroll. [CMS has published a list of entities approved to use the enhanced direct enrollment pathway as of 2020.]

Brokers and agents can make plan recommendations

Insurance brokers and agents who are certified by the exchanges can also explain plan details and help consumers determine subsidy or Medicaid eligibility, but — and this is a key difference — they can also make plan recommendations based on a client’s particular situation.
Agents and brokers continue to assist their clients after the plan is purchased, helping them sort out questions and problems regarding billing, utilization, claims, and appeals. Brokers and agents also generally carry errors and omissions insurance, and are licensed by their state department of insurance (this is in addition to their certification with the exchange; Navigators and CACs are trained and certified by the exchange, but are not licensed by the state insurance department).
For health insurance purposes, independent agents and brokers are virtually the same thing, although brokers may represent more carriers or offer different types of insurance products.
Brokers who are certified by the exchange are able to show clients plans both on- and off-exchange, and can explain the pros and cons of each. But the number of brokers who choose to work with the exchanges has declined since 2014, generally as a result of reduced or eliminated broker commissions for individual market enrollments (this trend began to reverse in many areas as of 2019; as more insurers become profitable in the individual market, they’re beginning to reinstate broker commissions that had previously been eliminated, or boost commissions that had been reduced when the insurers were facing a non-profitable individual market segment).
The number of brokers working with the exchanges dropped by almost 25 percent in 2018, but the total number of broker-facilitated enrollments dropped only slightly. This indicates that the high-volume brokers are continuing to work with the exchanges and/or individual market coverage, while lower-volume brokers are opting out. So it’s likely that you’ll be able to find a broker in your state who will assist you, but it might not be the local mom-and-pop brokerage in your town.

Agents with online portals also certified to help

It’s worth noting that many online portals — originally designed to provide a quick health insurance quote — are now devoting more resources to phone support, with agents licensed in each state to help customers through the enrollment process. (You can call one of our partners at 1-844-608-2739 to talk with a licensed, exchange-certified broker who can enroll you in an ACA-compliant plan.)
CMS has published a list of frequently asked questions pertaining to agents and brokers who assist enrollees with the federally facilitated exchange.

If they’re certified, they’re trained to help enroll.

Brokers are licensed and regulated by their state insurance commissioner, and must comply with state requirements for continuing education that pre-date the ACA. To be able to assist consumers enrolling through the exchange, brokers must also complete the required training and be certified by the exchange.
Navigators are regulated by the exchanges, although states can impose additional training and certification requirements. For 2020 enrollment, Navigators in the federally-facilitated marketplace had to complete seven or eight online Navigator Curriculum courses (and receive a passing score on the associated assessments), depending on whether they had already been certified as a Navigator or were new to the program. There is also an option to complete several additional courses. Updated training requirements are available here each year, in advance of open enrollment.
Certified application counselors are also regulated by the exchanges. In federally facilitated exchanges, CACs were required to complete eight online CAC Curriculum courses and pass the associated assessments in order to help with enrollment in 2020 plans. The rest of the courses are optional — but recommended — for CACs. In states that run their own exchanges, certification requirements are up to the state and the exchange
Brokers and agents are required to maintain their licenses with the states where they sell coverage, and to be certified with the exchange ( or a state-run exchange, depending on the state) if they wish to help clients enroll in exchange plans. Brokers and agents are required to completed continuing education courses in order to remain licensed and in order to maintain their certification with the exchange. Most states and insurers also require brokers to have errors and omissions insurance.

Attitudes about the Affordable Care Act may vary

Navigators and certified application counselors tend to be supportive of healthcare reform and the ACA, although some of them are relatively new to the health insurance industry, since both positions only became available in 2013.
The organizations that employ Navigators and certified enrollment counselors are often grant-funded advocacy groups, healthcare centers, universities, and public health agencies, and in many cases, they’re providing invaluable in-person assistance in communities with very high uninsured rates and significant enrollment obstacles.
Brokers pre-date the ACA, and have been helping consumers obtain health insurance for decades. Some brokers have been vocal in their opposition to the ACA, and some have opted to leave the individual health insurance industry. And certainly, not all of those who remain have chosen to get certified with the exchanges. But the ones who have gotten certified are committed to health care reform and see it as an opportunity to help their clients rather than a hindrance.

Regardless of who helps, help should be free

So what’s the price of this advice? Your consultations are actually free (with very limited exceptions for brokers in some states*).
Navigators are hourly employees, paid by state and federal exchange grant programs, and they cannot be compensated by the insurance companies.
CACs are not paid by insurance companies either. They can be hourly employees or volunteers, with a variety of public funding from outside the exchange. Many are employees of organizations such as hospitals or clinics that want to have a trained staff member who can help uninsured patients enroll in coverage.
Brokers are generally paid on commission by the insurance carriers, although some exchanges have salaried or hourly brokers as part of their staff.
But while there is a difference in how brokers and Navigators are compensated, there are typically no consultation fees*, and there’s no difference in the health insurance premiums you’ll pay, regardless of whether you work with a Navigator or enrollment counselor, broker or agent — or even if you apply entirely without assistance.
* Brokers in some areas charge fees when insurers don’t pay commissions, but this requires regulatory changes at the state level. Louisiana implemented a law in 2017 that allows brokers to charge a fee if they want to do so, but it has to be clearly disclosed to the client. Colorado passed similar legislation in 2018, allowing brokers to charge a fee if the insurance company isn’t paying a commission (some Colorado insurers pay commissions, and some don’t). In general, when agents and brokers can charge fees, the process is regulated by the state insurance department (here’s an example of how it works in Texas) It’s unclear how popular this business model will eventually become with brokers, but the general rule of thumb is that if brokers are charging fees, they are typically required to disclose that fact upfront.

Your help may depend on choices you’ve made already

Regardless of whether you work with a Navigator, CAC, or an exchange-certified broker, you’ll be getting skilled help with the enrollment process. This is preferable to doing it alone, especially since your premium will be the same regardless of whether you enroll on your own or with assistance.
If you feel like you need help in choosing a plan, a broker is likely your best bet. But if you already know what you want in terms of coverage and you just need help with the application process, a Navigator or CAC might be the perfect fit.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Donna Vaughn
Donna Vaughn
1 year ago

If a native american purchases health insurance through the marketplace and is given the premium tax credit, are they required to pay back any excess credit on their tax return? Are they exempt from this?

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