Chapter 6: Insider’s Guide to Obamacare’s Open Enrollment

Agents and brokers and navigators … oh my

ACA's exchanges have gotten easier to use, but consumers who are still confused have options for personal help in selecting coverage

The Insider's Guide to Obamacare's Open Enrollment 2016-2017 EditionDuring 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.

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.

How they help you

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. Navigators are not permitted to recommend one plan over another or direct consumers towards a particular policy.

Navigators earn about $31,000 per year, paid by state and federal grant programs, and they cannot be compensated by the insurance companies. In September 2015, HHS announced $67 million in Navigator grants for 100 organizations working in 34 states with federally run or partnership exchanges. This money is being used to pay Navigators and maintain the Navigator programs at these organizations for three years, through September 1, 2018. (States that are running their own exchanges also have exchange-funded Navigator programs.)

In early 2017, HHS laid out enhanced requirements for Navigators – most of which will go into effect in 2018 – including targeted assistance for underserved and uninsured populations, as well as post-enrollment assistance (things like eligibility appeals and health insurance utilization).

Certified application counselors (CACs) can also provide assistance with the enrollment process. They are similar to Navigators, but they are not required to perform outreach activities, and will not be required to perform post-enrollment assistance (although they can do so if properly trained). Their role is more limited and their focus tends to be strictly on helping people enroll.

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.

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.

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 and independent agents will be able to show clients plans both on- and off-exchange, and can explain the pros and cons of each.

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 brokers who can enroll you in an ACA-compliant plan.)

In early 2016, CMS published a list of frequently asked questions pertaining to agents and brokers who assist enrollees with the federally facilitated exchange.

Training and experience

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 2017 enrollment (which begins November 1, 2016), Navigators in the federally-faciliated marketplace have to complete 14 online Navigator Curriculum courses with at least an 80 percent score. HHS has also added one additional optional course for 2017.

Certified application counselors are also regulated by the exchanges. In federally facilitated exchanges, CACs are required to complete six online CAC Curriculum courses with at least an 80 percent score (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.

Attitudes about Obamacare

Navigators and certified application counselors tend to be supportive of healthcare reform and the ACA, although many 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 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 reform and see it as an opportunity to help their clients rather than a hindrance.

The bottom line

So what’s the price of this advice? Your consultations are actually free. Navigators are hourly employees, paid by state and federal 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. Brokers are generally paid on commission by the insurance carriers.

But while there is a difference in how brokers and Navigators are compensated, there are never any 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.

So how do you choose?

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 might be the perfect fit.

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