The Affordable Care Act established a number of consumer assistance programs, to help consumers understand their new health coverage options and to assist them in applying for and enrolling in appropriate coverage.
Three of these programs are the Patient Navigators, In-Person Assisters, and Certified Application Counselors.
They will play a large part in enrolling all the newly eligible in the State Insurance Exchanges and Medicaid program. They will help consumers prepare electronic and paper applications to establish eligibility and enroll in coverage, as well as providing general outreach, education, and referrals.
Some of these programs offer funding for training of personnel to perform these positions. HIV providers should consider how these roles may be incorporated into their practices.
**HIV Providers should visit our Health Reform & My Patients page for specific resources on enrolling your patients!
*HIV patients should visit our Health Reform & My Practice page for enrollment information.
A variety of challenges including a limited knowledge of health insurance, language barriers, and disability will face new enrollees and there will be a great need for assistance.
Patient Navigators will be responsible for guiding consumers through all coverage options offered through exchanges and the entire enrollment process. Navigators are single entities that will be funded through state and federal grant programs, and must complete comprehensive training.
They will help consumers prepare electronic and paper applications to establish eligibility and enroll in coverage through the Exchange. This includes steps to help consumers find out if they qualify for insurance affordability programs (including a premium tax credit, cost sharing reductions, Medicaid and the Children’s Health Insurance Program), and if they’re eligible, to get enrolled.
Navigators will also provide outreach and education to consumers to raise awareness about the Exchange, and will refer consumers to other consumer assistance programs when necessary.
Patient Navigators will be selected based on their established relationships with populations who will become eligible and ability to reach a wide population.
The Navigators in federally-run Exchanges will complete federal training and certification. In a State-based Exchange, Navigators will be required to have state training and certification, though federal training may also be used. Under the state-federal Partnership Exchanges option federal training are required and may be supplemented by the state.
“Non-Navigator assistance personnel” (also known as “In-person Assisters”) will perform generally the same functions as Navigators but will exist in either a State-based Exchanges or a State-Federal Partnership Exchanges.
In-person Assisters will be funded through separate grants or contracts administered by a state. They must also complete comprehensive training.
Certified Application Counselors
The Federally-facilitated Exchanges will designate organizations to certify application counselors who perform many of the same functions as Navigators and In-person Assisters, including educating consumers and helping them complete an application for coverage.
A State-based Exchange may choose to certify application counselors directly rather than designate organizations to do so.
Certified application counselors and Exchange-designated organizations won’t receive new federal grant money through the Exchanges. The counselors and organizations could, however, receive federal funding through other grant programs or Medicaid to help support their consumer assistance and enrollment activities.
Examples of possible certified application counselors include staff at Ryan White clinics, community health centers, hospitals, other health care providers, or social service agencies.
In states that already have their own certification programs, staff at consumer non-profit organizations may also be certified as application counselors by Exchange-designated organizations.
All certified application counselors are required to complete comprehensive training.
Agents and Brokers:
To the extent permitted by a state, licensed health insurance agents and brokers may enroll individuals, small employers, and employees in coverage through the Exchanges.
Agents and brokers will be compensated by the issuer or by the consumer to the extent permitted under state law. Federal and state training and certification requirements will apply to agents and brokers who enroll or assist consumers in the Exchanges.
In August 2013 the Centers for Medicare & Medicaid Services (CMS) announced its grant awards to fund Navigator programs in both state partnership and federally –facilitated insurance marketplaces. Grants were awarded to public organizations (national, regional, or state-based), private entities, and self-employed individuals to serve as Navigators.
Navigators and Assisters Resource Center – Families USA
Webinar-So You Want To Be A Navigator – Enroll America
Preparing Navigators – Families USA
Assistance Roles to Help Consumers Apply & Enroll in Health Coverage through the Marketplace – CCIIO
OUTREACH, ELIGIBILITY AND ENROLLMENT - NASTAD