1. THE AFFORDABLE CARE ACTAND
HEALTH INSURANCE PRODUCERS
Presented by the
Utah Insurance Department
July 16, 2013
2. A New Language
โข ACA: Affordable Care Act
โข FFM: Federally-facilitated Marketplace
โข Grandfathered plan: Health plan issued prior to March 23, 2010 that
has not had significant changes to benefits and plan design
โข MLR: Medical loss ratio
โข Non-grandfathered: Health plan offered after March 23, 2010
โข PPACA: Patient Protection and Affordable Care Act of 2010
โข QHP: Qualified Health Plan
โข SBC: Summary of benefits and coverage
โข SHOP: Small business Health Options Program
โข Federal offices:
โข HHS: U.S. Department of Health and Human Services
โข CCIIO: Center for Consumer Information & Insurance Oversight
โข OPM: Office of Personnel Management
10. Producers
Avenue H
Assist employers and employees in
completing the application, selecting
and enrolling in QHPs
Must be:
โข Licensed
โข Appointed with insurers
โข Complete Avenue H training
Individual Federal Marketplace
Assist qualified individuals in
completing the eligibility application,
receiving eligibility determinations,
and selecting and enrolling in QHPs
Must be:
โข Licensed
โข Appointed with insurers
โข Complete Federal Marketplace
training
โข Register with the Federal
Marketplace
11. Federal Guidance on the Role of Producers in
the Individual Federally-facilitated Marketplace
โข HHS is working with producers on the individual
Federally-facilitated Marketplace so producers can help
consumers:
โข Complete the tax subsidy eligibility application
โข Compare and select qualified health plans (QHPs)
โข Enroll through the Marketplace
โข HHS lays out three pathways producers may use to sell
coverage through the FFM:
โข Insurerโbased Pathway
โข Marketplace Pathway
โข Webโbroker Pathway
* http://cciio.cms.gov/resources/regulations/Files/agentโbrokerโ5โ1โ2013.pdf
13. Federal Guidance on the Role of
Producers in the Individual Marketplace
(CONTINUED)
Option 1: Insurerโbased pathway
โข The producer logs onto the insurerโs website.
โข The consumer determines that he or she would like to get
coverage through the individual Marketplace.
โข The producer is redirected from the insurerโs website to the
individual Marketplace website to complete the eligibility
application.
โข The application is completed and the consumerโs eligibility
determination is received from the Marketplace.
โข The producer is securely redirected back to the insurerโs
website to assist consumer with plan comparison, plan
selection, and enrollment.
โข The producerโs FFM user ID and NPN are included in the
Marketplace enrollment record sent to the insurer.
14. Federal Guidance on the Role of
Producers in the Individual Marketplace
(CONTINUED)
Option 2: Marketplace pathway
โข With help from the producer, the consumer logs directly
onto his or her own Marketplace account.
โข The producer works with the consumer to complete the
eligibility application.
โข After the consumer receives an eligibility determination,
the producer assists the consumer in comparing QHPs on
the Marketplace website and submitting the consumerโs
selection.
โข At both the eligibility application stage and the enrollment
stage, consumer will enter the producerโs Marketplace
user ID and NPN to indicate that producer has assisted
the consumer.
15. Federal Guidance on the Role of
Producers in the Individual Marketplace
(CONTINUED)
Option 3: Webโbroker pathway
โข Consumers in the individual Marketplace may select a
QHP through a producerโs publicโfacing website.
โข CMS is developing the capacity to support integration
between the webโbrokerโs website and the FFM website.
โข This interface will allow an individual to begin his or her
shopping on the webโbrokerโs website, connect securely
to the Markplace website to complete the eligibility
determination, and return securely to the webโbrokerโs
site to compare plans, select a QHP, and enroll.
16. Parity in Producer Compensation
HHS requires insurers to pay producers for enrollment in
health plans offered through the individual Marketplace at
the same rate as similar individual health plans offered
outside the Marketplace
*http://www.gpo.gov/fdsys/pkg/FRโ2013โ03โ11/pdf/2013โ04
902.pdf
18. What is the role of a Navigator?
โข Navigator Duties
โข Conduct public education activities to raise awareness of the availability of
qualified health plans
โข Distribute fair and impartial information about enrollment in qualified health
plans and the availability of premium tax credits
โข Facilitate enrollment in qualified health plans
โข Provide referrals to an office of health insurance consumer assistance or
ombudsman, or any other appropriate state agencies, for any enrollee with
a grievance, complaint, or question regarding their health plan
โข Provide information in a manner that is culturally and linguistically
appropriate to the needs of the population served by the Exchange
โข Navigators may not receive any direct or indirect payments from
health insurers.
โข Navigators are funded through grants established by the Marketplace
19. Navigator Licensing
HB160, Health System Reform Amendments (J. Dunnigan),
created the Navigator License Act (31A-23b)
โข Mirrors producer licensing requirements (31A-23a)
โข Licensing process will include:
โข Background check
โข Pre-training and test requirements
โข Requires continuing education
โข Requires a surety bond to cover errors and omissions
20. Navigator License Exemptions
โข Created certain exemptions from navigator licensure:
โข Person who assists an individual with enrollment in a public program or an application for
premium subsidy AND is employed by or contracts with:
โข health care facility
โข state, a political subdivision of the state, an entity of a political subdivision of the state, or a public
school district
โข federally qualified health center
โข Producer, if the producer is licensed in the appropriate line of authority to sell, solicit, or negotiate
accident and health insurance plans
โข Officer, director, or employee of a navigator who does not receive compensation or commission
from an insurer
โข Person who does not sell, solicit, or negotiate insurance and is not directly or indirectly
compensated by an insurer issuing an insurance contract, an agency administering a public
program, an individual who enrolled in a public program or insurance product, or an exchange
โข Class of persons, as exempted by the commissioner via rule, if the functions performed by the
class of persons do not require:
โข special competence;
โข special trustworthiness; or
โข regulatory surveillance
21. Differences Between Producers and Navigators
Producer Navigator
INFORMATION TO BE PROVIDED TO THE CONUMSER
Eligibility information for coverage through the Marketplace, premium tax credits or publicly subsidized programs such
as Medicaid, CHIP, Medicare, etc
X X
Methods to purchase and enroll in a QHP: Marketplace web portal, Marketplace call-in center, walk-in centers, kiosks
located in community service centers, mail in applications and fax applications
X X
Education on the benefits of health insurance and what health insurance provides for the individual X X
Definitions of health insurance terms, for example, aiding the consumer to understand the difference between a
premium, deductible and co-insurance
X X
Providing information to the consumer to find avenues to resolve disputes with insurers X X
Providing culturally and linguistically appropriate health insurance education to persons including but not limited to
Hispanics, Asians and American Indians
X X
Outreach to consumers focusing on broad topics related to health insurance and coverage options X X
COMPENSATION
Funded by grants from the Marketplace X
Funded by commissions paid by the insurers X
LICENSING, CERTIFICATION AND TRAINING
Licensed and regulated by Utah Insurance Department (UID) X X
Certified and regulated by HHS in partnership with the Marketplace X
Criminal background check required X X
ENROLLMENT
Enroll consumers in plans offered in the Marketplace X X
Enroll consumers in plans offered outside of the Marketplace X
Assist in submission of enrollment documentation to the Marketplace X X
Provide the consumer with documentation stating the date coverage will start and the appropriate agencies to contact
if the consumer encounters problems with enrollment, coverage or payment
X X