Challenges about Navigators, Licensing, Regulation, Medicaid and Call Centers

As of mid-December, 19 states indicated they will develop their own state-based health insurance exchanges.  The majority of these states are in the West, with only Arizona, Alaska, Wyoming and Montana opting not to pursue state-based exchanges at this point.   In the mid-west, only Minnesota  will develop a state based exchange and only Mississippi, Kentucky, and Maryland plus Washington DC in the South said they will develop their own exchanges. New England states are a mixed bag.

Approximately six states have indicated they will create partnership exchanges with the federal government and the rest will default to using the exchange plan created by the federal government.  Most of those states are in the Midwest and the South. This chart shows what the states are planning to do:


A major challenges facing the states and the federal government is explaining the options that will be available to consumers.  Another issue is who ‘regulates’ the Navigators who will help consumers and small businesses make enrollment decisions.  The ACA requires that consumers have at least two choices of Navigators—individuals or non-profit organizations.

Regulation is a ticklish issue.  Health care insurance is regulated at the state level.  Consequently, insurance regulations differ state by state.  Medicaid coverage also differs state by state.  There are federal Medicaid requirements, but the states are free to make some coverage changes—largely additions—but they must offer what the federal government requires.  In this new environment with state exchanges, joint exchange and federal exchanges, who will have oversight?

Individual and small business insurance policies are sold by insurance agents and brokers.  Current concerns exist about the adequacy of training for these new Navigators because the Navigators will not only be in a position to explain commercial products available to individuals, but Medicaid as well.  There will be no easy cookie-cutter insurance policy.  And, to date, not even a range of templates like Medicare supplements.

Many of the people helping consumers make  decisions now largely about individual insurance policies and Medicare supplemental policies are insurance brokers who are licensed—and regulated–to do so.    Navigators may accept service fees, but not commissions or other compensation from insurance companies.

A Task Force of the National Association of Insurance Commissioners (NAIC) is developing some guidelines and the Center for Consumer Information and Insurance Oversight (CCIIO) of the US Department of Health and Human Services is expected to publish guidelines about Navigators  this month (January).


The ACA plan is that Medicaid eligibility and commercial product availability and eligibility would be “merged” into one marketplace/website so consumers can go to one place, enter their income and family size and learn the programs they are eligible for.  This might work relatively well for a state like Washington that uses a state-based exchange.  It is not clear to me yet, how this will work for states that opt for a state-federal partnership or states that default to using the new federal exchange.

Medicaid differs state by state.  What is covered and how it is covered in Washington State is not the same as Medicaid programs in Illinois or Mississippi.   If some 20+ states are deferring to the federal exchange, how will Navigators explain all those different state options?  And where will those Navigators be located—at the state or federal levels?   Who will train them and who will have oversight?

There are people at the state and federal levels who do know those differences, but the potential scale of the changes represent an operational challenge.  Theoretically, this chart developed by the Kaiser Family Foundation and the American Medical Association, outlines the steps in gaining coverage.

Here in Washington state, the HBE is now in the final hiring phase for a company to serve as a call center to answer consumer questions about their enrollment choices.   The company is based in Virginia.  Much depends on the adequacy and thoroughness of the training for products that have not yet been developed.

We hope to find answers to these as other questions as the marathon to implement the ACA continues.

Kathleen O’Connor, January 2, 2013

Coming up:  A look at benefits options and challenges

About Kathleen

Kathleen O’Connor: 30+ year health care consumer advocate, non-profit executive and author. For more information about Kathleen, please see "About" on the main content bar above.
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