CMS Proposes Flexibilities for ACA Exchange Navigator Grantees

Jerry Ashworth
January 28, 2019 at 07:16:40 ET

The Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule that would provide greater flexibilities for entities receiving Navigator program grants under the Patient Protection and Affordable Care Act (ACA) (Pub. L. 111-148).

ACA created the American Health Benefit Exchanges, which are marketplaces through which qualified employers can purchase health insurance coverage. Under the Navigator program established by the act, exchanges may award grants to entities (called “navigators”) to conduct public education activities to raise awareness of the availability of qualified health plans and facilitate enrollment in these plans. Program regulations require that the information made available by these entities is fair, accurate and impartial.

Authorized, but Not Required

The ACA regulation at 45 C.F.R §155.210(e)(9) currently states that federally facilitated exchanges (FFE) — which are operated by HHS — may require or authorize a navigator receiving grant awards beginning in 2018 to provide assistance on a number of topics not specifically mentioned in the statute. These include helping users:

  • understand the process of filing exchange eligibility appeals;
  • understand and apply for exemptions from the individual shared responsibility payment that are granted through the exchange;
  • understand the exchange-related components of the premium tax credit reconciliation process;
  • understand basic concepts and rights related to health coverage and how to use their coverage; and
  • locate licensed tax advisers, tax preparers or other resources for assistance with tax preparation and tax advice related to consumer questions about the exchange application and enrollment process.

Under the proposed rule, CMS sought to provide more flexibility by amending this regulation at 45 C.F.R §155.210(e)(9) to make assistance with these topics permissible, but not required, for navigators that receive these grants in 2019.

“We believe making assistance with these topics optional for navigators would reduce regulatory burden on navigator entities and better meet consumers’ needs by allowing navigators to prioritize work according to consumer demand, community needs and organizational resources,” CMS explained. Although providing assistance would not be required, CMS emphasized that FFE navigators still would be authorized to continue to provide assistance with these topics based on an assessment of the communities needs, and to “build competency in the assistance activities in which they are engaging.” The CMS proposal also would continue to allow state-based exchanges (SBE) — which are operated by states — to determine whether to require or to authorize SBE navigators to perform these activities, if such would best meet the state’s needs and resources.

To better understand the impact of removing this requirement, CMS sought public comments on how many hours navigator grantees currently spend each month providing such assistance activities, what percentage of their current work involves providing these types of assistance, and how that amount of work would be impacted if proving these types of assistance would no longer be required. Further, CMS wanted to know how navigators might reprioritize work and spend time fulfilling their other duties if not required to provide this type of assistance. Comments on the proposed rule are due by 5 p.m. Eastern time on Feb. 19. Comments can be sent to, referring to the file code “CMS-9926-P.”

Training Requirements

CMS also has proposed regulatory changes to 45 C.F.R. §155.210(b)(2) and §155.215(b)(2) related to the training requirements that exchanges establish for navigators. Exchanges currently are required at 45 C.F.R. §155.210(b)(2) to develop and publicly disseminate a set of training standards that navigator entities must meet under their grants to ensure expertise in four topic areas (e.g., the needs of underserved and vulnerable populations; eligibility and enrollment rules and procedures; the range of qualified health plan options and insurance affordability; and applicable privacy and security standards). Exchanges that opt to require navigators to provide assistance with the topics found at 45 C.F.R. §155.210(e)(9) also must develop training standards for these specific assistance areas. FFE navigator grantees also must be trained in 15 additional topics found at 45 C.F.R. §155.215(b)(2) (e.g., information on qualified health plans, health insurance concepts, working with individuals with limited English proficiency, etc.).

While CMS is proposing to maintain the requirement for training standards for the four topic areas mentioned under 45 C.F.R. §155.210(b)(2), it seeks to eliminate the requirement that exchanges develop training requirements for navigators providing assistance with the topics found under 45 C.F.R. §155.210(e)(9), since those are no longer required. It also proposed to replace the current list of 15 additional FFE navigator training topics at 45 C.F.R. §155.215(b)(2) with a simple cross-reference to the topics at 45 C.F.R. §155.210(b)(2).

“This approach would provide exchanges greater flexibility in designing their navigator training programs to ensure coverage of the most instructive and timely topics and to align the training with future changes in the Navigator program or the operation of the exchanges, while still ensuring that navigators are qualified to carry out their required duties,” CMS explained. “This additional flexibility would also allow exchanges to focus on training areas they determine to be most relevant to the populations they serve, and on the policy and operations of the exchange in which they operate.”

CMS also proposed to allow, but not require, navigators to assist consumers with applying for eligibility for insurance affordability programs and qualified health plan enrollment through web-broker websites under certain circumstances.

For More Information

The proposed rule is available at

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