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Consumer Assistance and the DC Health Benefit Exchange

Navigator Program

To meet the needs of the large number of consumers who will become newly eligible for health insurance beginning in 2014, the Affordable Care Act (ACA) charges health benefit exchanges with establishing a network of Navigators to assist consumers with:

  1. Learning about and enroll in Qualified Health Plans (QHPs);
  2. Obtaining federal tax credits and cost-sharing subsidies; and
  3. Enrolling in affordability programs such as Medicaid.

Section 1311(i) of the ACA requires Exchanges to establish a Navigator program and award grants to entities to perform the following functions:

  • Conduct public education activities to raise awareness of the availability of QHPs;
  • Distribute fair and impartial information concerning enrollment in QHPs and the availability of premium tax credits and cost-sharing reductions in accordance with federal laws;
  • Facilitate enrollment in QHPs;
  • Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman or any other appropriate state agency or agencies, of any enrollees with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such a plan or coverage; and
  • Provide information in a manner that is culturally and linguistically appropriate to meet the needs of the population being served by the Exchange.

In-Person Assisters Program

In-Person Assisters (IPAs) will provide the same services as Navigators, but the source of funding for the programs is different.  Navigators must be funded by state exchanges and federal grant dollars cannot be utilized to pay for the program. IPA funding will be provided through a federal grant program for the first two years of Exchange open enrollment.

In order to fully leverage available federal funding the District’s Exchange intends to have a large IPA program and a much smaller Navigator program in the initial years of the program.

Certified Application Counselors

In addition to the Navigator and IPA programs, the federal government has proposed a new Certified Application Counselor program as a means to leverage the experience of state Medicaid programs in leveraging unpaid application assistance at provider and other community locations. This program would:

  • Provide information about insurance affordability programs and coverage options;
  • Assist individuals and employees to apply for coverage in a QHP through the Exchange and for insurance affordability programs; and
  • Help to facilitate enrollment of eligible individuals in QHPs and insurance affordability programs.

DC HBX Authority Actions

Recommendations on the design, composition, and funding of the above consumer assistance programs will be led by the Consumer Assistance and Outreach Advisory Committee. This committee is comprised of consumer advocates, agents & brokers, insurance carriers.

In addition to the Advisory Committee, the DC Exchange Executive Director has established three working groups to address specific policy areas related to consumer assistance:

  • Assister Grant Estimates working group
    • This working group will recommend to the DC HBX Executive Board the necessary level of federal funding to support the IPA grant program.
  • Broker information technology (IT) working group
    • This working group will develop business requirements for broker interactions and broker functionality for on-line enrollment and plan selection. The group will also recommend standards for broker selection and participation.
  • Assister IT working group
    • This working group will develop business requirements for assister interactions and functionality for on-line enrollment and plan-selection.