This Robert Wood Johnson Foundation-Health Affairs policy brief describes the important continuing role of navigators and in-person assisters (IPAs) during the upcoming third open enrollment period under the Affordable Care Act (ACA), beginning November 1, 2015. Given that millions of uninsured Americans remain eligible for health insurance through the health insurance marketplaces, proactive efforts to reach out and enroll the remaining uninsured are vital to the ACA’s success. During the first open enrollment period, navigators, IPAs, and certified application counselors helped more than 10.6 million people apply for and obtain financial assistance, enroll in Medicaid or a Children’s Health Insurance Program, compare private health plan options, and provide outreach and education. In-person assisters reported spending an average of one to two hours with each potential applicant. Since the first open enrollment period, navigator and IPA roles have evolved to include re-enrollment efforts, educating consumers on how to use their insurance, and addressing post-enrollment questions and problems. This policy brief updates an earlier policy brief published in 2013.
Navigators are individuals or community-based organizations funded by federal or state funds to help guide consumers in the marketplaces, assist with subsidy applications, and enroll in a health plan. The U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS) has provided federal funding for navigators for the federally facilitated marketplace. While the ACA prohibits states from using ACA state marketplace establishment funds to fund navigators, it also requires state-based marketplaces to establish and fund navigators as part of their marketplace operations.
For the third open enrollment period, after decreasing its federally-funded navigator grants from $67 million in 2013 to $60 million last year, CMS has restored the original $67 million budget for this year. In addition, rather than requiring navigators to re-apply each year for one-year grants, CMS is now providing three-year grants beginning in 2015, to be funded in twelve-month increments. CMS announced the recipients of these navigator funds in early September, which include 100 organizations in the 34 states that operate either federally facilitated marketplaces or state partnership marketplaces.
As the operations of both the federally facilitated and state-based marketplaces settles into more routine annual cycles of enrollment and re-enrollment, there remain questions about how much funding and support for navigators and assisters there will be in the future. The policy brief also discusses the role of insurance brokers, who operated in many states even prior to the ACA. Brokers are governed by state insurance laws and have played significant roles in enrolling individuals, families, and small businesses for health insurance through the marketplaces. Concerns remain about conflicts of interest when brokers are paid by the health insurance plans and whether brokers have sufficient training, knowledge, and capacity to reach all the remaining uninsured populations.
IPAs were not included in the ACA legislation but were established by CMS through its regulatory authority. CMS required all IPAs to meet the same training, certification, and conflict-of-interest standards required for navigators and allowed states that operated their own state health insurance marketplaces to fund IPAs from their marketplace establishment grants from CMS. This allowed additional federal funding for these important roles.
A third category of enrollment assisters, certified application counselors, help people fill out applications and compare health plans but perform more limited functions than navigators and IPAs. Like navigators, certified application counselors cannot be funded using state marketplace establishment grants and have to be funded from external grants or other marketplace revenue. Application counselors exist in all states and are similar to counselors who have provided application assistance with Medicaid in some states.
Ignatius Bau 