The purpose of this bulletin is to summarize the newly enacted law for navigators and nonnavigator assisters. The law establishes requirements that include prelicensing training, licensure or registration as well as regulatory oversight for navigators and nonnavigator assisters. The law amends portions of ch. 628, Wis. Stat., by amending subch. IV and creating subch. V to include references and requirements for navigators and nonnavigator assisters. The Office of the Commissioner of Insurance (Office) will be providing additional guidance through emergency and permanent regulations, outreach and training opportunities and possibly additional notices or bulletins.
A navigator can be an individual or an entity that supervises or employs an individual who performs any activities and duties related to the navigator program on behalf of the federal Exchange and who receives funding to perform such functions on behalf of the federal Exchange. An individual navigator does not include a person acting as an insurance intermediary; however, an insurance intermediary may apply to be licensed as a navigator provided the intermediary complies with federal restrictions.
In addition to federally required training and education, navigators must be licensed and complete 16 hours of prelicensing training and successfully pass a written examination. To apply for a navigator license s. 628.92, Wis. Stat., delineates minimum requirements including minimum age, state residency, completion of training and successful passage of a written examination. Additionally, pursuant to s. 628.92, Wis. Stat., in order to be licensed navigators must possess the requisite character, competency and trustworthiness. Navigators will need to submit fingerprints and complete a criminal background investigation consistent with requirements for insurance intermediaries. Fingerprinting and examination fees apply and are in addition to any fees associated with training. Additionally, navigators who are not affiliated with a navigator entity must furnish and maintain a minimum bond no less than $100,000 from an authorized insurer or provide other evidence of financial responsibility capable of protecting all persons against the wrongful acts, misrepresentations, errors or omissions, or the negligence of the navigator. The emergency rule will provide further details related to this requirement. Once licensed, navigators will need to complete at least 8 hours of approved training annually.
Entities functioning as, or intending to function as, navigators, supervising individual navigators or receiving funds to perform such activities must register with the Office. Prior to registration, the entity must demonstrate that it has policies and procedures in place to ensure that all activities are performed by properly licensed navigators, and acknowledge that the entity assumes full legal responsibility for the acts of the navigators it employs, supervises or is affiliated with that are within the scope of the license. The entity must demonstrate that it is sound, reliable and entitled to public confidence and pay applicable annual fees as well as furnish and maintain a minimum bond no less than $100,000 from an authorized insurer or provide other evidence of financial responsibility capable of protecting all persons against the wrongful acts, misrepresentations, errors or omissions, or the negligence of the navigator.
Navigator entities must identify to the Office one individual licensed navigator who is to be the responsible navigator and provide a list of all individual navigators that it employs, supervises or is affiliated with. After initial registration, navigator entities must file monthly updates with the Office of the individual navigators that it employs, supervises or is affiliated with. The navigator entity is bound by the acts of each individual navigator who has or should have been reported as working for, being supervised by or affiliated with the navigator entity.
Nonnavigator assisters are individuals who have been designated by or working on behalf of the federal Exchange. Nonnavigator assisters include in-person assisters, enrollment assisters, application assisters and certified application counselors.
Certified application counselors are required to meet the training and examination requirements established for navigators including the 16 hours of prelicensing training, successful passage of the written examination, and annual 8 hours of approved training in addition to any federal training requirements established at 45 CFR 155.225. There are fees associated with the written examination. The Office will soon be announcing the availability of training and any costs associated with the training. With similar pre-registration training requirements, certified application counselors may also choose to be licensed as individual navigators. Certified application counselors typically are employed at community health centers, hospitals or non-profit consumer organizations and may obtain some funding through Medicaid or grant programs separate from the federal Exchange.
All other nonnavigator assisters must become authorized by the federal Exchange to provide nonnavigator assistance to consumers. Entities employing one or more nonnavigator assisters must provide the Office with a list of all nonnavigator assisters that it employs, supervises or is affiliated with once the nonnavigator assisters are authorized by the federal Exchange to provide assistance. After the initial registration, the entity employing, supervising or affiliated with nonnavigator assisters must file monthly updates with the Office of the individual nonnavigator assister names. These nonnavigator assisters will need to comply with federal training requirements prior to being eligible for registration. Entities employing, supervising or affiliated with nonnavigator assisters assume legal responsibility for the acts of the nonnavigator assisters that are performed in this state and within the scope of the nonnavigator assisters' apparent authority to act on behalf of the entities.
Navigator and Nonnavigator Assister Activities:
Licensed navigators and registered nonnavigator assisters are considered to be transacting the business of insurance when functioning within the scope of their license or registration. Activities permitted and prohibited for navigators and nonnavigator assisters include the following:
- Conduct public education activities to raise awareness of available Qualified Health Plans (QHP) within the federal Exchange.
- Distribute fair and impartial information concerning enrollment in a QHP through the federal Exchange and the availability of premium tax credits and cost-sharing reductions that may be available.
- Explain that consumers may purchase health plans through the federal Exchange or off the Exchange.
- Make consumers aware that plans are available in the outside market and that they may want to talk with a licensed health insurance agent about health insurance options.
- Facilitate enrollment in a QHP through the federal Exchange. Outline information that a consumer will need to have available when applying for coverage through the federal Exchange. Provide information that will allow the consumer to access the federal Exchange either at their home or a computer terminal provided by the navigator.
- Explain to the consumer the following information: potential eligibility for public/governmental programs, and how the federal health insurance premium tax credit and cost-sharing reductions work and potential risks, if any, for use of the federal health insurance premium tax credit.
- Describe the features and benefits of health coverage in general terms, including cost-sharing mechanisms like deductibles, co-pays or co-insurance and how these work or affect the consumer.
- Describe what a summary of benefits document is and where to locate a summary of benefits and relevant cost-sharing provisions within the information from QHPs.
- Explain how to find information about provider networks.
- Describe the different metal tiers (i.e., bronze, silver, gold and platinum) and how the benefits may change at different metal tiers based upon the consumer's income.
- Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the federal Exchange.
- Provide a referral for an individual to an appropriate state or federal agency who has a grievance, complaint or question regarding their health plan, coverage, or a determination under such plan or coverage.
- Receive compensation from an insurer, stop-loss insurance or a third-party administrator.
- Receive compensation that is dependent upon, in whole or in part, whether an individual enrolls in or renews coverage in a health benefit plan.
- Provide any information related to enrollment or other insurance products not offered in the federal Exchange.
- Make or cause to be made false or misleading statements.
- Provide advice comparing health benefit plans that may be better or worse for the consumer or employer.
- Recommend a particular health benefit plan or insurer or advise consumers or employers regarding a particular insurer or health benefit plan selection.
- Engage in any fraudulent, deceptive or dishonest acts or unfair methods of competition.
- Receive consideration directly or indirectly from any health insurance issuer in connection with the enrollment of individuals or employees into a QHP.
Any individual or entity acting in violation of the newly enacted law provisions may be subject to an administrative action including restitution and limitation or revocation of licensure or registration.
Governmental entities or any persons acting on behalf of a governmental entity are exempt from these requirements.
This bulletin applies to all insurers offering health insurance plans, intermediaries and persons or organizations interested in being licensed as a navigator or registering as nonnavigator assisters. Any questions concerning this bulletin should be directed to OCIAgentlicensing@wisconsin.gov.