Dec 21, 2020 — Section 1311(1) (3) of the ACA requires the Silver State Health Insurance Exchange (Exchange) establish a Navigator program to:.
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 2 of 15 T ABLE OF C ONTENTS T ABLE OF C ONTENTS .. .. .. .. 2 B ACKGROUND .. .. .. .. .. 3 E XCHANGE E NROLLMEN T F ACILITATOR C ERTIFICATION .. .. . 3 E XCHANGE EEF A PPOINTMENT .. .. .. 5 E XCHANGE E NROLLMENT F ACILITATOR R ENEWAL .. .. . 6 IN – PERSON ASSISTANCE PROGRAM N AVIGATORS .. .. .. .. 7 S ILVER S TATE H EALTH I NSURANCE E XCHANGE N AVIGATORS D EFINED .. . 7 R OLES AND R ESPONSIBILITIES OF N AVIGATORS / IPAS .. .. .. 8 N AVIGATOR / IPA E NTITY C OMPENSATION .. .. . 10 N AVIGATOR / IPA P ERFORMANCE M ETRICS .. .. 10 C ONFLICTS OF I NTEREST FOR N AVIGATORS / IPAS .. .. .. 11 R EMOVING N AVIGATOR / IPA E NTITIES .. .. . 12 C ERTIFIED A PPLICATION C OUNSELORS (CAC S ) .. .. . 12 R OLES AND R ESPONSIBILITIES OF CAC S .. .. 12 C ERTIFICATION OF CAC S .. .. .. . 13 C OMPENSATION OF CAC S .. .. .. 13 C ONFLICT OF I NTEREST FOR CAC S .. .. .. . 14 E XCHANGE C ONSUMER A SSISTANCE C ENTER .. .. .. 14 P RIVACY AND S ECURITY .. .. .. 15
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 3 of 15 B ACKGROUND Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (together referred to as the Affordable Care Act or ACA) were signed by President Obama in March 2010. Section 1311(b) of the ACA requires each state to establish health insurance exchanges. Section 1311(1 ) ( 3) of the ACA requires the Silver State Heal th Insurance Exchange (Exchange) establish a Navigator program to: C onduct public education activities to raise awareness of the availability of Q ualified H ealth P lans (QHP) ; D istribute fair and impartial information concerning enrollment in QHP s, and the availability of premium tax credits and cost – sharing reductions; F acilitate enrollment in QHP s; P rovide referrals to any applicable office of health insurance consumer assistance , health insurance ombudsman or any other appropriate State agency, for any en rollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage; and P rovide information in a manner that is culturally and linguistically appropriate to the needs of the population bein g served by the Exchange. Additionally, per 45 CFR §155.225 , t he Exchange must have a C ertified A pplication C ounselo r (CAC) program to: Provide information to individuals and employees about the full range of Q H P options and insurance affordability programs for which they are eligible ; P rovid e fair, impartial, and accurate information that assists consumers with submit ting the eligibility application ; C larify the distinctions among health coverage options, including QHPs; and helping consumers make informed decisions during the health coverage selection process; 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. E XCHANGE E NROLLMENT F ACILITATOR C ERTIFICATION Per NRS 695J , individuals who enroll qualified individuals, qualified employers and their employees in a QHP in the Exchange and who do not hold a Producer license with the Nevada Division of Insurance (DO I) must hold an Exchange Enrollment Facilitator (EEF) Certification issued by the DOI. This requirement would apply to Navigators / IPAs and CACs.
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 4 of 15 I ndividuals seeking appointment with Nevada Health Link as an EEF must first complete the following: Complete fingerprinting/background check. Enroll in and successfully complete (pass at a score of 70% or greater) the EEF Pre – certification course. Currently, there is only one course available from AD Banker (online): Exchange Enrollment Facilitator Pre – certification Course . Pearson VUE . . The exams are offered in Reno and Las Vegas, NV. Apply for certification with the DOI. . . Use the Uniform Application , as the license type and insert ‘Exchange Enrollment Facilit ator’ in the space provided. Application for DOI must be completed and mailed to the Division : Carson City office: 1818 E. College Pkwy., Suite 103 Carson City, NV 89706 Phone: (775) 687 – 0700 | Fax: (775) 687 – 0787 Consumer Compliance & Licensing Fax: (775) 687 – 0797 Include with the application the certification fee in the amount of $185.00. Questions regarding DOI Licensing can be directed to the DOI (775) 687 – 0700. Receive EEF Certification from DOI. Individual must contact the Exchange and enroll into the required course for training. When the requirements are met, the individual will be appointed by the Exchange. Appointment from the Silver State Health Insurance Exchange (Exchange) must be completed within 30 days of certification issuance. The Exchange reserves the right to appoint and revoke appointment at its sole discretion. The EEFs will be required to attend annual continuing education. Continuing education will consist of topics covered in the initial training period and updates on any new or changed regulations. The EEFs must attend these courses and complete annual re – certification tests to maintain their active EEF status. Active status will be through the conclusion o f the following plan year as long as continually employed as an EEF. Training will be required in the summer/fall for continuation for the following plan year. For Plan Year 20 21 and forward, until instructed differently , EEFs will be required to complet e the online training provided by the Exchange . The list below shows the titles of the eleven Navigator / IPA modules and identifies with asterisks the five modules required for CAC training. Train ing modules for 20 21 plan year: Training Over view* Affordable Care Act Basics * Privacy, Security, and Fraud Prevention Standards* Marketplace Assister Essentials* Serving Vulnerable and Underserved Populations
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 5 of 15 Cultural Competence and Language Assistance Working with Consumers with Disabilities Customer Service Standards and Community Outreach Coverage To Care Assistance* Assister Standard Operating Procedures Nevada Health link Policies and Agreements E XCHANGE EEF A PPOINTMENT Per NRS 695J.260 , only Navigators / IPAs and CACs appointed by the Exchange can maintain an EEF Certification: An EEF has 30 days after the date on which the certificate was issued to obtain appointment with the Exchange barring any extenuating circumstances . If the Exchange terminates an EEF EEF is prohibited from engaging in the business of an EEF under his or her certificate until the EEF receives a new appointment by the Exchange. If the EEF does not obtain a new appointment by the Excha nge within 30 days after the date the appointment was terminated, the EEF The Exchange utilizes the following process to appoint EEFs: Navigators and IPAs o Only EEF certified Navigators / IPAs designated by current grant awarded Naviga tor / IPA entities can be appointed as Exchange Navigators / IPAs to allow them to maintain their EEF certification. Navigator and IPA entities will submit a list of approved Navigators and IPA to the Exchange monthly to verify continued appointment. When a Navigator is reported as no longer employed by a Navigator / IPA entity (or not reported at all on the monthly census), that Navigator / IPA may be reported to the DOI as one of the following: Un – appointed with the Exchange and the date the Navigator / IPA no longer serves as an Exchange Navigator; or Re – appointed with the Exchange as a CAC and the re – appointment date (see more on CAC appointments below). Former Navigators / IPAs and CACs must request in writing their need to remain appointed by the Exchange within 20 days after the Navigator / IPA entity/CAC organization reports them no longer employed/needed in that capacity for consideration as an Exchange designated and appointed CAC. Certified EEFs must inform the Exchange if changing employment fr om Navigator / IPA or CAC organization and or address change within 20 days of change. o The Exchange reserves the right to unappoint any EEF, Navigator / IPA , or CAC at any time for any reason.
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 6 of 15 Certified Application Counselors (CAC) o EEF certified CA Cs designated by approved CAC o rganizations can be appointed as Exchange CACs and allow them to maintain their EEF certification. CAC organizations will submit a list of EEF certified CACs to the Exchange as part of their CAC o rganization application. Th e CAC o rganization appointment is valid for one year and must be renewed annually. When a CAC is reported as no longer employed by a CAC o rganization, that CAC may be reported to the DOI as u n – appointed with the Exchange and the date the CAC no longer serves as an Exchange CAC. o EEF certified CACs designated by the Exchange can be appointed as Exchange CACs to allow them to maintain their EEF certification. Navigators / IPAs who are no longer employed by Navigator / IPA entities or CACs no longer employed with CAC o rganizations may retain their Former Navigators / IPAs and CACs must request in writing their need to remain appointed by the Exchange within 20 days after the Navigator / IPA entity/CAC o rganization reports them no longer employed/needed in that capacity for consideration as an Exchange designated and appointed CAC. Certified EEFs must inform the Exchange if changing employment from Navigator / IPA or CAC organizat ion and or address change within 20 days of change. o The Exchange reserves the right to unappoint any CAC at any time for any reason. The Exchange may report as necessary all appointments and un – appointments to the Division of Insurance. E XCHANGE E NROLLMENT F ACILITATOR R ENEWAL Per NRS 695J.140 EEFs can renew their license for an additional 3 – year period by submitting to the Insurance Commissioner an application for renewal and the following; All applicable renewal fees . Proof of the successful completion of appropriate courses of study required for renewal, as established by the Commissioner by regulation. IN – PERSON ASSISTANCE PROGRAM The Exchange has establ ished an I n P erson A ssistance (IPA) program and has a process in place to operate the program consistent with t he applicable requirements of 45 CFR 155.205(c), (d), and ( e ). CFR 45 §155.205 (c) Accessibility. Information must be provided to applicants a nd enrollees in plain language and in a manner that is accessible and timely to:
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 8 of 15 45 CFR 155.210(c)(2) states that t he Exchange will designate , as a Navigator entity , a community and consumer – focused nonprofit group and an entity from at least one of the following categories: Trade, industry and professional associations; Commercial fishing industry organizations, ranching and farming organizations; Chambers of commerce; Unions; Resource partners of the Small Business Administration; Licensed agents and brokers; or Other public or private entities or individuals that may in clude but are not limited to Native American tribes, tribal organizations, urban Indian organizations, and State or local human service agencies. The above entities will receive the Navigator designation if they successfully submit an approved Navigator g rant application in response to a Request for Application (RFA) and have employees or associated volunteers who have an EEF Certification issued by the DOI. To ensure consumers are properly protected, only individuals who have the EEF Certification (and l icensed Producers) may enroll consumers in QHPs . Pursuant to 45 CFR 155.210(d) , Navigators must not be: A health insurance issuer or issuer of stop loss insurance; A subsidiary of a health insurance issuer or issuer of stop loss insurance; An association that includes members of, or lobbies on behalf of, the insurance industry; or An entity or individual that receives any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any individuals or employees in a QHP or a non QHP. This requirement does not exclude providers from being Navigators; providers may be Navigators. However, provider organizations that are owned by an insurance issuer may not be Navigators, pursuant to 45 CFR 155.210(d)(2). R OLES AND R ESPONSIBILITIES OF N AVIGATORS Navigators will be responsible for outreach , education , and enrollment for the currently uninsured or underinsured populations and will present to those populations the options available under the ACA. This outreach and education will include information regarding the ACA as it relates to the Exchange including but not limited t o: Program Eligibility – Rules to purchase subsidized insurance through the Exchange and eligibility for Medicaid, CHIP, Medicare or other programs ; Methods of Purchase – Different means available to purchase and enroll in a QHP: Exchange web portal, Exchang e call – in center, walk – in centers, kiosks located in community service centers and state agencies, mail – in applications and fax applications; Reasons to Purchase – Education on the benefits of health insurance and what health insurance provides for individu al and employers ; Definitions of health insurance terms – For Example, aiding the consumer to understand the difference between a premium, deductible and co – insurance;
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 9 of 15 Dispute Resolution – Providing information to the consumer to find avenues to resolve disp utes with carriers, such as directing them to the DOI and G C onsumer H ealth A ssistance , and referring enrollment disputes to the Exchange ; Cultural Diversity – Providing culturally and linguistically appropriate health insurance education to Hispanics, Asians, Native Americans, those with disabilities and other groups; o Develop and maintain general knowledge about the racial, ethnic, and cultur al literacy, and other needs. o language at no cost to the consumer, including the provision of ora l interpretations of non – English languages and the translation of written documents in non – English languages when necessary to ensure meaningful access. o Provide oral and written notice to consumers with limited English proficiency informing them of their right to receive language assistance services and how to obtain them. Group Outreach Opportunities – Outreach to consumers typically in group settings, focusing on broad topics related to health insurance and coverage options ; Access to enrollment localiti es – Provide access , including access to those people with disabilities to locations or mobile computing centers that will facilitate access to the hard copies of enrol lment documents to the Exchange processing center; Answers to enrollment questions – Address questions regarding access to any of the enrollment methods and the submission of enrollment documentation to the Exchange; Explain eligibility criteria – Explain th e eligibility criteria for purchasing insurance through the Exchange, enrolling in Medicaid and other State programs designed to provide medical coverage; Provide documentation – Provide the consumer with documentation regarding the available plans, enrollment letters stating the date coverage will start, etc.; Furnish unbiased explanations of coverage provided on the web portal – The enrollment Navigators mu st not offer any opinion or editorial on the QHPs in the Exchange. Information provided by Navigators must be limited to that information available on the web portal ; Navigators must furnish a consent form for the applicant prior to obtaining an applica P ersonally I dentifiable I nformation (PII) , approved by t he Exchange which is provided on the Nevada Health Link website, consent forms if applicable ; Navigators must o btain continuing education and be certified and/or recertified on at least an annual basis.
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 10 of 15 R OLES AND R ESPONSIBILITIES OF IN – PERSON ASSISTERS I n P erson A ssisters (IPAs) have the same roles and responsibilities as Navigators . The IPA primary focus will be on consumer assistance, outrea ch , education , and enrollment of under reached populations, which include, but are not limited to : individuals and families, Hispanic /Latino , rural, the self – employed, Tribal, and millennials. N AVIGATOR / IPA E NTITY C OMPENSATION The Exchange will review competitive grant applications and award grants to qualified Navigator / IPA Entities throughout the state of Nevada. P ursuant to Section 1311(i)(6) of the AC A , Navigators cannot be paid by the ACA Establishment Grant funds awarded by the Federal Government to the State of Nevada. The Exchange will fund these grants through operational funds consisting of Exchange Fees. Navigators / may not impose any char ge on applicants for application assistance. Upon request, p otential Navigators / will submit applications requesting consideration as a Navigator / IPA . This application should : Demonstrate to the Exchange that the entity has existing relationships, or could readily establish relationships, with employers and employees, consumers (including uninsured and underinsured consumers), or self – employed individuals likely to be eligible for enrollment in a QHP ; Demonstrate willingness to m eet the standards pr escribed by the Exchange ; Show the Navigator / IPA has or will have prior to the commencement of Navigator / IPA operations employees or associated volunteers who have an EEF Certification issued by the DOI . Per NRS 695J.280: If the Navigator / IPA ceases to ha ve an EEF certified individual on staff, all Navigator / IPA operations and funding must cease; Include contract language that indicates the entity will n ot have a conflict of interest during its term as Navigator / IPA and if a conflict of interest occurs (including receipt of payment or other consideration from health insurance issuer in connection with enrollment of individuals or groups), the Navigator / IPA may be required to pay back grant funds to the Exchange; Demonstrate that the entity has processes in place that c omply with the privacy and security standard s adopted by the Exchange as required in accordance with 45 C FR RF 155.260 ; and service area and clientele will be leveraged to support the Navigator / IPA mission and show how Navigator / IPA funds will support the Navigator / IPA mission and ancillary functions of the entity. N AVIGATOR / IPA P ERFORMANCE M ETRICS The Exchange will monitor avail able enrollment and outreach metrics so the Exchange can provide reasonable future improvements to the system. Navigators / IPAs will access and complete enrollments via the Certified Enrollment Counselor (CEC) portal Enrollment trends can be analyzed to determine if certain Navigators / IPAs are steering business in a manner that is statistically significant when compared to other Navigators / IPAs .
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Navigator /IPA Program & CAC Plan Updated: December 21, 2020 Page 11 of 15 C ONFLICTS OF I NTEREST FOR N AVIGATORS / IPA S Navigators / IPAs cannot have conflicts of interest, financial or otherwise, and will need to / IPAs cannot receive any consideration, financial or otherwise, from carriers. All Navigators / IPA enti ties must submit to the Exchange a written attestation that the Navigator / IPA , and staff, conflict of interest standards during the entire period grant funds are received by the entity. Conflict of interest includes, but is not limited to, the following: Financial considerations: Entities performing the duties of Navigator / IPA shall not receive compensation from funds derived from the enrollment of individuals, families or groups in heal th insurance plans or Issuers of stop loss insurance . This includes but is not limited to: o Employees who work for subsidiaries of health insurance I ssuers or Issuer of stop loss insurance even if that subsidiary does not offer health insurance for purchas e. o Employees of hospitals that are owned in whole or in part by health insurance Issuers. o Lobbyists or employees of entities that lobby for the interests of health insurance Issuers. Nonfinancial considerations: Entities performing the duties of Navigator / IPA shall not receive gifts, rebates, vacations, prizes or any other non – financial consideration from a health insurance Issuer , employer , or a consumer for the enrollment of an individual, family or group in the Exchange. Navigators / IPAs are required to disclose the following information to the Exchange and to consumers seeking assistance: The impact of an potentially conflicted entities, including the employment of a family member by a health insurance i ssuer including agents, brokers , and producers. Existing financial , non – financial , or contractual relationships with health insurance i ssuers or i ssuers of stop loss insurance including pensions from i ssuers, investments in i ssuers and receiving funds from i ssuers for other activities (health outreach sponsored by i ssuers, Public Awareness Campaigns sponsored by i ssuers, etc.) Any lines of insurance business not covered by the restrictions on participation and prohibitions on conduct which the Navigator / IPA intends to sell while carrying out the consumer assistance functions of the Exchange. To ensure that the public is protected from possible conflicts of interest in the Exchange, the Exchange will monitor Navigator s / IPAs ba sed enrollment patterns to make sure that the entities are providing unbiased information to the consumer. If a Navigator / IPA is found to be steering consumers into a certain plan for the purpose of financial or material gain, the Exchange and/or the Neva da Division of Insurance will inform individuals of the legal and financial recourses for consumers that have been adversely affected by a Navigator / IPA with a conflict of interest. The
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