Patient navigators educate and assist United States citizens in enrolling into health benefit plans stipulated in the Patient Protection and Affordable Care Act (ACA). Patient navigators are also called "insurance navigators" or "in-person assisters" who have defined roles under the ACA. Although their roles might overlap, patient navigators are not community health workers or health advocates. "Navigators" work in states with Federally-Facilitated Exchanges (FFEs) or State Partnership Exchanges.
Under the ACA, a health insurance marketplace, or exchange, is required to develop and fund a patient navigator program. The patient navigator's primary role, as defined in section 1311, is to educate the public on information about health care plans, to facilitate enrollment into health plans, and provide information for tax credits and cost-sharing reductions. The education and information provided by patient navigators must be culturally and linguistically appropriate and provided in a fair and impartial manner. Patient navigators are required to meet standards and core proficiencies established by the Secretary of Health and Human Services.
Standardization and Qualifications
Conflict-of-Interest Rules
Prior to certification and training, the Centers for Medicare and Medicaid Services (CMS) require that all navigator and non-navigator individuals or entities seeking to facilitate public enrollment in plans disclose information that may result in a conflict of interest to exchanges and consumers. This information includes: Lines of insurance that a navigator intends to sell; Existing or former employment relationships within 5 years with an issuer of health or Stop loss policy (insurance); Existing employment relationship between an individual's spouse or domestic partner and any issuer of health or stop-loss insurance; and, Existing or anticipated financial, business or contractual relationships with any issuer of health or stop-loss insurance.
If a navigator or non-navigator does have a conflict of interest while serving in their respective roles, they are to provide a plan for mitigating these conflicts. Failure to submit a mitigation plan will result in the inability to serve as a navigator and promote ACA health plan benefits.
Certification and Training Requirements
The ACA requires that all navigator and non-navigator personnel and entities be certified by the Federally-Facilitated Exchange or State Partnership Exchange through which they are funded. Certification is provided upon completion of a training program approved by the U.S. Department of Health and Human Services (HHS).
Certification Requirements
Navigators and non-navigators must first register with their exchange prior to completing a training program and qualifying for certification. Certification entails: Completing up to 30 hours of training, Passing an HHS-approved certification test, and Having the ability to provide culturally and linguistically appropriate services (CLAS standards) to individual and small business exchanges. Continuing education and refresher trainings are also required to ensure that navigators and non-navigators remain appropriately trained and comply with their recertification requirements on at least an annual basis.
Navigator and Non-navigator Training
Training programs for navigators and non-navigators must be approved by the U.S. Department of Health and Human Services (HHS). The Medicare Learning Network is the primary source of HHS-approved training materials. Other approved programs include the: Harold P. Freeman Patient Navigator Institute, Patient Navigator Training Collaborative, and Sonoma State University Patient Navigator Certificate Program.
State Exchanges may develop their own training programs, but they must also be approved by HHS. Training standards outlined by the Centers for Medicare and Medicaid Services include: Working with vulnerable and underserved populations Culturally and linguistically appropriate services (CLAS standards) Ensuring services are accessible to people with disabilities Insurance affordability programs such as Medicaid, CHIP and other public programs Eligibility and enrollment rules and process Qualified health plans Differences between health plans Privacy, security, and customer service standards Outreach and education methods and strategies