In-Person Assistance in the Health Insurance Marketplaces

Background

Starting October 1, 2013, consumers in all states were able to access affordable health insurance options through the Health Insurance Marketplace. Some states set up a State-based Marketplace and the remaining states opted for the Federally-facilitated Marketplace.

No matter what state they live in, consumers can receive help as they apply for and choose new insurance through the Marketplace.

Open Enrollment for the 2021 plan year begins November 1, 2020 and individuals will again be able to provide assistance to consumers in a number of different ways: by becoming Navigators or certified application counselors. In addition, agents and brokers will still be able to help consumers enroll in health insurance through the Marketplace.

Key Resources

Navigators

Navigators play a vital role in helping consumers prepare applications to establish eligibility and enroll in coverage through the Marketplaces and potentially qualify for an insurance affordability programs. They also provide outreach and education to raise awareness about the Marketplace, and refer consumers to health insurance ombudsman and consumer assistance programs when necessary. Navigators are funded through federal grant funds and must complete comprehensive federal Navigator training, criminal background checks, and state training and registration (when applicable), prior to assisting consumers.

On August 28, 2020, the Centers for Medicare & Medicaid Services (CMS) awarded $10 million in Navigator grant awards to 30 organizations who will serve as Navigators in Federally-facilitated Marketplace states. These awards will support the work of organizations that offer assistance to consumers navigating, shopping for, and enrolling in health insurance coverage for plan year 2021.

A list of 2020 Navigator grant recipients can be found here: 2020 Navigator Grant Recipients (PDF). The 2020 Navigator awards are for the second 12-month budget period of a 24-month period of performance, which runs through August 29, 2021. Entities and individuals cannot serve as Navigators in the Federally-facilitated Marketplaces without receiving federal grant funding from CMS to perform Navigator duties.

On June 4, 2021, CMS published its sixth Notice of Funding Opportunity (NOFO), making $80 million available in grants to Navigators in the Federally-facilitated Marketplaces for the 2022 plan year. The complete NOFO application package can be viewed on grants.gov by searching for CFDA # 93.332. The NOFO provides detailed information on applicant eligibility requirements, required Navigator duties, and instructions for application preparation and submission. Applications must be submitted electronically and received through grants.gov by 3:00 pm Eastern Daylight Time on July 6, 2021.

Additional Resources for Navigator Applicants

Archived Resources for Navigator Grantees

Navigator Grant Recipients

Certified Application Counselors (CACs)

Certified application counselor designated organizations (CDOs) are a vital component of the assister community. In the Federally-facilitated Marketplaces (FFMs), CDOs oversee certified application counselors (CACs) who are trained and able to help consumers seeking health insurance coverage options through an FFM. Organizations that wish to become CDOs designated by the Centers for Medicare & Medicaid Services (CMS) to serve in an FFM must submit an online application and enter into an agreement with CMS. These groups might include community health centers or other health care providers, hospitals, or social service agencies.

Additional Resources for CACs

Enrollment Assistance Program (EAP)

The Enrollment Assistance Program contracts established temporary storefronts and labor forces in CMS identified population centers to help enroll consumers during the beginning years of the Health Insurance Exchanges. The contracts were intended to supplement the year round in-person enrollment support services of Navigators, Certified Application Counselors, and local insurance agents and brokers. CMS awarded base plus four option year contracts to Cognosante and CSRA on August 29, 2013.  CSRA’s final exercised option year contract was for $12,780,966 and Cognosante’s was $9,632,563. The contract option year expired on August 29, 2017, for Cognosante’s contract and September 30, 2017 for CSRA’s contract.

The Enrollment Assistance Program engaged with more than 19,300 consumers and assisted 14,500 enrollments during the 2017 Open Enrollment period.  In addition, they helped with approximately 11,000 account creations and 2,500 Medicaid referrals.

Agents and Brokers

Agents and brokers also play a key role in the Health Insurance Marketplace. To the extent permitted by states, agents and brokers play an important role in educating consumers about Marketplaces and insurance affordability programs, and helping consumers receive eligibility determinations, apply for premium tax credits and cost-sharing reductions, compare plans, and enroll in coverage. In particular, agents and brokers play a critical role in helping qualified employers and employees enroll in coverage through the Small Business Health Options Program (SHOP). Consumers may want to obtain professional advice from agents and brokers when applying for and selecting a qualified health plan. Below is a link to the CMS webpage for agents and brokers choosing to participate in Federally-facilitated Marketplaces.

Additional Resources for Agents and Brokers

 

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