M ARYLAND H EALTH B ENEFIT E XCHANGE Navigator Program Advisory - - PowerPoint PPT Presentation

Navigator Program Advisory Committee Second Meeting

July 30, 2012 11:00 am - 2:00pm Maryland Department of Transportation

MARYLAND HEALTH BENEFIT EXCHANGE

Definitions Overview

• 2 -

Individual Exchange Navigator Entity Local DSSs, LHDs, and other Non-Navigator Customer Assistance Entities

• Authorized by the Individual Exchange
• Engages Individual Exchange

Navigators to carry out all or some Navigator functions

• May not be a health insurance issuer
• r receive compensation for the sale of

health plans1

• May provide customer assistance

through current funding streams

• May not assist individuals with the

sale, solicitation, or negotiation of plans in or outside the Exchange

1 Navigator Entities may receive compensation from issuers for services unrelated to the sale of health plans

Health Insurance Issuer

• Authorized by the Individual Exchange
• Engages Individual Exchange

Navigators to carry out all or some Navigator functions

Definitions Overview

• 3 -

Individual Exchange Navigator SHOP Exchange Navigator Health Insurance Producer

• Employed by Individual Exchange Navigator Entity
• Certified by Health Insurance Commissioner
• Compensated by the Exchange
• May only provide assistance regarding health and dental

plans in the Individual Exchange

• May not be an insurance producer
• Employed by unknown
• Licensed by Health Insurance Commissioner
• Compensated by the Exchange
• May only provide assistance regarding health and dental

plans in the SHOP Exchange

• May not be an insurance producer
• Employed by Health Insurance Issuer
• Licensed by Health Insurance Commissioner
• Compensated by Health Insurance Issuer
• May provide assistance regarding health and dental plans in
• r out of the Individual and SHOP Exchange, provided

additional training and licensure by the Commissioner

Definitions Overview

• 4 -

Assister Consumer Rep Employee of a Navigator Entity or outside entity; may not assist with the sale, solicitation, or negotiation of plans in or outside the Exchange Uncompensated individual; may not assist with the sale, solicitation, or negotiation of plans in or outside the Exchange

Definitions Overview

• 5 -

Assister Consumer Representa- tive Individual Exchange Navigator Insurance Producer SHOP Exchange Navigator Who can provide customer assistance services in the Exchange? Who can be compensated for their services? Who can be compensated by the Exchange? Who can be compensated by Issuers? Who can assist with the sale, solicitation, or negotiation of plans in the Exchange? Who can provide customer assistance services outside the Exchange? Who can assist with the sale, solicitation, or negotiation of plans

• utside the Exchange?

Operational Models Overview and Request for Information Discussion

Draft Regulations Discussion

• 8 -

Regulation Promulgation Process

• 9 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language Proposed Regulation Recommendation

Eligibility Requirements To qualify for an Individual Exchange Navigator Certification, an applicant shall:

• Be of good character
• Be at least 18 yrs old
• Complete and comply with any
• ngoing requirements of the training

program and applicable requirements

• f DHMH

An Individual Exchange Navigator: shall be employed or engaged by an Individual Exchange navigator entity To be eligible to apply for initial Individual Exchange Navigator Certification, an applicant must:

• Be of good character
• Be at least 18 yrs old
• Complete and comply with any
• ngoing requirements of the training

program and applicable requirements of DHMH

• Be employed or engaged by a

Navigator Entity

• 10 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language (Paraphrased) Proposed Regulation Recommendation

Eligibility Requirements Under the authorization program/process, the SHOP/Individual Exchange shall provide an authorization to sell qualified plans to:

• a licensed producer
• who registers and applies for an authorization from

the SHOP/Individual Exchange,

• completes and complies with any ongoing

requirements of the SHOP/Individual Exchange Insurance Producer Authorization training program,

• (for SHOP) and in providing assistance to a small

employer, informs the small employer of all qualified health plans available in the SHOP Exchange

• (for Individual Exchange) refer individual seeking

insurance who may qualify for Medicaid or MCHP to the Navigator Program for the Individual Exchange An insurance producer may not be compensated by the SHOP or Individual Exchange for the sale of a qualified plan and shall be compensated directly by a carrier. To be eligible to apply for initial Insurance Producer Authorization, an applicant must:

• Be a licensed insurance

producer in good standing under the Insurance Article of the state

• 11 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language Proposed Regulation Recommendation

Application Procedures N/A In order to obtain an Individual Exchange Navigator Certification, the applicant shall submit:

• An application on the form provided by the Exchange
• Pay to the Exchange an application fee of $75
• Submit evidence that the applicant has successfully

completed the Individual Exchange Navigator Certification training, including, as appropriate, the annual Exchange Consumer Assistance Training

• Submit evidence of employment or engagement by a

Navigator Entity The Exchange may not consider an application as complete until it has received all required materials. If the application is not completed with all required materials within 45 days after the Exchange receives the signed application form, the Exchange may deny the application.

• 12 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language Proposed Regulation Recommendation

Application Procedures N/A In order to obtain an Insurance Producer Authorization, the applicant shall submit to the Exchange:

• An application on the form provided by the Exchange
• Pay to the Exchange the application fee of $75
• Submit evidence that the applicant is a licensed insurance

producer in good standing under the Insurance Article of the state

• Submit evidence that the applicant has successfully

completed, as appropriate, the SHOP Exchange Insurance Producer Authorization training or the Individual Exchange Producer Authorization training, including the annual Exchange Consumer Assistance Training The Exchange may not consider an application as complete until it has received all required materials. If the application is not completed with all required materials within 45 days after the Exchange receives the signed application form, the Exchange may deny the application.

• 13 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language (Paraphrased) Proposed Regulation Recommendation

Training Standards: Scope, Conduct, and Type of Training The training program shall:

• Provide Individual Exchange Navigators

with the full range of skills, knowledge, and expertise necessary to meet the consumer assistance , eligibility, enrollment, renewal, and disenrollment needs of individuals who are eligible for Medicaid or CHIP or seeking qualified plans in the Individual Exchange;

• Enable the Navigator Program for the

Individual Exchange to provide robust protection of consumers and adherence to high quality standards; and

• Enable the Individual Exchange to

ensure that, with respect to Individual Exchange Navigators who offer any form of assistance to individuals regarding Medicaid or CHIP, the Individual Exchange Navigator Certification program shall comply with all DHMH requirements Scope of the Training: The training shall include, as appropriate to the Individual Exchange Navigator functions:

• Consumer assistance and

protection expertise

• Quality assurance standards

Conduct: The exchange shall conduct the training in several, geographically diverse locations across the state. The training must be conducted in facilities equipped to provide access in accordance with the American with Disabilities Act (ADA) of 1990. Type: The training shall include a final examination. The examination will be multiple choice.

• 14 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language (Paraphrased) Proposed Regulation Recommendation

Training Standards: Frequency and Assessment of Training The training program shall:

• Provide Individual Exchange Navigators

with the full range of skills, knowledge, and expertise necessary to meet the consumer assistance , eligibility, enrollment, renewal, and disenrollment needs of individuals who are eligible for Medicaid or CHIP or seeking qualified plans in the Individual Exchange;

• Enable the Navigator Program for the

Individual Exchange to provide robust protection of consumers and adherence to high quality standards; and

• Enable the Individual Exchange to

ensure that, with respect to Individual Exchange Navigators who offer any form of assistance to individuals regarding Medicaid or CHIP, the Individual Exchange Navigator Certification program shall comply with all DHMH requirements Frequency: The Exchange shall conduct trainings:

• 1. At least monthly during all other

months except those listed in (2)

• 2. At least weekly for the three

months preceding the Open Enrollment Period The Exchange shall schedule an annual Exchange Consumer Assistance training and shall notify Individual Exchange Navigators of the annual training. Individual Exchange Navigators shall complete the annual training, including any examination, within 60 days before the Open Enrollment Period. . Assessment: The Exchange shall review the content of the training program at least every two years.

• 15 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language (Paraphrased) Proposed Regulation Recommendation

Training The SHOP/Individual Exchange shall develop, implement, and as appropriate, update a training program for insurance producers who seek authorization to sell qualified plans in the SHOP/Individual

• Exchange. The training program shall:
• Impart the skills and expertise necessary

to perform functions specific to the SHOP/Individual Exchange

• (for Individual Exchange) enable the

Exchange to provide robust protection of consumers and adherence to high quality assurance standards

• (for Individual Exchange) be approved by

the Commissioner An applicant for the SHOP Exchange Insurance Producer Authorization shall complete the Exchange-approved SHOP Insurance Producer Authorization training. An applicant for the Individual Exchange Insurance Producer Authorization shall complete the Commissioner-approved Individual Exchange Insurance Producer Authorization training.

• 16 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language (Paraphrased) Proposed Regulation Recommendation

Training The SHOP/Individual Exchange shall develop, implement, and as appropriate, update a training program for insurance producers who seek authorization to sell qualified plans in the SHOP/Individual

• Exchange. The training program shall:
• Impart the skills and expertise necessary

to perform functions specific to the SHOP/Individual Exchange

• (for Individual Exchange) enable the

Exchange to provide robust protection of consumers and adherence to high quality assurance standards

• (for Individual Exchange) be approved by

the Commissioner The Exchange shall schedule an annual Exchange Consumer Assistance training and shall notify Authorized Insurance Producers of the annual training. Authorized Insurance Producers shall complete the annual training, including any examination, within 60 days before the Open Enrollment Period. Assessment: The Exchange shall review the content of the training program at least every two years.

• 17 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language

Proposed Regulation Recommendation Renewal A certification shall expire 2 years after the date it is issued unless it is renewed. An Individual Exchange Navigator Certification expires two years after the date it is issued unless it is renewed. At least 60 days before the expiration of an Individual Exchange Navigator Certification, the Exchange shall notify the Individual Exchange Navigator, either directly or by contacting the Navigator Entity by which the Individual Exchange Navigator is employed or engaged, of the expiration of an Individual Exchange Navigator

• Certification. The notification shall include:
• A renewal application
• The date by which the Exchange must receive the

renewal application for the renewal to be issued before the certification expires

• The amount of the renewal fee

A holder of an Individual Exchange Navigator Certification must submit, either by mail or electronically, an application for renewal on the form provided by the Exchange and a renewal fee of $75.

• 18 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language

Proposed Regulation Recommendation Renewal A certification shall expire 2 years after the date it is issued unless it is renewed. Eligibility for renewal: The holder of an Individual Exchange Navigator Certification may renew it for an additional two-year term if the holder:

• Is otherwise entitled to receive Individual Exchange

Navigator Certification, in accordance with the eligibility requirements for Individual Exchange Navigator Certification

• Files a renewal application on the form provided by

the Exchange before expiration of the certification

• Pays to the Exchange a renewal fee of $75
• Completes the annual Exchange Consumer

Assistance Training and any continuing education requirements under this section Continuing Education: A holder of an Individual Exchange Navigator Certification must complete at least 16 hours of Exchange-approved continuing education per renewal term.

• 19 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language

Proposed Regulation Recommendation Renewal A certification shall expire 2 years after the date it is issued unless it is renewed. Timely Receipt of Application: Before the date of expiration of the certification, a holder

• f the Individual Exchange Navigator Certification shall

complete and return to the Exchange a renewal application and a renewal fee according to the renewal

• instructions. A holder of an expired Individual Exchange

Navigator Certification may not provide any consumer assistance services that must be provided by Individual Exchange Navigators as described under the Maryland Health Benefit Exchange Act of 2012 (no sale, solicitation, or negotiation of qualified plans, including the application of tax subsidies to selected qualified plans, or examining or offering to examine qualified plans for the purposes of giving or offering to give advice about the qualified plans).

• 20 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language

Proposed Regulation Recommendation Renewal An authorization shall expire 2 years after the date it is issued unless it is renewed. An Insurance Producer Authorization expires two years after the date it is issued unless it is renewed. At least 60 days before the expiration of an Insurance Producer Authorization, the Exchange shall notify the holder of Insurance Producer Authorization of the expiration of an authorization. The notification shall include:

• A renewal application
• The date by which the Exchange must receive the

renewal application for the renewal to be issued before the authorization expires

• The amount of the renewal fee

A holder of an Insurance Producer Authorization must submit, either by mail or electronically, an application for renewal on the form provided by the Exchange and a renewal fee of $75.

• 21 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language

Proposed Regulation Recommendation Renewal An authorization shall expire 2 years after the date it is issued unless it is renewed. Eligibility for renewal: The holder of an Insurance Producer Authorization may renew it for an additional two-year term if the holder:

• Is otherwise entitled to receive Insurance Producer

Authorization, in accordance with the eligibility requirements for Insurance Producer Authorization

• Files a renewal application on the form provided by

the Exchange before expiration of the authorization

• Pays to the Exchange a renewal fee of $75
• Completes the annual Exchange Consumer

Assistance Training and any continuing education requirements under this section Continuing Education: A holder of an Insurance Producer Authorization must successfully complete at least 8 hours of Exchange- approved continuing education per renewal term

• 22 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language

Proposed Regulation Recommendation Renewal An authorization shall expire 2 years after the date it is issued unless it is renewed. Timely Receipt of Application: Before the date of expiration of the Insurance Producer Authorization, a holder of the Insurance Producer Authorization shall complete and return to the Exchange a renewal application and a renewal fee according to the renewal instructions. A holder of an expired Insurance Producer Authorization may not sell qualified plans in the SHOP Exchange or Individual Exchange.

• 23 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language Proposed Regulation Recommendation

Reinstatement N/A For up to 1 year after the expiration date, an individual whose Individual Exchange Navigator Certification has expired may apply to reinstate the expired Individual Exchange Navigator Certification by:

• Filing a reinstatement application, either by mail or

electronically, on the form approved by the Exchange

• Paying to the Exchange the renewal fee of $75
• Paying to the Exchange a reinstatement fee of $100
• Submitting evidence that the individual has successfully

completed the annual Exchange Consumer Assistance Training and the continuing education requirements under this section An individual who does not file for reinstatement within 1 year after the expiration date of the Individual Exchange Navigator Certification shall re-apply for an Individual Exchange Navigator Certification under the application procedures for an initial Individual Exchange Navigator Certification.

• 24 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language Proposed Regulation Recommendation

Reinstatement N/A For up to 1 year after the expiration date, a licensed insurance producer whose Insurance Producer Authorization has expired may apply to reinstate the expired Authorization by:

• Filing a reinstatement application, either by mail or

electronically, on the form approved by the Exchange

• Paying to the Exchange the renewal fee of $75
• Paying to the Exchange a reinstatement fee of $100
• Submitting evidence that the licensed insurance producer

has successfully completed the annual Exchange Consumer Assistance Training and the continuing education requirements under this section A licensed insurance producer who does not file for reinstatement within 1 year after the expiration date of the Insurance Producer Authorization shall re-apply for an Insurance Producer Authorization under the application procedures for an initial Insurance Producer Authorization.

• 25 -

Individual Exchange Navigator Certification

Topic MHBE Act

• f 2012

Language Proposed Regulation Recommendation

Reactivation N/A Inactive Certifications: In addition to the causes for suspension, the Commissioner may inactivate an individual’s Individual Exchange Navigator Certification when the individual fails to complete the annual Exchange Consumer Assistance Training. The Commissioner shall inactivate an individual’s Individual Exchange Navigator Certification whenever the individual is not employed or engaged by a Navigator Entity. Reactivation: A holder of inactive Individual Exchange Navigator Certification shall apply for reactivation of the certification by:

• Filing a reactivation application with the Exchange on a form

approved by the Exchange;

• Submitting evidence that the individual has successfully

completed the annual Exchange Consumer Assistance Training and the continuing education requirements under this section; and

• Submitting evidence, when necessary, of employment or

engagement by a Navigator Entity

• 26 -

Individual Exchange Navigator Certification

Topic MHBE Act of 2012 Language Proposed Regulation Recommendation

Revocation Causes for suspension or revocation under the Maryland Health Benefit Exchange Act of 2012 are when a Certified Individual Exchange Navigator or an Authorized Insurance Producer:

• Has willfully violated the Act or any regulation adopted under

the Act

• Has intentionally misrepresented or concealed a material fact

in the application for certification/authorization

• Has obtained the certification/authorization by

misrepresentation, concealment, or other fraud

• Has engaged in the fraudulent or dishonest practices in

conducting activities under the certification/authorization

• Has misappropriated, converted, or unlawfully withheld money

in conducting activities under the certification/authorization

• Has failed am examination required by the Act
• Has forged another’s name on an application for a qualified

plan or on any other document in conducting activities under the certification/authorization

• Has otherwise shown a lack of trustworthiness or competence

to the Act as an Certified Individual Exchange Navigator/Authorized Insurance Producer

• Has willfully failed to comply with or violated a proper order or

subpoena of the Commissioner The Commissioner may suspend or revoke an Individual Exchange Navigator Certification for the reasons listed under the Maryland Health Benefit Exchange Act

• f 2012.

• 27 -

Insurance Producer Authorization

Topic MHBE Act of 2012 Language Proposed Regulation Recommendation

Revocation Causes for suspension or revocation under the Maryland Health Benefit Exchange Act of 2012 are when a Certified Individual Exchange Navigator or an Authorized Insurance Producer:

• Has willfully violated the Act or any regulation adopted under

the Act

• Has intentionally misrepresented or concealed a material fact

in the application for certification/authorization

• Has obtained the certification/authorization by

misrepresentation, concealment, or other fraud

• Has engaged in the fraudulent or dishonest practices in

conducting activities under the certification/authorization

• Has misappropriated, converted, or unlawfully withheld money

in conducting activities under the certification/authorization

• Has failed am examination required by the Act
• Has forged another’s name on an application for a qualified

plan or on any other document in conducting activities under the certification/authorization

• Has otherwise shown a lack of trustworthiness or competence

to the Act as an Certified Individual Exchange Navigator/Authorized Insurance Producer

• Has willfully failed to comply with or violated a proper order or

subpoena of the Commissioner The Exchange may suspend or revoke an Insurance Producer Authorization for the reasons listed under the Maryland Health Benefit Exchange Act

• f 2012.

Questions & Comments