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What is a health benefits navigator?

Written by: Elizabeth Walker
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Published on January 13, 2023.

If your employer offers a health reimbursement arrangement (HRA), you will likely be shopping for an individual health insurance plan on the federal or state exchanges, also known as the health insurance marketplaces.

If you’ve never chosen your own health insurance plan before, there are several ways to get help, including health benefits navigators. In this article, we’ll go over what a health benefits navigator is, how they’re different from agents and brokers, and how they can help you find a health insurance plan for you and your family.

Learn more about health reimbursement arrangements in our guide

What is a health benefits navigator?

A health benefits navigator is an individual or entity trained to help consumers and small businesses shop for health coverage options through the Marketplace and fill out their eligibility and enrollment forms during the application process.

By law, navigators must be unbiased when offering their services, which are free to all consumers as a federal benefit. The Affordable Care Act (ACA) requires state exchanges to establish a “navigator” program to help eligible individuals purchase health insurance coverage through a Marketplace, learn about their new coverage options, and enroll in a plan.

Navigators have compliance requirements that they must complete before assisting consumers. Requirements include federal navigator training, criminal background checks, and state training and registration (if applicable).

State-run exchanges have their own certification and training for navigators, while the Centers for Medicare and Medicaid Services (CMS) conducts the certification and training for navigators that work with the federal Marketplace.

Annual training courses can take between five to 20 hours, not including the time spent on each course's certification exams. The government provides annual recertification programs and other training to keep up to date on current health insurance-related issues.

Lastly, navigators can’t be paid a commission from health insurance companies. Instead, they are paid by state and federal programs with grants. For instance, CMS recently gave $80 million in funding1 for 60 navigator programs serving consumers in 30 states.

What does a health benefits navigator do?

Health benefits navigators have a wide range of duties, including:

  1. Conducting public education about the availability of qualified health plans
  2. Distributing fair, impartial information about enrollment in qualified plans and eligibility for premium tax credits, Medicaid, CHIP, and other cost-sharing assistance in the exchange
  3. Facilitating enrollment and certain post-enrollment duties in qualified health plans
  4. Referring people who need help resolving a problem with their health plan or with their premium assistance to a consumer assistance or ombudsman program or another appropriate agency that can help with a grievance or appeal
  5. Providing information in a culturally and linguistically appropriate manner to the population being served by an exchange

Additional benefits2 that navigators now provide include targeted health insurance assistance in vulnerable communities and post-enrollment services. These services include help with appeals, assistance with premium payment issues, information about how to use your health coverage, and help understanding how subsidy reconciliation works.

Who can become a benefits navigator?

The law lists many different kinds of entities that could become navigators, including:

  • Community- and consumer-focused nonprofits
  • Trade, industry, and professional associations
  • Commercial fishing, ranching, and farming organizations
  • Chambers of commerce
  • Unions
  • Small Business Administration resource partners
  • Licensed insurance agents and brokers
    • If a licensed health insurance agent or broker serves as a navigator, this disqualifies them from acting as a traditional producer (selling policies on or off the exchanges and receiving commissions)

To be eligible to receive navigator grants, an entity must meet the following criteria:

  • Establish relationships
    • The entity must already have relationships or be readily able to establish relationships with the employer or employees, consumers (including uninsured and underinsured consumers), or the self-employed individuals they’re serving
  • Capable of performing duties
    • The entity must be capable of performing the duties of a navigator, described above
  • Meet the following standards established by the Secretary of HHS
    • Navigators are qualified and licensed (if appropriate)
    • Navigators avoid conflicts of interest
    • Navigators are not health insurers
    • Navigators don’t receive direct or indirect compensation from an insurer in connection with enrollment of any exchange-eligible individuals or employers in a qualified health plan
  • Deliver fair and impartial information
    • The HHS Secretary and states will develop standards to ensure that navigators deliver fair, impartial, and accurate information

How are health benefits navigators different from agents and brokers?

While benefit navigators, agents, and brokers offer similar services, a few differences make navigators stand out. First and foremost, navigators are there to help you solely with shopping for a plan on the government exchanges—nowhere else. On the other hand, agents and brokers can help determine coverage for people in off-exchange plans.

Agents and brokers can also make personal recommendations and advocate for you if you run into trouble with an insurance company. Navigators can’t make these kinds of personal recommendations and will need to refer you to another appropriate agency if you have a problem with an insurance company.

The following chart helps break down the major similarities and differences between health benefits navigators and health insurance agents and brokers:

 

Health benefits navigators

Health insurance agents/brokers

Are their services free?

Yes

Yes

Can they help you apply for a premium tax credit?

Yes

Yes

Can they help you understand plans on government exchanges?

Yes

Yes

Can they help you understand plans that aren’t on government exchanges, like alternative coverage options?

No

Yes

Can they offer recommendations based on your personal needs?

No

Yes

Can they act as an advocate if you have problems with an insurance company?

No

Yes

Are they required to be licensed in every state?

No

Yes

How can I find a health benefits navigator?

If you have a healthcare benefit that requires you to choose your own policy on the marketplace, the type of exchange you use will determine how you can find a navigator.

If you have a state-based exchange, you’ll be directed to your state’s website to find a navigator in your area. If your state uses the federal Marketplace on HealthCare.gov, enter your zip code into the “find local help” tool to see the navigators in your area that can help you enroll in a policy.

Remember to filter for “assisters” to see only navigators and enrollment counselors in your area. Otherwise, your results will include brokers and agents as well.

Are there other ways I can get help shopping for health insurance?

Shopping for health insurance on your own can be an arduous process. Luckily, if your employer administers your healthcare benefits through PeopleKeep, you can shop for a policy right from your account dashboard with the help of our partner, Stride Health.

You can also use tools such as the KFF premium calculator3 to find out if you’re eligible to receive any subsidies or premium tax credits to help you lower the cost of your health insurance premium.

And with your HRA through PeopleKeep, your premiums and other qualified medical expenses will be reimbursed each month with the allowance provided by your employer.

Conclusion

Whether it’s your first time shopping for your own health insurance plan or you’d just like a little extra help, health benefits navigators are a great community resource for consumers exploring the federal and state exchanges for a health insurance plan.

With assistance from benefits programs like navigators, you can review your current coverage and determine where to make changes to fit your healthcare needs and budget. Their free services help provide health coverage to millions, taking the stress and confusion out of navigating the world of health insurance on your own.

This article was originally published on February 26, 2013. It was last updated on January 13, 2023.

1. https://www.kff.org/private-insurance/issue-brief/navigator-funding-restored-in-federal-marketplace-states-for-2022/

2. https://www.cms.gov/newsroom/fact-sheets/patient-protection-and-affordable-care-act-updating-payment-parameters-section-1332-waiver

3. https://www.kff.org/interactive/subsidy-calculator/

Originally published on January 13, 2023. Last updated January 13, 2023.
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