The Affordable Care Act (ACA) created a new entity that is involved in the distribution of health insurance products to the health insurance exchange or the health insurance marketplace as they are now known by. Navigators were created under ACA to assist with an individual’s enrollment in plans offered through the marketplace. Texas consumers can either work with a navigator or a broker to evaluate health insurance options in the marketplace. What is the difference between the two distribution channels?
What does the Navigator do?
According to ACA, navigators have five basic responsibilities. Navigators are responsible for:
- Conducting public education programs to explain the availability of health insurance coverage;
- Distributing accurate, unbiased information about enrollment in qualified plans and educating individuals about premium subsidies and cost-sharing benefits offered in the marketplace
- Facilitating enrollment for eligible individuals
- Assisting individuals with issues pertaining to their health insurance coverage by directing the individual to the appropriate agency; and
- Providing information in an appropriate manner as it pertains to the individual’s cultural or linguistic requirements.
What role does the insurance agent play in healthcare reform?
Little has changed regarding the role of insurance agents under healthcare reform. Agents can evaluate policies available in the marketplace on behalf of clients. In 2019, the most recent plan year with data, agents assisted in 43.6% of all enrollments issued by healthcare.gov. Agents can make recommendations on which policy is most suitable for an individual and can directly assist with the enrollment of a marketplace plan. Agents also play an important role as the client advocate with insurance carriers for customer service issues
What is the difference? Navigator or Agent?
When you compare the two distribution channels, agents and navigators, it seems that there are similarities, but this is not the case at all. The first major difference between navigators and insurance agents is that agents maintain a license to sell policies in and out of the marketplace while navigators are only required to complete a training program and can only assist with policies in the marketplace. The licensed agent is required to pass an examination conducted by the Texas Department of Insurance and complete 30 hours of continuing education every two years. In order to be licensed by the Texas Department of Insurance a complete, background check is conducted including fingerprinting. Navigators are not licensed by the Texas Department of Insurance, are not required to participate in continuing education and are not subject to background checks. Most health insurance carriers require appointed agents to maintain professional liability coverage, which is not required by navigators.
When discussing coverage options with consumers, agents can explain each carrier’s plan options and can make a recommendation on the plan that best fits the needs of the Texas consumer. Navigators can only describe plans and cannot make a carrier recommendation.
Agents are either self-employed or work for an agency that maintains contractual appointments with various health insurance carriers which offer plans in the marketplace, which are eligible for a premium subsidy, or outside of the marketplace. Navigators either volunteer or work for an organization such as community non-profits; trade, industry or professional associations; chambers of commerce or unions. The main focus of the insurance agent is to serve the client and provide exceptional customer service to maintain a long-term business relationship. The principal goal of the navigator is to educate and enroll individuals in plans offered in the marketplace. Customer service after the sale is not a requirement of navigators, and they have very little incentive to provide customer service after enrollment has been completed.
The compensation paid to either a licensed agent or a navigator does not affect the premium. The premium is not reduced if you elect not to use the services of an agent or a navigator. Agents are paid a commission when the application is approved. Navigators are paid a flat fee for a successful enrollment.
Agencies such as Stateside Insurance Services maintain websites (www.texasplans.com) to provide consumer-oriented information regarding health insurance. Navigators typically do not have the office support and technology to facilitate client contact. An example of the importance of the information maintained on a website and the health insurance experience of the agent would be C.O.B.R.A., which can have complicated coverage enrollment and termination rules. Agents are well versed with insurance rules covering areas such as C.O.B.R.A. in contrast to the limited knowledge by navigators.
Navigators will play an important role with ACA by assisting historically under-served populations with enrollment. However, the role of the licensed agent is probably more important today than at any time due to the complexity of health insurance options and the enrollment rules, especially in qualifying for premium subsidies.
STATESIDE CAN HELP!
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.
Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
Stateside is available to answer any general questions regarding your coverage options, can provide a subsidy determination, and even assist in creating and submitting online applications for ACA compliant plans during an Open Enrollment or throughout Special Enrollment periods.
By using the Telephone Appointment System, clients can take advantage of scheduling a health insurance discussion when convenient for their schedule. During Open Enrollment phone appointment availability is expanded to include extended hours and weekends.