Stop-loss Insurers Maneuvered out of Navigator Role in Final Reform Rules

Stop-loss insurers for self-funded health plans are among the entities excluded from assisting consumers and small businesses in researching health insurance exchange options under health care reform. Those insurers, as well as individuals and other entities with too close a financial relationship to such insurers, cannot be “Navigators,” according to final rules issued July 17 from the U.S. Department of Health and Human Services (78 Fed. Reg. 42824).

HHS said in order to provide information to consumers, Navigators must be “fair and impartial.” However, in the agency’s view, stop-loss insurers cannot meet this standard because they have a financial incentive both to encourage small employers to self-fund, and to not explain coverage options that may include insured products.

The rules become effective on Aug. 12, 2013.

Background

Under the Patient Protection and Affordable Care Act, individuals and small businesses will be able to purchase health insurance through affordable insurance exchanges (also known as health insurance marketplaces). States can establish such exchanges; federally facilitated exchanges will exist for states that choose not to operate an exchange or won’t have one operational by Jan. 1, 2014.

Consumers can receive assistance from a variety of sources when seeking access to exchange coverage. Under the reform law and its exchange regulations, exchanges are to give grants to “Navigators” that are to provide:

1. “fair and impartial” information to consumers about health insurance, the exchanges; qualified health plans; insurance affordability programs such as premium tax credits, Medicaid and the Children’s Health Insurance Program; and
2. referrals to consumer assistance programs and health insurance ombudsmen for enrollees with grievances, complaints or questions about their health plan or coverage.

Navigators are not to not make eligibility determinations and will not select QHPs for consumers or enroll applicants into QHPs. They will, however, help consumers through the eligibility and enrollment process.

To read the full story, go to hrcompliancexpert.com.