CMS Issues Final Rule Setting Out Standards for Health Exchange Navigators

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By Ralph Lindeman  


The Centers for Medicare & Medicaid Services July 12 released a final rule addressing requirements for so-called navigators and other consumer aides who will assist people applying for health coverage on insurance marketplaces, or exchanges.

The rule (CMS-9955-F; CMS-2334-F2), which finalizes two earlier proposed rules, establishes standards for navigators and other consumer aides relating to training, certification, and conflict of interest.

It also addresses issues related to how exchanges ensure access to people with disabilities, as well as those with diverse racial and cultural backgrounds.

The rule will become effective Aug. 12.

It will apply to navigators on federally facilitated exchanges (in states that do not establish their own exchange); state partnership exchanges (where states join with the Department of Health and Human Services in operating their exchange); and to other consumer aides--known as “non-navigator assistance personnel”--on state-based exchanges that are funded through federal grants.

CMS said in a release that the state-based marketplaces have the option of “using this guidance or developing their own.”

The final rule also outlines standards for “certified application counselors,” who will also be available to assist people obtain coverage on the exchanges.

Navigators and certified application counselors will provide advice to people in 33 states that have opted for the federally facilitated exchange or that partner with the federal exchange. Seventeen states and the District of Columbia will establish their own marketplaces and will have consumer aides known as non-navigator personnel.

Conflict of Interest

Conflict-of-interest provisions in the rule will require navigators and non-navigator personnel to submit a written statement attesting that they:

• are not a health insurance issuer or issuer of stop-loss insurance;

• are not a subsidiary of a health insurance issuer or issuer of stop-loss insurance;

• are not an association that includes members of, or lobbies on behalf of, the insurance industry; and

• will not receive any payments directly or indirectly from any health insurance issuer or issuer of stop-loss insurance in connection with enrolling individuals or employees in a health plan offered on the exchange.


In addition, navigators and non-navigator personnel must disclose any existing employment relationships or former employment relationships (within the past five years) with any health insurance issuers, including any existing employment by a spouse or domestic partner.

Training, Certification Standards

The rule also outlines training and certification standards for navigators and non-navigator personnel, which include:

• completing an HHS-approved training course;

• achieving a passing score on all approved certification examinations prior to carrying out any consumer assistance activities;

• obtaining recertification on an annual basis; and

• being prepared to offer assistance on both the individual exchange and Small Business Health Options (SHOP) exchange for small businesses.


The rule states that training for navigators and non-navigator personnel must include the following topics:

• qualified health plans in all coverage levels and how they operate, including benefits covered, payment processes, and appeals;

• range of insurance programs for the poor, including Medicaid and the Children's Health Insurance Program;

• tax implications of enrollment decisions;

• eligibility requirements for federal subsidies, or premium tax credits, and cost-sharing reductions; and

• contact information for federal and state agencies providing additional consumer assistance on coverage options.


To ensure that low-income applicants, as well as applicants from diverse racial and cultural backgrounds, have access to assistance on exchanges, the rule states that the exchanges must collect and maintain information on the composition of the populations served on the exchange.

In this regard, navigators and non-navigator personnel also must be able to provide or obtain appropriate translation services where needed, according to the rule.

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