Last week, we referenced the new regulations that were released by the Centers for Medicare & Medicaid Services. Families USA has prepared a succinct explanation of how these roles impact navigators and enrollment specialists. Their explanation of the final regulations is as follows:
- Specifies several types of state requirements that would conflict with federal requirements for assisters, including: a) requirements for assisters to refer consumers to entities that are not required to provide impartial assistance, b) requirements that would prevent assisters from providing assistance to all consumers, c) requirements that would prevent assisters from providing advice regarding substantive benefits or comparative benefits of different health plans, and d) requirements that would directly or in effect prevent the implementation of marketplace enrollment assistance programs.
- Allows health care providers to become assisters, regardless of their relationship to health insurance issuers.
- Clarifies that it is within assisters’ scope of duties to provide comprehensive information to consumers about the substantive benefits and features of health plans, including clarifying the similarities and differences among plans, and assisting consumers with making informed decisions.
- Clarifies that assisters can make unsolicited contact with consumers to conduct outreach – but not to provide enrollment assistance unless they have a prior relationship with the consumer.
- Clarifies that assisters cannot provide applicants with gifts unless they are of nominal value, nor can they offer promotional items from third parties to incentivize enrollment. Note that assisters can provide reimbursement for limited consumer expenses, such as travel costs or postage.
- Permits the Centers for Medicare and Medicaid Services (CMS) to impose civil money penalties on assisters or require corrective action plans for a) violations of federal obligations (for assisters in the federal marketplace) and b) improper use of personally identifiable information, or providing false or fraudulent information to a marketplace (for assisters in both state and federal marketplaces). No penalty will be imposed if CMS concludes that an assister acted in good faith.
