Presented by the Utah Insurance Department

1. THE AFFORDABLE CARE ACTAND
HEALTH INSURANCE PRODUCERS
Presented by the
Utah Insurance Department
July 16, 2013

2. A New Language
• ACA: Affordable Care Act
• FFM: Federally-facilitated Marketplace
• Grandfathered plan: Health plan issued prior to March 23, 2010 that
has not had significant changes to benefits and plan design
• MLR: Medical loss ratio
• Non-grandfathered: Health plan offered after March 23, 2010
• PPACA: Patient Protection and Affordable Care Act of 2010
• QHP: Qualified Health Plan
• SBC: Summary of benefits and coverage
• SHOP: Small business Health Options Program
• Federal offices:
• HHS: U.S. Department of Health and Human Services
• CCIIO: Center for Consumer Information & Insurance Oversight
• OPM: Office of Personnel Management

3. Exchange or Marketplace
FFE / FFM
Exchange
Marketplace
SBE / SBM

4. Where are we?
HHS asked states to choose one of three doors:

5. Where are we?
Utah chose door #4:

6. Utah’s SHOP Exchange,Avenue H

7. A Glimpse into Avenue H

8. Federal Marketplace for Individuals

9. The Marketplaces Need Producers !

10. Producers
Avenue H
Assist employers and employees in
completing the application, selecting
and enrolling in QHPs
Must be:
• Licensed
• Appointed with insurers
• Complete Avenue H training
Individual Federal Marketplace
Assist qualified individuals in
completing the eligibility application,
receiving eligibility determinations,
and selecting and enrolling in QHPs
Must be:
• Licensed
• Appointed with insurers
• Complete Federal Marketplace
training
• Register with the Federal
Marketplace

11. Federal Guidance on the Role of Producers in
the Individual Federally-facilitated Marketplace
• HHS is working with producers on the individual
Federally-facilitated Marketplace so producers can help
consumers:
• Complete the tax subsidy eligibility application
• Compare and select qualified health plans (QHPs)
• Enroll through the Marketplace
• HHS lays out three pathways producers may use to sell
coverage through the FFM:
• Insurer‐based Pathway
• Marketplace Pathway
• Web‐broker Pathway
* http://cciio.cms.gov/resources/regulations/Files/agent‐broker‐5‐1‐2013.pdf

12. Producers Registration in the Individual Marketplace
(CONTINUED)

13. Federal Guidance on the Role of
Producers in the Individual Marketplace
(CONTINUED)
Option 1: Insurer‐based pathway
• The producer logs onto the insurer’s website.
• The consumer determines that he or she would like to get
coverage through the individual Marketplace.
• The producer is redirected from the insurer’s website to the
individual Marketplace website to complete the eligibility
application.
• The application is completed and the consumer’s eligibility
determination is received from the Marketplace.
• The producer is securely redirected back to the insurer’s
website to assist consumer with plan comparison, plan
selection, and enrollment.
• The producer’s FFM user ID and NPN are included in the
Marketplace enrollment record sent to the insurer.

14. Federal Guidance on the Role of
Producers in the Individual Marketplace
(CONTINUED)
Option 2: Marketplace pathway
• With help from the producer, the consumer logs directly
onto his or her own Marketplace account.
• The producer works with the consumer to complete the
eligibility application.
• After the consumer receives an eligibility determination,
the producer assists the consumer in comparing QHPs on
the Marketplace website and submitting the consumer’s
selection.
• At both the eligibility application stage and the enrollment
stage, consumer will enter the producer’s Marketplace
user ID and NPN to indicate that producer has assisted
the consumer.

15. Federal Guidance on the Role of
Producers in the Individual Marketplace
(CONTINUED)
Option 3: Web‐broker pathway
• Consumers in the individual Marketplace may select a
QHP through a producer’s public‐facing website.
• CMS is developing the capacity to support integration
between the web‐broker’s website and the FFM website.
• This interface will allow an individual to begin his or her
shopping on the web‐broker’s website, connect securely
to the Markplace website to complete the eligibility
determination, and return securely to the web‐broker’s
site to compare plans, select a QHP, and enroll.

16. Parity in Producer Compensation
HHS requires insurers to pay producers for enrollment in
health plans offered through the individual Marketplace at
the same rate as similar individual health plans offered
outside the Marketplace
*http://www.gpo.gov/fdsys/pkg/FR‐2013‐03‐11/pdf/2013‐04
902.pdf

17. There are new kids on the block……Navigators

18. What is the role of a Navigator?
• Navigator Duties
• Conduct public education activities to raise awareness of the availability of
qualified health plans
• Distribute fair and impartial information about enrollment in qualified health
plans and the availability of premium tax credits
• Facilitate enrollment in qualified health plans
• Provide referrals to an office of health insurance consumer assistance or
ombudsman, or any other appropriate state agencies, for any enrollee with
a grievance, complaint, or question regarding their health plan
• Provide information in a manner that is culturally and linguistically
appropriate to the needs of the population served by the Exchange
• Navigators may not receive any direct or indirect payments from
health insurers.
• Navigators are funded through grants established by the Marketplace

19. Navigator Licensing
HB160, Health System Reform Amendments (J. Dunnigan),
created the Navigator License Act (31A-23b)
• Mirrors producer licensing requirements (31A-23a)
• Licensing process will include:
• Background check
• Pre-training and test requirements
• Requires continuing education
• Requires a surety bond to cover errors and omissions

20. Navigator License Exemptions
• Created certain exemptions from navigator licensure:
• Person who assists an individual with enrollment in a public program or an application for
premium subsidy AND is employed by or contracts with:
• health care facility
• state, a political subdivision of the state, an entity of a political subdivision of the state, or a public
school district
• federally qualified health center
• Producer, if the producer is licensed in the appropriate line of authority to sell, solicit, or negotiate
accident and health insurance plans
• Officer, director, or employee of a navigator who does not receive compensation or commission
from an insurer
• Person who does not sell, solicit, or negotiate insurance and is not directly or indirectly
compensated by an insurer issuing an insurance contract, an agency administering a public
program, an individual who enrolled in a public program or insurance product, or an exchange
• Class of persons, as exempted by the commissioner via rule, if the functions performed by the
class of persons do not require:
• special competence;
• special trustworthiness; or
• regulatory surveillance

21. Differences Between Producers and Navigators
Producer Navigator
INFORMATION TO BE PROVIDED TO THE CONUMSER
Eligibility information for coverage through the Marketplace, premium tax credits or publicly subsidized programs such
as Medicaid, CHIP, Medicare, etc
X X
Methods to purchase and enroll in a QHP: Marketplace web portal, Marketplace call-in center, walk-in centers, kiosks
located in community service centers, mail in applications and fax applications
X X
Education on the benefits of health insurance and what health insurance provides for the individual X X
Definitions of health insurance terms, for example, aiding the consumer to understand the difference between a
premium, deductible and co-insurance
X X
Providing information to the consumer to find avenues to resolve disputes with insurers X X
Providing culturally and linguistically appropriate health insurance education to persons including but not limited to
Hispanics, Asians and American Indians
X X
Outreach to consumers focusing on broad topics related to health insurance and coverage options X X
COMPENSATION
Funded by grants from the Marketplace X
Funded by commissions paid by the insurers X
LICENSING, CERTIFICATION AND TRAINING
Licensed and regulated by Utah Insurance Department (UID) X X
Certified and regulated by HHS in partnership with the Marketplace X
Criminal background check required X X
ENROLLMENT
Enroll consumers in plans offered in the Marketplace X X
Enroll consumers in plans offered outside of the Marketplace X
Assist in submission of enrollment documentation to the Marketplace X X
Provide the consumer with documentation stating the date coverage will start and the appropriate agencies to contact
if the consumer encounters problems with enrollment, coverage or payment
X X

22. Questions?