(a)General Requirements. The Exchange must establish a Navigator program consistent with this section through which it awards grants to eligible public or private entities or individuals described in paragraph (c) of this section.
(b)Standards. The Exchange must develop and publicly disseminate—
(1) A set of standards, to be met by all entities and individuals to be awarded Navigator grants, designed to prevent, minimize and mitigate any conflicts of interest, financial or otherwise, that may exist for an entity or individuals to be awarded a Navigator grant and to ensure that all entities and individuals carrying out Navigator functions have appropriate integrity; and
(2) A set of training standards, to be met by all entities and individuals carrying out Navigator functions under the terms of a Navigator grant, to ensure expertise in:
(i) The needs of underserved and vulnerable populations;
(ii) Eligibility and enrollment rules and procedures;
(iii) The range of QHP options and insurance affordability programs; and,
(iv) The privacy and security standards applicable under § 155.260.
(c)Entities and individuals eligible to be a Navigator.
(1) To receive a Navigator grant, an entity or individual must—
(i) Be capable of carrying out at least those duties described in paragraph (e) of this section;
(ii) Demonstrate to the Exchange that the entity has existing relationships, or could readily establish relationships, with employers and employees, consumers (including uninsured and underinsured consumers), or self-employed individuals likely to be eligible for enrollment in a QHP;
(iii) Meet any licensing, certification or other standards prescribed by the State or Exchange, if applicable;
(iv) Not have a conflict of interest during the term as Navigator; and,
(v) Comply with the privacy and security standards adopted by the Exchange as required in accordance with § 155.260.
(2) The Exchange must include an entity as described in paragraph (c)(2)(i) of this section and an entity from at least one of the other following categories for receipt of a Navigator grant:
(i) Community and consumer-focused nonprofit groups;
(ii) Trade, industry, and professional associations;
(iii) Commercial fishing industry organizations, ranching and farming organizations;
(iv) Chambers of commerce;
(vi) Resource partners of the Small Business Administration;
(vii) Licensed agents and brokers; and
(viii) Other public or private entities or individuals that meet the requirements of this section. Other entities may include but are not limited to Indian tribes, tribal organizations, urban Indian organizations, and State or local human service agencies.
(d)Prohibition on Navigator conduct. The Exchange must ensure that a Navigator must not—
(1) Be a health insurance issuer;
(2) Be a subsidiary of a health insurance issuer;
(3) Be an association that includes members of, or lobbies on behalf of, the insurance industry; or,
(4) Receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any individuals or employees in a QHP or a non-QHP.
(e)Duties of a Navigator. An entity that serves as a Navigator must carry out at least the following duties:
(1) Maintain expertise in eligibility, enrollment, and program specifications and conduct public education activities to raise awareness about the Exchange;
(2) Provide information and services in a fair, accurate and impartial manner. Such information must acknowledge other health programs;
(3) Facilitate selection of a QHP;
(4) Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the PHS Act, or any other appropriate State agency or agencies, for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage; and
(5) Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange, including individuals with limited English proficiency, and ensure accessibility and usability of Navigator tools and functions for individuals with disabilities in accordance with the Americans with Disabilities Act and section 504 of the Rehabilitation Act.
(f)Funding for Navigator grants. Funding for Navigator grants may not be from Federal funds received by the State to establish the Exchange.
Title 45 published on 2013-10-01
The following are only the Rules published in the Federal Register after the published date of Title 45.
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This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.