Ohio Admin. Code 3901-5-13 - Insurance navigator certification and agent exchange requirements

(A) Purpose

The purpose of this rule is to set forth procedures and requirements for the certification of insurance navigators as recognized by the department as both an individual and business entity, and the requirements for agents who sell health coverage on the exchange.

(B) Authority

This rule is promulgated pursuant to the authority vested in the superintendent under sections 3901.041, 3905.12, 3905.47 to 3905.473 of the Revised Code.

(C) Insurance navigator certification

(1) An individual applying for certification as an insurance navigator must comply with the requirements contained in section 3905.471 of the Revised Code.

(2) An individual applying for certification shall do all of the following:

(a) The applicant shall complete at least twenty-four hours of pre-certification education requirements including all of the following, but not limited to;

(i) Compliance with the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg, as amended, and any regulation adopted thereunder;

(ii) Ethics;

(iii) Provisions of the Patient Protection and Affordable Care Act (ACA), 124 Stat. 119, 42 U.S.C. 18031 (2011);

(iv) Levels of coverage available under the ACA;

(v) Eligibility requirements to purchase qualified health plans;

(vi) Means of appeal and dispute resolution;

(vii) Conflict of interest and impartiality;

(viii) Exchange privacy policies and requirements;

(ix) Individual eligibility requirements for medicaid;

(x) Advanced premium tax credits and cost sharing reductions;

(xi) Publicly funded health care (children's health insurance program, medicaid); and

(xii) Eligibility requirements for employers to make insurance available to their employees through the "Small Business Health Options Program" (SHOP) created by division (b)(1)(B) of section 1311 of the ACA.

(b) The applicant shall successfully complete a criminal background check pursuant to section 3905.051 of the Revised Code and the results of which must be satisfactory to the superintendent. Any applicant with a conviction notes in the background check may submit information to the superintendent on why the conviction does not impact their fitness to perform as a navigator.

(c) The applicant shall successfully complete a comprehensive exam including pertinent information that is included within the required education credits. This requirement will be met by the successful completion of an examination administered under the regulations implemented by the secretary of health and human services.

(d) The applicant shall submit an application and disclosure form by which the insurance navigator shall disclose any potential conflicts of interest based upon the regulations implemented by the secretary of health and human services to avoid conflicts of interest.

(3) If the applicant has met the required education standards set forth by the exchange as defined in division (W) of section 3905.01 of the Revised Code, the applicant shall have subsequently met all education requirements listed in this rule.

(4) A certified insurance navigator must notify the department of a criminal conviction within thirty days of a court ruled conviction.

(5) Information regarding individual insurance navigator certification applications (INS3003 rev. 07/2013 04/2017) can be found on the department website.

(D) Business entity insurance navigator certification

Pursuant to section 3905.471 of the Revised Code, an insurance navigator business entity applying for certification must comply with the following requirements:

(1) Complete a business entity application and provide information required by the superintendent;

(2) The applicant has designated a certified insurance navigator who will be responsible for the applicant's compliance with the insurance navigator laws of this state and has certified there are no conflicts of interest, as defined in the regulations implemented by the secretary of health and human services;

(3) A business entity applicant must certify that all applicants have met the required training, background check, and disclosure standards;

(4) A business entity must maintain a list of every individual insurance navigator who is affiliated with the entity;

(5) A business entity must provide an assigned federal identification number as well as proof of federal funding under division (i) of section 1311 of the ACA;

(6) If the business entity ceases to exist as a corporate or other legal entity, its insurance navigator certification shall be revoked;

(7) A business entity insurance navigator must report any change in its name, address, email address, certified insurance navigators, officers, directors, and members or owners with ten per cent or more voting interest in the certified entity to the superintendent within thirty days of such change;

(8) A business entity applicant must apply for certification under the legal name of the applicant as registered with the Ohio secretary of state. The superintendent may deny the use of a name that is too similar to a name already in use by another business entity or a name that may be misleading to the public;

(9) The applicant must be authorized to do business in the state of Ohio by the Ohio secretary of state if so required by section 1703.03, 1705.54, or 1775.64 of the Revised Code;

(10) Each business entity applicant for certification as an insurance navigator shall pay the following fees prescribed by the superintendent:

(a) For entities with less than one hundred employed insurance navigators an application fee not to exceed two hundred fifty dollars and an annual certification renewal fee not to exceed one hundred dollars for each renewal thereafter; and

(b) For entities with one hundred or more employed insurance navigators an application fee not to exceed five hundred dollars for an initial certification and an annual certification renewal fee not to exceed two hundred fifty dollars for each renewal thereafter.

(11) The applicant must be found suitable to be certified by the superintendent.

(12) Information regarding business entity insurance navigator certification applications (INS3004 rev. 07/2013 05/2017) can be found on the department website.

(E) Certification renewal requirements

(1) Individual and business entity insurance navigator certifications expire annually on July thirty-first.

(a) Certified insurance navigators must annually submit a renewal application on or before July thirty-first. The renewal application must include all of the following, but not limited to:

(i) Proof of completion of continuing education which can be demonstrated by completing renewal requirements of the federally-facilitated exchange under the regulations implemented by the secretary of health and human services; and

(ii) A renewal application.

(b) A business entity insurance navigator certification must be renewed annually. The renewal application must include all of the following, but not limited to:

(i) A renewal application; and

(ii) Pay the renewal fee as prescribed in paragraph (D)(10) of this rule.

(c) If an individual or business entity does not apply for the renewal of the individual or business entity's insurance navigator certification on or before the certification renewal date specified in paragraph (E)(1) of this rule, the individual or business entity may submit a late renewal application along with a fifty dollar fee prior to September first. Failure to submit a late renewal application along with a fifty dollar fee prior to September first, will result in cancellation of the insurance navigator certificate on September first.

(2) The superintendent has the authority to waive any fees required by this rule or reinstate any insurance navigator certificate cancelled pursuant to this rule, due to military service, a long term medical disability, or some other special or extenuating circumstance.

(3) Information regarding individual insurance navigator renewal certification applications (INS3005 rev 07/13 04/2017); and business entity insurance navigator renewal certification applications (INS3006 rev 07/13 05/2017) can be found on the department website.

(F) A contracted third party acting under the authority of an entity described in paragraph (F)(1), (F)(2), (F)(3) or (F)(4) of this rule, to provide information on the entity's premises to persons not covered under a health benefit plan, or persons acting within the scope of their employment for a:

(1) Licensed health care provider or a hospital registered with the Ohio department of health;

(2) Federally qualified health center or a federally qualified health center look-alike as defined in section 3701.047 of the Revised Code;

(3) Non-profit organization whose primary purpose is the distribution of food stuffs, groceries, donated goods or purchased goods in their community or surrounding communities, to meet the emergency needs of the communities or participating outlets; and

(4) An agency of the state or a political subdivision as defined in division (D) of section 3905.36 of the Revised Code.

That is not holding itself out as a person or an entity serving as an insurance navigator, are exempt from the requirements of sections 3905.47 to 3905.474 of the Revised Code and this rule.

(G) Agent exchange requirements

(1) Pursuant to section 3905.47 of the Revised Code, a licensed insurance agent that wishes to sell, solicit, or negotiate a qualified health plan through the exchange must first complete a training program required by the exchange. If the applicant has met the required education standards set forth by the exchange, the applicant shall have met all initial education requirements.

(2) A non-resident applicant who has taken substantially similar courses in exchange training within their home state will be deemed to be in compliance with paragraph (G)(1) of this rule.

(H) Severability

If any paragraph, term or provision of this rule is adjudged invalid for any reason, the judgment shall not affect, impair or invalidate any other paragraph, term or provision of this rule, but the remaining paragraphs, terms and provisions shall be and continue in full force and effect.

Notes

Ohio Admin. Code 3901-5-13

Effective: 11/4/2018
Five Year Review (FYR) Dates: 8/20/2018 and 08/31/2023
Promulgated Under: 119.03
Statutory Authority: 3905.471, 3905.47, 3905.12, 3901.041
Rule Amplifies: 3905.471
Prior Effective Dates: 09/01/2013