The affordable care act and health insurance producers
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The affordable care act and Health insurance Producers. Presented by the Utah Insurance Department August 19, 2013. A New Language. ACA: Affordable Care Act PPACA: Patient Protection and Affordable Care Act of 2010

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The affordable care act and Health insurance Producers

Presented by the

Utah Insurance Department

August 19, 2013

A New Language

  • ACA: Affordable Care Act

  • PPACA: Patient Protection and Affordable Care Act of 2010

  • Grandfathered plan: Health plan issued prior to March 23, 2010 that has not had significant changes to benefits and plan design

  • Non-grandfathered: Health plan offered after March 23, 2010

  • MLR: Medical loss ratio

  • 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

Exchange or Marketplace





Where are we? The Utah Model

HHS asked states to choose one of three doors.

Utah chose door #4:

The Marketplaces Need Producers !


Avenue H

Individual Federal Marketplace

Assist qualified individuals in completing the eligibility application, receiving eligibility determinations, and selecting and enrolling in QHPs

Must be:


Appointed with insurers

Complete Federal Marketplace training

Register with the Federal Marketplace

Assist employers and employees in completing the application, selecting and enrolling in QHPs

Must be:

  • Licensed

  • Appointed with insurers

  • Complete Avenue H training

Federal Guidance on the Role of Producers in the Individual Federally-facilitated Marketplace

  • For the FFMs (individual market QHPs), agents and brokers can work with consumers in either of two ways:

    • Directly accessing the FFM website through the issuer’s connection

    • Assisting consumers who are accessing the FFM website

  • To participate in the Individual FFM, agents/broker must:

    • Adhere to all state requirements for licensure

    • Complete HHS’s Marketplace on-line training

    • Complete the applicable Marketplace Agreement(s)

    • Complete security authentication steps for FFM registration

Federal Guidance on the Role of Producers in the Individual Federally-facilitated Marketplace

  • The registration process for agents/brokers in the FFMS include two parts.

    • Part I (available 8/1)

      • Occurs on the Medicare Learning Network (MLN)

      • Includes courses, exams, and signing Marketplace Agreement(s)

      • Takes approximately 3.5 – 4 hours to complete, and depends on the specific Marketplace curriculum selected

    • Part II (coming soon)

      • Occurs on the CMS Enterprise Portal

      • Covers the establishment of an FFM User ID, and completion of identity verification

      • Takes approximately 30 minutes to complete

      • Only required for producers serving in the individual market

Producer Individual FFM Registration Overview

  • Part 1 – Medicare Learning Network


      • Register on MLN

      • Complete assigned training courses and pass exams

      • Read and accept the applicable Marketplace Agreement(s)

  • Part 2 – Federally Facilitated Marketplace User Account

    • CMS Enterprise Portal

      • Create a user account

      • Complete identity verification through the Enterprise Identity Management (EIDM) System

  • Resource


Producer Marketplace Pathway


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


There are new kids on the block……Navigators

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

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

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

Utah’s Individual Marketplace Navigators

  • Utah Health Policy Project. Anticipated grant amount: $406,788. The Utah Health Policy Project is a nonprofit organization dedicated to lasting solutions to the crisis of the uninsured and rising health care costs. The Utah Health Policy Project will lead the Take Care Utah Navigator Hub that will connect nonprofit community-based organizations with resources on health coverage options.

  • Cardon Healthcare Network, LLC DBA Cardon Outreach. Anticipated grant amount: $238,000. Cardon Healthcare Network (of Sandy) has over 20 years of experience providing in-person eligibility assistance to Medicaid enrollees in 33 states. Cardon Healthcare Network will use this experience to provide outreach and assistance with existing robust infrastructure.

  • Utah AIDS Foundation. Anticipated grant amount: $126,258. Utah AIDS Foundation (UAF) is the oldest and largest AIDS service organization in Utah, with over 27 years of experience providing effective, culturally-sensitive services to people living with HIV and populations at high risk for HIV in Utah. UAF will hire two full-time staff to serve as Navigators to educate target communities about Exchanges and to help individuals determine eligibility, understand their options, select, and complete all necessary steps to enroll in a Qualified Health Plan.

  • National Council of Urban Indian Health. Anticipated grant amount: $35,000. National Council of Urban Indian Health is the only national, membership-based organization dedicated to outreach and education on behalf of Urban Indian Health. It provides training, technical assistance, outreach, and education to Urban Indian Health Programs.

Differences Between Producers and Navigators


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