5.03 Navigator program

General requirements.87 AHS conducts a Navigator program consistent with this subsection through which it awards grants to eligible entities to perform the functions of navigator organizations, and certifies individuals as Navigators. The functions of navigator organizations include providing assistance to individuals and employers with enrollment in Medicaid programs and qualified health plans. Standards.88 AHS maintains and publicly disseminates: 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 to be awarded a Navigator grant, and to ensure that all entities and individuals carrying out Navigator functions have appropriate integrity; and 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) Benefits rules and regulations governing all health-benefits programs and QHPs offered in the state; (iv) The range of QHP options and health-benefits programs; (v) The privacy and security standards applicable under § 4.08; (vi) The process of filing eligibility appeals; (vii) General concepts regarding exemptions from the requirement to maintain minimum essential 85 42 CFR § 435.907(a); 45 CFR § 155.20. 86 All Programs Rule 2014. 87 45 CFR § 155.210(a); 33 VSA § 1807. 88 45 CFR §§ 155.205(d) and 155.210(b). General Provisions and Definitions Part 1 – Page 32 (Sec.5.00, Sub.5.03) coverage and from the individual shared responsibility payment, including the application process for exemptions, and IRS resources and exemptions; (viii) The premium tax credit reconciliation process and IRS resources on this process; (ix) Basic concepts and rights related to health coverage and how to use it; and (x) Providing referrals to licensed tax advisers, tax preparers, or other resources for assistance with tax preparation and tax advice. Entities and individuals eligible to be a Navigator.89 To receive a Navigator grant, an entity must: Be capable of carrying out at least those duties described in paragraph (f) of this subsection; Demonstrate to AHS 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; Meet any licensing, certification or other standards prescribed by the state or AHS; Not have a conflict of interest during the term as Navigator; and Comply with the privacy and security standards applicable under § 4.08. Prohibition on Navigator conduct.90 A Navigator must not: Be a health insurance issuer or issuer of stop loss insurance; Be a subsidiary of a health insurance issuer or issuer of stop loss insurance; Be an association that includes members of, or lobbies on behalf of, the insurance industry; Receive any consideration directly or indirectly from any health insurance issuer or issuer of stop loss insurance in connection with the enrollment of any individuals or employees in a QHP or a non-QHP; Charge any applicant or enrollee, or request or receive any form of remuneration from or on behalf of an individual applicant or enrollee, for application or other assistance related to Navigator duties; Provide to an applicant or potential enrollee gifts of any value as an inducement for enrollment. The value of gifts provided to applicants and potential enrollees for purposes other than an inducement for enrollment must not exceed nominal value, either individually or in the aggregate, when provided to that individual during a single encounter. For purposes of this paragraph, the term gifts includes gift items, gift cards, cash cards, cash, and promotional items that market or promote the products or services of a third 89 45 CFR § 155.210(c). 90 45 CFR § 155.210(d). General Provisions and Definitions Part 1 – Page 33 (Sec.5.00, Sub.5.03) party, but does not include the reimbursement of legitimate expenses incurred by a consumer in an effort to receive application assistance, such as, but not limited to, travel or postage expenses; Use AHS funds to purchase gifts or gift cards, or promotional items that market or promote the products or services of a third party, that would be provided to any applicant or potential enrollee; Solicit any individual for application or enrollment assistance by going door-to-door or through other unsolicited means of direct contact, including calling an individual to provide application or enrollment assistance without the individual initiating the contact, unless the individual has a pre-existing relationship with the individual Navigator or Navigator entity and other applicable state and federal laws are otherwise complied with. Outreach and education activities may be conducted by going door-to-door or through other unsolicited means of direct contact, including calling an individual; or Initiate any telephone call to an individual using an automatic telephone dialing system or an artificial or prerecorded voice, except in cases where the individual Navigator or Navigator entity has a relationship with the individual and so long as other applicable state and federal laws are otherwise complied with. Conflict-of-interest standards.91 In addition to prohibited conduct in (d) of this subsection, the following standards apply to Navigators: All Navigator entities must submit to VHC a written attestation that the Navigator, including the Navigator’s staff, complies with (d)(1). All Navigator entities must submit to VHC a written plan to remain free of conflicts of interest during the term as a Navigator. All Navigator entities, including the Navigator's staff, must provide information to consumers about the full range of QHP options and health-benefits programs for which they are eligible. All Navigator entities, including the Navigator's staff, must disclose to VHC and, in plain language, to each consumer who receives application assistance from the Navigator: (i) Any lines of insurance business, not covered by the restrictions on participation and prohibitions on conduct in (d) of this subsection, which the Navigator intends to sell while carrying out the consumer assistance functions; (ii) Any existing or anticipated financial, business, or contractual relationships with one or more health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance; and (iii) For Navigator staff, any existing employment relationships, or any former employment relationships within the last 5 years, with any health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance, including any existing employment relationships between a spouse or domestic partner and any health insurance issuers or 91 45 CFR § 155.215(a). General Provisions and Definitions Part 1 – Page 34 (Sec.5.00, Sub.5.03) issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance. Duties of a Navigator.92 An entity that serves as a Navigator must carry out at least the following duties: Maintain expertise in eligibility, enrollment, and program specifications and conduct public education activities to raise awareness about VHC; Conduct public education activities to raise awareness of the availability of qualified health benefit plans; Distribute information to health care professionals, community organizations, and others to facilitate the enrollment of individuals who are eligible for Medicaid, Dr. Dynasaur, VPharm, other public health- benefits programs, or QHP; Provide information and services in a fair, accurate and impartial manner, which includes providing information that assists individuals with submitting the eligibility application; clarifying the distinctions among health coverage options, including QHPs; and helping individuals make informed decisions during the health coverage selection process. Such information must acknowledge other health programs; Distribute fair and impartial information concerning enrollment in QHPs and concerning the availability of premium tax credits, premium reductions, and cost-sharing reductions; Facilitate selection of a QHP or public health-benefits program such as Medicaid, Dr. Dynasaur, or VPharm; Provide referrals to any applicable office of health insurance consumer assistance, health insurance ombudsman, or any other appropriate state agency or agencies, for any individual with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage; Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by VHC, 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 § 504 of the Rehabilitation Act; Ensure that individuals: (i) Are informed, prior to receiving assistance, of the functions and responsibilities of Navigators, including that Navigators are not acting as tax advisers or attorneys when providing assistance as Navigators and cannot provide tax or legal advice within their capacity as Navigators; (ii) Provide authorization in a form and manner as determined by AHS prior to a Navigator’s obtaining access to an individual’s personally identifiable information, and that the Navigator maintains a record of the authorization provided in a form and manner as determined by AHS. AHS will establish 92 45 CFR § 155.210(e); 33 VSA § 1807. General Provisions and Definitions Part 1 – Page 35 (Sec.5.00, Sub.5.04) a reasonable retention period for maintaining these records; and (iii) May revoke at any time the authorization provided to a Navigator. Maintain a physical presence in the service area, so that face-to-face assistance can be provided to applicants and enrollees. Provide targeted assistance to serve underserved or vulnerable populations, as identified by AHS. Provide information and assistance with the following topics: (i) Understanding the process of filing eligibility appeals; (ii) Understanding and applying for exemptions from the individual shared responsibility payment, understanding the availability of exemptions from the requirement to maintain minimum essential coverage and from the individual shared responsibility payment that are claimed through the tax filing process and how to claim them, and understanding the availability of IRS resources on this topic; (iii) The premium tax credit reconciliation process, and understanding the availability of IRS resources on this process; (iv) Understanding basic concepts and rights related to health coverage and how to use it; and (v) Referrals to licensed tax advisers, tax preparers, or other resources for assistance with tax preparation and tax advice. Funding for Navigator grants Funding for navigator grants may not be from Federal funds received by the state to establish VHC.