As open enrollment approaches, consumers will need accurate information to choose the right health plan. The Affordable Care Act provides assistance to consumers in a variety of flavors, from Navigators to In-Person Assisters to Certified Application Counselors. These roles, all governed by HHS regulations, are slated to help millions of people enroll starting in October. While the ACA created new, regulated roles for helping with enrollment, insurance brokers and agents have often been the means of purchasing coverage, especially for small businesses. Since brokers and agents will continue to play a role in enrolling people in insurance, federal regulations governing their role are necessary to ensure consumer needs come first throughout the outreach and enrollment phase of the ACA. Recently, HHS released guidance for their conduct in selling insurance through the Exchanges.
First, the regulations leave it up to states to decide whether they will permit brokers to sell qualified health plans (QHPs) through the Exchanges at all. If states opt in (which most or all will), then all brokers who intend to sell Exchange plans must register, complete an online Exchange-specific training course, and agree to comply with all federal regulations. The training will include Medicaid and CHIP so brokers are able to effectively refer consumers to the relevant agencies if they meet eligibility criteria for these services. The broker training will be different from the training for Navigators and other assisters. The regulations then distinguish between two pathways through which brokers can assist consumers in plan selection, purchase, and enrollment: the issuer-based pathway and the Exchange pathway.
Through the Exchange pathway, brokers would assist consumers using the same Exchange website consumers see if they sign up unassisted by a broker. This web portal ensures all plan options are directly displayed to the consumer. In contrast, through the issuer-based pathway, brokers use an insurer’s website to aid with plan selection and enrollment, and are redirected to the Exchange only to determine a consumer’s eligibility for financial assistance or other programs. This means brokers do not have to display all options to the consumer, which could mean people would not see the full range of options based on affordability, quality and benefits. However, CMS states that although they recognize brokers may try to push certain plans based on financial incentives, they are required to disclose to the consumer that they are doing so, and provide them the option of using the Exchange website themselves. What is unclear, however, is how oversight of this provision will happen.
The regulations differ between states with Federally-Facilitated Exchanges (FFEs) and those who have State-Based Exchanges (SBEs). For FFEs, CMS is responsible for registering brokers and conducting training. In SBEs, the state is responsible for licensing and regulating brokers and establishing continuing education requirements. All types of Exchanges, state-based or Federal, can require additional state-specific training or additional rules as a condition of licensure.
It is critical to the success of health reform implementation to enroll as many people in health plan options as possible. To achieve this goal it’s important to have everyone with enrollment experience, including brokers helping insure people. However, we need to make sure brokers are not steering consumers toward certain plans based on financial incentives, and are acting in the best interest of the consumer they are serving. One way to do this would be to track their enrollment practices and monitor experiences to ensure consumers are getting adequate assistance. Moving forward, oversight and enforcement will be key to ensuring brokers in the Exchanges are putting consumer needs first.
– Sarah Gordon, Private Insurance Team intern
& Christine Barber, senior policy analyst