The New York Health Benefit Exchange — What it Means for You

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The New York Health Benefit Exchange —
What it Means for You

On October 1, 2013, individuals and small businesses can start to enroll in the New York Health Benefit Exchange ("the Exchange"), created by the Affordable Care Act (ACA). The ACA requires the states to create "Navigator" programs to help people understand the complexities of exchanges and assist them in the enrollment process. At EmblemHealth, we are sensitive to concerns about how this may impact your business, which is why we would like to give you this update.

The Role of Navigators

Under the ACA, navigators must be fair and impartial. Unlike producers (agents, brokers), who represent their respective health insurance issuer or work on behalf of their client, navigators are employed by the Exchange. They must receive training from the Exchange and be able to provide instruction on how it works. Their role includes these functions:

  • Explain to consumers about the qualified health plans available on the Exchange at the various metal levels.
  • Simplify the enrollment process.
  • Determine who is eligible for premium tax credits and cost-sharing reductions.
  • Provide outreach and education in communities where consumers will likely purchase coverage through the Exchange. This includes the uninsured and underinsured.
  • Inform consumers in a culturally sensitive manner. This is especially important for those who don't speak English well or at all; people with disabilities that have unique communication needs; and low-income, disadvantaged and hard-to-reach populations.
  • Provide information on how the Exchange, Medicaid and other public programs work together with the private insurance markets.
  • Be trusted by the community to provide clear and correct information.
  • Be free from conflicts of interest, including payments or incentives from insurers.
  • Provide referrals for any enrollee with a grievance, complaint or question regarding their health plan or coverage.
  • Act in the interest of the consumer, not the insurer.

The Role of Producers

Producers can sell health insurance on or off the Exchange. They are paid commission directly from the carriers and are not compensated by the Exchange. Producers who sell health insurance on the Exchange have the support of the Exchange’s dedicated online portal and full customer service center to facilitate applications and renewals. These producers must:

  • Complete an Exchange-approved training program and pass a test to certify its completion.
  • Enter into an agreement with the Exchange to fully disclose their role and compensation arrangement.
  • Be licensed and in good standing with the New York State Department of Financial Services.

What's the Difference

While producers and navigators have distinct roles, there is some overlap in the services they provide. Both can offer one-to-one assistance to individuals and small businesses. However, navigators cannot sell; they can only advise. As such, they will be more involved in outreach and education of the uninsured and underinsured. Producers will likely continue to be the primary distribution channel for small group enrollment through the Small Business Health Options Program (SHOP). Currently, 88 percent of the state's small group coverage is sold through brokers.

We will continue to provide you with updates as more information becomes available.


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