Rules Laid Down for ‘Navigators’

The government last month reinforced the firewall between the soon-to-be launched health insurance exchanges and the managed care industry.

Through the exchanges, which open in October, health plans will compete for the business of people who are not covered by employers or other sponsors.

Consumers may call on “navigators” to help them choose their coverage, and those people must not, in any way, be associated with the insurance industry.

The rule, issued by the Department of Health and Human Services, says that a navigator “may not be a health insurance issuer; be a subsidiary of a health insurance issuer; be an association that includes members of, or lobbies on behalf of, the insurance industry; or receive any consideration, directly or indirectly, from any health insurance issuer in connection with the enrollment of any individuals or employees in a [qualified health plan (QHP)].” (See

The navigator cannot actually select a plan for a customer. “That said, navigators may play an important role in facilitating a consumer’s enrollment in a QHP by providing fair, impartial, and accurate information that assists consumers with submitting the eligibility application, clarifying the distinctions among QHPs, and helping qualified individuals make informed decisions during the health plan selection process.”

Richard G. Stefanacci, DO, MGH, MBA, and a member of Managed Care’s Editorial Advisory Board, says the HHS standards do not address everything. He wonders how providers will be able to refer patients to navigators, and how patients who don’t usually deal with the health care system will be able to find navigators.

“And of course from a health plan perspective — will navigators be truly objective when it comes to providing direction regarding plans or will they carry some bias,” says Stefanacci.

Jaan Sidorov, MD, a consultant and another member of our Editorial Advisory Board, wonders how costly this might become.

California, for instance, wants 21,000 navigators. “It’d be interesting to combine those estimates with the $20–$48 per hour [that a navigator might be paid] to come up with a PMPM,” says Sidorov. “I’ll bet the number will produce sticker shock. That’s especially true because of the Fed’s remarkable ability to underestimate program costs and generate cost overruns.”