	Introduction

The 2010 Patient Protection and Affordable Care Act (ACA, P.L. As of July 2014, 14 states and the District of Columbia had secured HHS approval to create their own exchanges, 7 to enter into partnership exchanges, 29 to have federally facilitated exchanges, and 2 to have state-based SHOP/federally facilitated individual exchanges. The insurance policies, and the exchanges, were fully operational on January 1, 2014. An exchange is not an insurer, but is rather a type of marketplace where private insurance companies may sell qualified health plans (QHP) that meet certain federal standards. Consumers, businesses, and issuers are not required to use the exchanges to purchase insurance. Small businesses that apply for coverage through the exchanges may be eligible for small business tax credits. The Congressional Budget Office (CBO) projects that 25 million individuals will be enrolled in health insurance through the exchanges in 2024. Consumer Assistance Programs

Under the ACA and implementing regulations issued by the HHS Centers for Medicare & Medicaid Services (CMS), consumer assistance outreach programs include the following:
Mandatory navigator programs designed to provide "fair and impartial" information about exchange-based insurance plans, as well as the availability of federal assistance to help defray the cost of insurance and other health programs. In addition, consumers and businesses may use insurance brokers and agents, including web-based brokers (where allowed by states), to purchase QHPs. Brokers and agents, licensed by states, are generally paid a commission by insurance companies for selling their policies. A number of states have passed legislation to require navigators to have additional training and licensing, or to undergo background checks. This report outlines federal and state oversight of navigators, the role of brokers and agents, and previous education and outreach efforts for federal health care programs. CMS regulations to implement the ACA specify that navigators may offer consumers assistance in comparing and analyzing insurance options, but may not tell applicants which health plan to select. Insurance brokers and agents may apply to become navigators, but under CMS rules they may not accept compensation from health or stop loss insurers in this role. Organizations and individuals that apply for the navigator program are required to submit certain information to CMS, including 
a plan for carrying out outreach and education activities specified in the ACA and in CMS regulations; a description of existing relationships with employers and employees, consumers (including uninsured and underinsured consumers), or self-employed individuals likely to be eligible to enroll in a qualified health plan; or a description of how such relationships could be readily established; a statement attesting that the applicant is not ineligible for the program due to a financial or other relationship with health insurers; a plan to perform the statutory and regulatory duties of a navigator for the entire length of the agreement; an attestation that staff and volunteers will remain free of conflicts of interest while acting as a navigator; a plan to ensure that staff and volunteers complete all required training; and a plan to comply with data privacy and security standards. Health providers or other entities may not be disqualified from becoming certified application counselors solely because they receive payment from a health insurer for providing health care services. State exchanges may also develop their own training, with approval by HHS. Navigator and Non-navigator Training

To be certified by an exchange, navigator and non-navigator personnel at federally facilitated exchanges, including partnership exchanges, and all federally funded non-navigators at state-based exchanges, must 
Complete 20 hours of HHS-approved training and receive a passing score on HHS-approved exams. States may set additional eligibility criteria and background checks for navigators and non-navigators, so long as they do not prevent the application of Title I of the Affordable Care Act. Exchange Website

Agents and brokers may assist consumers and qualified small employers and their employees directly on an exchange website. CMS also worked through State Health Insurance and Assistance Programs (see below) and increased funding to the SHIPs to help expand outreach. Outstanding Issues

Some lawmakers have raised questions and concerns about the navigator programs.
The 2010 Patient Protection and Affordable Care Act (ACA, P.L. 111-148) allows certain individuals and small businesses to buy qualified health insurance through state exchanges. The exchanges are not themselves insurers, but rather are special marketplaces where insurance firms may sell health policies that meet set, federal guidelines. As of July 2014, 14 states and the District of Columbia had secured HHS approval to create and run their own exchanges, 7 to enter into partnership exchanges, 29 to have federally facilitated exchanges, and two to have state-based SHOP/federally facilitated individual exchanges. An estimated 25 million individuals are expected to secure coverage through the exchanges by 2024.
The ACA requires exchanges to perform outreach to help consumers and small businesses make informed decisions about their insurance options, including the operation of "navigator" programs. Navigators carry out public education activities; provide information to prospective enrollees about insurance options and federal assistance; and examine enrollees' eligibility for other federal or state health care programs, such as Medicaid. Navigators may assist consumers in comparing insurance plans, but may not determine their eligibility for subsidies or enroll them in plans—functions that are left to the exchanges. A variety of organizations may become navigators, including labor unions, trade associations, chambers of commerce, and other entities. Navigators may not be health insurers or take compensation from insurers for selling health policies. Navigators must have 20 hours of training on consumer privacy, exchange-based insurance offerings, and other issues. HHS has provided about $60 million in yearly grants for navigators at federally financed and state partnership exchanges. In addition, HHS has determined that state-based exchanges may use ACA exchange establishment funds to create parallel, in-person, non-navigator assistance programs that perform the same function as navigators. Exchanges must also certify "certified application counselors" to help with outreach and enrollment, though no new ACA funds are available for such programs.
Consumers and small businesses may continue to use insurance brokers and agents, including web-based brokers, to compare and buy coverage, both on and off the exchanges. Brokers and agents are licensed by the states, and are generally paid on a commission basis by insurance companies. While brokers and agents may choose to become navigators, they may not accept compensation from health insurance companies in that role. Consumers may also purchase policies directly from health insurers. Outside non-profit groups and businesses, such as insurers, operate their own separate efforts to educate consumers about the ACA and the process of applying for qualified health plans (QHP) and other programs.
Some lawmakers, agents, and brokers have raised questions about the navigator and other assistance programs. Issues include whether navigators have sufficient training and whether HHS regulations provide sufficiently stringent consumer and privacy safeguards. A number of states have passed legislation to further regulate navigators, including requiring navigators to be licensed and to be liable for financial losses due to their advice. HHS has determined that the ACA gives states authority to set additional standards, so long as they do not prevent implementation of Title I of the law, which includes the exchanges and navigator program. This report describes exchange outreach programs, the role of brokers, agents, and insurers, and issues regarding consumer outreach assistance.