Section 3905.471 | Insurance navigator certification.
(A) No individual or entity shall act as or hold itself out to be an insurance navigator unless that individual or entity is certified as an insurance navigator under this section and is receiving funding under division (i) of section 1311 of the Affordable Care Act.
(B) An insurance navigator who complies with the requirements of this section may do any of the following:
(1) Conduct public education activities to raise awareness of the availability of qualified health plans;
(2) Distribute fair and impartial general information concerning enrollment in all qualified health plans offered within the exchange and the availability of the premium tax credits under section 36B of the Internal Revenue Code of 1986, 26 U.S.C. 36B, and cost-sharing reductions under section 1402 of the Affordable Care Act;
(3) Facilitate enrollment in qualified health plans, without suggesting that an individual select a particular plan;
(4) Provide referrals to appropriate state agencies for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan coverage;
(5) Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the exchange.
(C) An insurance navigator shall not do any of the following:
(1) Sell, solicit, or negotiate health insurance;
(2) Provide advice concerning the substantive benefits, terms, and conditions of a particular health benefit plan or offer advice about which health benefit plan is better or worse or suitable for a particular individual or entity;
(3) Recommend a particular health plan or advise consumers about which health benefit plan to choose;
(4) Provide any information or services related to health benefit plans or other products not offered in the exchange. Division (C)(4) of this section shall not be interpreted as prohibiting an insurance navigator from providing information on eligibility for medicaid;
(5) Engage in any unfair method of competition or any fraudulent, deceptive, or dishonest act or practice.
(D) An individual shall not act in the capacity of an insurance navigator, or perform insurance navigator duties on behalf of an organization serving as an insurance navigator, unless the individual has applied for certification and the superintendent finds that the applicant meets all of the following requirements:
(1) Is at least eighteen years of age;
(2) Has completed and submitted the application and disclosure form required under division (F)(2) of this section and has declared, under penalty of refusal, suspension, or revocation of the insurance navigator's certification, that the statements made in the form are true, correct, and complete to the best of the applicant's knowledge and belief;
(3) Has successfully completed a criminal records check under section 3905.051 of the Revised Code, as required by the superintendent;
(4) Has successfully completed the certification and training requirements adopted by the superintendent in accordance with division (F) of this section;
(5) Has paid all fees required by the superintendent.
(E)(1) A business entity that acts as an insurance navigator, supervises the activities of individual insurance navigators, or receives funding to provide insurance navigator services shall obtain an insurance navigator business entity certification.
(2) Any entity applying for a business entity certification shall:
(a) Apply in a form specified, and provide any information required by, the superintendent; and
(b) Pay an initial licensure fee of two hundred dollars or renewal fee of one hundred dollars.
(3) A business entity certified as an insurance navigator shall, in a manner prescribed by the superintendent, make available a list of all individual insurance navigators that the business entity employs, supervises, or with which the business entity is affiliated.
(F) The superintendent of insurance shall, prior to any exchange becoming operational in this state, do all of the following:
(1)(a) Adopt rules to establish a certification and training program for a prospective insurance navigator and the insurance navigator's employees that includes screening via a criminal records check performed in accordance with section 3905.051 of the Revised Code, initial and continuing education requirements, and an examination;
(b) The certification and training program shall include training on compliance with the "Health Insurance Portability and Accountability Act of 1996," 110 Stat. 1955, 42 U.S.C. 1320d, et seq., as amended, training on ethics, and training on provisions of the Affordable Care Act relating to insurance navigators and exchanges.
(2) Develop an application and disclosure form by which an insurance navigator may disclose any potential conflicts of interest, as well as any other information the superintendent considers pertinent.
(G)(1) The superintendent may suspend, revoke, or refuse to issue or renew the insurance navigator certification of any person, or levy a civil penalty against any person, that violates the requirements of this section or commits any act that would be a ground for denial, suspension, or revocation of an insurance agent license, as prescribed in section 3905.14 of the Revised Code.
(2) The superintendent shall have the power to examine and investigate the business affairs and records of any insurance navigator.
(3)(a) The superintendent shall not certify as an insurance navigator, and shall revoke any existing insurance navigator certification of, any individual, organization, or business entity that is receiving financial compensation, including monetary and in-kind compensation, gifts, or grants, on or after October 1, 2013, from an insurer offering a qualified health benefit plan through an exchange operating in this state.
(b) Notwithstanding division (G)(3)(a) of this section, the superintendent may certify as a navigator a qualified health center and a federally qualified health center look-alike, as defined in section 3701.047 of the Revised Code.
(4)(a) If the superintendent finds that a violation of this section made by an individual insurance navigator was made with the knowledge of the employing or supervising entity, or that the employing or supervising entity should reasonably have been aware of the individual insurance navigator's violation, and the violation was not reported to the superintendent and no corrective action was undertaken on a timely basis, then the superintendent may suspend, revoke, or refuse to renew the insurance navigator certification of the supervising or employing entity.
(b) In addition to, or in lieu of, any disciplinary action taken under division (G)(4)(a) of this section, the superintendent may levy a civil penalty against such an entity.
(H) A business entity that terminates the employment, engagement, affiliation, or other relationship with an individual insurance navigator shall notify the superintendent within thirty days following the effective date of the termination, using a format prescribed by the superintendent, if the reason for termination is one of the reasons set forth in section 3905.14 of the Revised Code, or the entity has knowledge that the insurance navigator was found by a court or government body to have engaged in any of the activities in section 3905.14 of the Revised Code.
(I) Insurance navigators are subject to the laws of this chapter, and any rules adopted pursuant to the chapter, in so far as such laws are applicable.
(J) The superintendent may deny, suspend, approve, renew, or revoke the certification of an insurance navigator if the superintendent determines that doing so would be in the interest of Ohio insureds or the general public. Such an action is not subject to Chapter 119. of the Revised Code.
(L) The superintendent may, by rule, apply the requirements of this chapter to any entity or person designated by an exchange, the state, or the federal government to assist consumers or participate in exchange activities.
(M) Any fees collected under this section shall be paid into the state treasury to the credit of the department of insurance operating fund created under section 3901.021 of the Revised Code.
Last updated July 31, 2023 at 5:04 PM