Wednesday, November 27, 2013

Date: November 27, 2013

From:  Nick Gerhart, Iowa Insurance Commissioner

Subject:  Certified Application Counselors in Iowa


The role of enrollment assistance for comprehensive major medical insurance in the State of Iowa has traditionally been provided by licensed insurance agents and producers.  With the implementation of the Patient Protection and Affordable Care Act, the types of entities and individuals who may assist the general public in enrolling in health care coverage (prior to age 65) has expanded.  As established by federal regulation 45 CFR 155.255, certified application counselors (CAC) were established to assist individuals in enrolling in the Health Insurance Marketplace (Marketplace).  While the CACs serve a role in aiding Iowans in enrolling and selecting health care coverage through the Marketplace, the Iowa Insurance Division wants to ensure CACs fully understand their responsibilities and duties in order to remain compliant with applicable federal and Iowa laws.  


What does a CAC organization do?

In the state of Iowa, all CACs must be affiliated with a Certified Application Counselor Organization (CACO).  As a CACO, your staff and volunteers will help people understand, apply, and enroll for health coverage through the Marketplace. Your organization must agree to make sure that designated individuals complete required training, and that they comply with privacy and security laws, and other program standards.

Your organization must:

1.      Ensure the individuals performing the CAC services are trained;

2.      Have processes in place to screen your staff to make sure that they protect consumer information;

3.      Engage in services that position your organization or CAC individual to assist the people your organization serves  with health coverage issues; and

4.      Have experience providing social services to the community.


Certified ApplicationCounselors will assist individuals enroll in Qualified Health Plans in the Marketplace and assist eligible individuals enroll in Medicaid, Hawk I or the new Iowa Health and Wellness Plan. This includes:

 Providing information about insurance affordability programs and coverage options;

 Assisting individuals and employees to apply for coverage in a QHP through the Marketplace and for insurance affordability programs; and

 Helping to facilitate enrollment of eligible individuals in QHPs and insurance affordability programs.

Permitted Activities:

  • Conduct public education activities to raise awareness of available Qualified Health Plans (QHP) within the federal Marketplace.
  • Distribute fair and impartial information concerning enrollment in a QHP through the federal Marketplace and the availability of premium tax credits and cost-sharing reductions that may be available.
  • Explain that consumers may purchase health plans through the federal Marketplace or off the Marketplace.
  • Make consumers aware that plans are available in the market outside the federal Marketplace  and that they may want to talk with a licensed health insurance agent about health insurance options.
  • Facilitate enrollment in a QHP through the federal Marketplace. Outline information that a consumer will need to have available when applying for coverage through the federal Marketplace. Provide information that will allow the consumer to access the federal Marketplace either at their home or a computer terminal provided.
  • Explain to the consumer the following information: potential eligibility for public/governmental programs, and how the federal health insurance premium tax credit and cost-sharing reductions work and potential risks, if any, for use of the federal health insurance premium tax credit.
  • Describe the features and benefits of health coverage in general terms, including cost-sharing mechanisms like deductibles, co-pays or co-insurance and how these work or affect the consumer.
  • Describe what a summary of benefits document is and where to locate a summary of benefits and relevant cost-sharing provisions within the information from QHPs.
  • Explain how to find information about provider networks.
  • Describe the different metal tiers (i.e., bronze, silver, gold and platinum) and how the benefits may change at different metal tiers based upon the consumer's income.
  • Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the federal Marketplace.
  • Provide a referral for an individual to an appropriate state or federal agency who has a grievance, complaint or question regarding their health plan, coverage, or a determination under such plan or coverage.

Prohibited Activities:

  • Receive compensation from an insurer, stop-loss insurance or a third-party administrator.
  • Receive compensation that is dependent upon, in whole or in part, whether an individual enrolls in or renews coverage in a health benefit plan.
  • Provide any information related to enrollment or other insurance products not offered in the federal Marketplace.
  • Make or cause to be made false or misleading statements.
  • Provide advice comparing health benefit plans that may be better or worse for the consumer or employer.
  • Recommend a particular health benefit plan or insurer or advise consumers or employers regarding a particular insurer or health benefit plan selection.
  • Engage in any fraudulent, deceptive or dishonest acts or unfair methods of competition.
  • Receive consideration directly or indirectly from any health insurance issuer in connection with the enrollment of individuals or employees into a QHP.

In the State of Iowa the CAC program is handled by the federal government entirely.  Therefore, any individual or entity that violates the newly enacted law provisions may be subject to administrative action including restitution or revocation of licensure or registration.  In addition, any person acting in the capacity of a CAC may not violate the provision of Iowa Code 522(B) duties of an insurance agent.  Individuals or entities that provide enrollment assistance or selection into a health insurance policy without obtaining a license from the State of Iowa or certification from the federal government will be in violation of 522B.