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Federal Register / Vol. 86, No. 124 / Thursday, July 1, 2021 / Proposed Rules the activities that fall within the scope of this requirement is vital to improving health equity and helping to address social determinants of health, particularly among underserved and vulnerable populations.31 Navigators are already required under 155.210e8
to provide targeted assistance to underserved or vulnerable populations.
Underserved and vulnerable populations often experience lower levels of health literacy, which can be a barrier to enrolling in and accessing care.32 Social determinants of health can also create significant disparities in whether and how an individual is able to afford and access health coverage and health care services, including primary and preventive care. As trusted partners and members of local communities, Navigators are uniquely positioned to establish and build trust with individuals and families as they transition from enrolling in health coverage to using and maintaining their coverage throughout the year.
Additionally, Navigators in FFEs are already required under 155.215c1
to develop and maintain general knowledge about the racial, ethnic, and cultural groups in their service area, including each groups health literacy and other needs, and under 155.215c2 to collect and maintain updated information to help understand the composition of the communities in the service area. Because the health literacy needs of consumers will vary depending on their circumstances, we are not requiring Navigators to help consumers with specific health literacy topics. Instead, we propose to expand our interpretation of the Navigator duties proposed to be reinstituted as requirements at 155.210e9iv to include, for example, helping consumers understand 1 key terms used in health coverage materials, such as deductible and coinsurance, and how they relate to the consumers health plan; 2 the cost and care differences between a visit to the emergency department and a visit to a primary care provider under the coverage options available to the consumer; 3 how to evaluate their health care options and make cost-conscious decisions, including through the use of information required to be disclosed by their health plan as a result of the Transparency in Coverage Final 31 86

FR 7009 Jan. 25, 2021.
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Rules; 33 4 how to identify in-network providers to make and prepare for an appointment with a provider including utilizing tools and resources available through the No Surprises Act 34 to make informed decisions about their care; 5 how the consumers coverage addresses steps that often are taken after an appointment with a provider, such as making a follow-up appointment and filling a prescription;
and 6 the right to coverage of certain preventive health services without cost sharing under QHPsincluding information and resources related to accessing viral testing and vaccination options supported by Exchange coverage. If this proposal is finalized, CMS intends to make training materials and other educational resources available to Navigators regarding the proposed expanded interpretation of this requirement.
FFE Navigators will continue to be permitted to perform the Navigator duties specified in 155.210e9 until this proposal, if finalized, becomes effective. If this proposal is finalized, FFE Navigators would be required to perform the Navigator duties specified in 155.210e9 beginning with Navigator grants awarded after the effective date of this rule, including non-competing continuation awards.
For example, if this proposal is finalized prior to Navigator grant funding being awarded in fiscal year FY 2022, FY
2021 Navigator grantees will be required to perform these duties beginning with the Navigator grant funding awarded in FY 2022 for the second 12-month budget period of the 36-month period of performance. To the extent FFE
Navigators awarded grant funding in FY
2021 are not already performing these duties under their year one project plans when this proposal, if finalized, becomes effective, they can revise their project plans to incorporate performance of the duties specified in 155.210e9 as part of their noncompeting continuation application for their FY 2022 funding. If this proposal is finalized as proposed, we would codify in 155.210e9 the applicability date to make clear when the Navigator duties specified in 155.210e9 would once again be required.
We interpret the requirement to facilitate enrollment in a QHP under section 1311i3C of the ACA, and the requirement at 155.210e2 to provide information that assists 33 85

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consumers with submitting the eligibility application, to include assistance with updating an application for coverage through an Exchange, including reporting changes in circumstances and assisting with submitting information for eligibility redeterminations. Additionally, Navigators are already permitted, but not required, to help with a variety of other post-enrollment issues. For example, we interpret the requirements in 155.210e1 and 2 that Navigators conduct public education activities to raise awareness about the Exchange and provide fair and impartial information about the application and plan selection process to mean that Navigators may educate consumers about their rights with respect to coverage available through an Exchange, such as nondiscrimination protections, prohibitions on preexisting condition exclusions, and preventive services available without cost-sharing. We also interpret these requirements, together with the requirement in section 1311i3B of the ACA that Navigators distribute fair and impartial information concerning enrollment in QHPs, and the availability of Exchange financial assistance, to mean that Navigators may assist consumers with questions about paying premiums for coverage or insurance affordability programs enrolled in through an Exchange.
Finally, we interpret the requirement in section 1311i3D of the ACA and 155.210e4 to provide referrals for certain post-enrollment issues to mean that Navigators may help consumers obtain assistance with coverage claims denials.
Certified application counselors CACs do not receive grants from the FFEs, and thus may have more limited resources than Navigators. As a result, while we are not proposing to require CACs to further expand their required duties, we encourage CACs to help with activities consistent with their existing regulatory duties and recognize that many of these CACs may already be participating in these post-enrollment activities.
We seek comment on all aspects of this proposal.
3. Exchange Direct Enrollment Option 155.221j In part 1 of the 2022 Payment Notice final rule, we codified 155.221j, which established a process for states to elect a new Exchange Direct Enrollment option Exchange DE option. Under the Exchange DE option, State Exchanges, SBEFPs, and FFE states may work directly with private sector entities including QHP issuers, web-brokers,
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