SB1194sam001 98TH GENERAL ASSEMBLY

Sen. William R. Haine

Filed: 4/15/2013

09800SB1194sam001 LRB098 03986 RPM 44394 a

AMENDMENT TO SENATE BILL 1194

AMENDMENT NO. ______. Amend Senate Bill 1194 by replacing everything after the enacting clause with the following:

"Section 1. Short title. This Act may be cited as the Navigator Certification Act.

Section 5. Definitions. As used in this Act:

"Director" means the Director of Insurance.

"Exchange" means any health benefit exchange established or operating in this State, including any exchange established or operated by the United States Department of Health and Human Services.

"Navigator" means a person or entity selected to perform the activities and duties identified in 42 U.S.C. 18031(i) in this State. "Navigator" includes any person or entity who receives grant funds from the United States Department of Health and Human Services, the State of Illinois, or an exchange or private funds to perform any of the activities and duties identified in 42 U.S.C. 18031(i), including, but not limited to, in-person assisters and application counselors.

Section 10. Certificate required.

(a) No individual or entity shall perform, offer to perform, or advertise any service as a navigator in this State or receive navigator grant funding from the United States Department of Health and Human Services, the State of Illinois, or an exchange or private funds unless certified as a navigator by the Director under this Act.

(b) A navigator who complies with the requirements of this Act 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 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 federal Patient Protection and Affordable Care Act;

(3) facilitate enrollment in qualified health plans, without suggesting that an individual select a particular plan;

(4) provide referrals to appropriate federal and State agencies for any enrollee with a grievance, complaint, or question regarding their health plan or coverage or a determination under such plan or 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) A navigator may not:

(1) engage in any activities that would require an insurance producer license;

(2) provide advice concerning the substantive benefits, terms, and conditions of a particular health plan or offer advice about which health plan is better or worse for a particular individual or employer;

(3) recommend or endorse a particular health plan or advise consumers about which health plan to choose;

(4) provide any information or services related to health benefit plans or other products not offered in the exchange; or

(5) accept any compensation or consideration that is dependent, in whole or in part, on whether a person enrolls in or purchases a private health benefit plan.

(d) Items (2), (3), and (4) of subsection (c) of this Section do not apply to navigators who enroll individuals in the State Medicaid program or other public programs.

(e) Only a person licensed as an insurance producer in this State may:

(1) sell, solicit, or negotiate health insurance;

(2) provide advice concerning the substantive benefits, terms, and conditions of a particular health plan or offer advice about which health plan is better or worse for a particular individual or employer; or

(3) recommend a particular health plan or advise consumers about which health plan to choose.

Section 15. Application for certificate.

(a) An entity or individual applying for a navigator certificate shall make application to the Director on a form developed by the Director and declare under penalty of refusal, suspension, or revocation of the certificate that the statements made in the application are true, correct, and complete to the best of the individual's knowledge and belief. Before approving the application, the Director shall find that the individual:

(1) is at least 18 years of age;

(2) resides in this State or maintains his or her principal place of business in this State;

(3) is not disqualified due to having committed any act that would be grounds for denial, suspension, or revocation of a navigator certification in accordance with Section 30 of this Act;

(4) has successfully completed the federal and State training provided by the Exchange or equivalent State requirements as determined by the Department; and

(5) when applicable, has the written consent of the Director pursuant to 18 U.S.C. 1033, or any successor statute regulating crimes by or affecting persons engaged in the business of insurance whose activities affect interstate commerce.

(b) An entity that acts as a navigator, supervises the activities of individual navigators, or receives funding to perform such activities shall obtain a navigator entity certificate. An entity applying for a navigator entity certificate shall make application on a form containing the information prescribed by the Director and shall list the individuals acting as navigators under the entity certificate.

(1) The entity shall designate a certified navigator responsible for the business entity's compliance with the laws of this State and the Exchange.

(2) The entity, under penalty of revocation, suspension, or other discipline prescribed by the Director, shall certify that each individual completes the mandatory training required by item (4) of subsection (a) of Section 15 of this Act.

(c) The Director may require any documents deemed necessary to verify the information contained in an application submitted in accordance with subsections (a) and (b) of this Section.

(d) Entities certified as navigators shall provide the Director with a list of all individual navigators that it employs, supervises, or is affiliated with at renewal.

(e) The Director may require, in a manner determined by the Director, that each entity that acts as a navigator demonstrate a level of financial responsibility capable of protecting all persons against the wrongful acts, misrepresentations, or negligence of the navigator.

(f) Prior to any exchange becoming operational in this State, the Director, in coordination with the exchange, shall prescribe the initial training and continuing education requirements for navigators.

(g) Certificate holders must inform the Director, in writing, of a change of address within 340 days after the change.

(h) In order to assist in the performance of the Director's duties, the Director may contract with the National Association of Insurance Commissioners (NAIC), or any affiliates or subsidiaries that the NAIC oversees, to perform any ministerial functions, including the collection of fees, related to certification that the Director and the nongovernmental entity may deem appropriate.

Section 20. Certificate renewal.

(a) An individual navigator and entity certificate shall be valid for one year.

(b) A navigator may file an application for renewal of a certificate in a method prescribed by the Director. Any navigator who fails to timely file for certificate renewal shall be charged a late fee in an amount prescribed by the Director.

(c) Prior to the filing date for application for renewal of a certificate, an individual navigator shall comply with ongoing training and continuing education requirements established by the Director. The navigator shall file with the Director, by a method prescribed by the Director, satisfactory certification of completion of the continuing education requirements. Any failure to fulfill the ongoing training and continuing education requirements shall result in the expiration of the certificate.

Section 25. Navigator referrals. On contact with a person who acknowledges having existing health insurance coverage obtained through an insurance producer, a navigator shall refer the person back to that insurance producer for information, assistance, and any other services unless:

(1) the individual is eligible for but has not obtained a federal premium subsidy and cost-sharing assistance available only through an exchange;

(2) the insurance producer is not authorized to sell health plans in an individual exchange; or

(3) the individual would prefer not to seek further assistance from the individual's insurance producer.

Section 30. License denial, nonrenewal, or revocation.

(a) The Director may place on probation, suspend, revoke, or refuse to issue or renew a marketplace navigator's certificate or may levy civil penalty as established by emergency rule.

(b) If an action by the Director is to nonrenew, suspend, or revoke a certificate or to deny an application for a certificate, then the Director shall notify the applicant or certificate holder and advise, in writing, the applicant or certificate holder of the reason for the suspension, revocation, or denial or nonrenewal of the applicant's or certificate holder's certificate. The applicant or certificate holder may make written demand upon the Director within 30 days after the date of mailing for a hearing before the Director to determine the reasonableness of the Director's action. The hearing must be held within not fewer than 20 days nor more than 30 days after the mailing of the notice of hearing and shall be held pursuant to Part 2402 of Title 50 of the Illinois Administrative Code.

(c) A marketplace entity license may be suspended, revoked, or refused or information turned over to the U.S. Department of Health and Human Services and applicable state agencies if the Director finds, after hearing, that an individual licensee's violation was known or should have been known by one or more of the partners, officers, or managers acting on behalf of the marketplace navigator entity.

(d) In addition to or instead of any applicable denial, suspension, or revocation of a certificate, a person may, after hearing, be subject to a civil penalty in accordance with emergency rules issued by the Director.

(e) The Director has the authority to enforce the provisions of and impose any penalty or remedy authorized by this Act against any person who is under investigation of or charged with a violation of this Act or rules even if the person's certificate has been surrendered or has lapsed by operation of law.

(f) Upon the suspension, denial, or revocation of a certificate, the certificate holder or other person having possession or custody of the certificate shall promptly deliver it to the Director in person or by mail. The Director shall publish all suspensions, denials, or revocations after the suspensions, denials, or revocations become final in a manner designed to notify the public.

(g) A person whose certificate is revoked or whose application is denied pursuant to this Section is ineligible to apply for any license for 3 years after the revocation or denial. A person whose certificate as a marketplace navigator has been revoked, suspended, or denied may not be employed, contracted, or engaged in an Exchange-related capacity during the time the revocation, suspension, or denial is in effect.

Section 35. Reporting to the Director.

(a) Each navigator shall report to the Director within 30 calendar days after the final disposition of a matter that violates the provisions set forth in this Act that results in any administrative action taken against him in another jurisdiction or by another governmental agency in this State. The report shall include a copy of the order, consent to order, or other relevant legal documents.

(b) Within 30 days after the initial pretrial hearing date, a navigator shall report to the Director any criminal prosecution of the navigator of a matter that violates the provisions set forth in this Act taken in any jurisdiction. The report shall include a copy of the initial complaint filed, the order resulting from the hearing, and any other relevant legal documents.

(c) An entity that acts as a navigator that terminates the employment, engagement, affiliation, or other relationship with an individual navigator shall notify the Director within 30 days following the effective date of the termination, using a format prescribed by the Director, if the reason for termination is one of the reasons set forth in this Act or the entity has knowledge the navigator was found by a court or government body to have engaged in any of the activities prohibited by this Act. Upon the written request of the Director, the entity shall provide additional information, documents, records, or other data pertaining to the termination or activity of the individual.

Section 40. Hospitals; hospital affiliates; All Kids Application Agents.

(a) The requirements of this Act shall not apply to hospitals or hospital affiliates or any entity or medical provider enrolled with the Department of Healthcare and Family Services as an All Kids Application Agent (AKAA), that do not actively recruit enrollees in the Illinois Health Benefits Exchange, with regard to assisting uninsured individuals seeking medical care in understanding the process for enrolling in the Illinois Healthcare Marketplace.

(b) The Director may by rule establish registration and training requirements applicable to hospitals or hospital affiliates or any AKAA that desire to assist uninsured individuals that seek medical care to understand the process for enrolling in the Illinois Health Benefits Exchange.

(c) No hospitals or hospital affiliates or any AKAA that assists uninsured individuals that seek medical care may:

(1) sell, solicit, or negotiate health insurance;

(2) provide advice concerning the substantive benefits, terms, and conditions of a particular health plan or offer advice about which health plan is better or worse for a particular individual or employer;

(3) recommend or endorse a particular health plan or advise consumers about which health plan to choose; or

(4) provide any information or services to uninsured individuals related to the purchase of health benefit plans or other products not offered in the exchange.

(d) Nothing in this Section shall prohibit hospitals or hospital affiliates or any AKAA from informing patients in non-emergency situations about the provider's participation in particular networks or plans in order to ensure that patients can understand their payment responsibilities relating to copayments, coinsurance, or deductibles.

(e) Nothing in this Section shall prohibit hospitals or hospital affiliates or any AKAA, otherwise authorized by the Department of Healthcare and Family Services to enroll individuals into Medicaid, from continuing that practice in the absence of rules required by this Section.

(f) Nothing in this Section authorizes the Director to make determinations or adopt rules relating to the ability for hospitals or hospital affiliates or any AKAA to enroll individuals in Medicaid if those entities have otherwise been authorized by the Department of Healthcare and Family Services to enroll individuals into Medicaid.

Section 45. Other laws; rulemaking authority.

(a) The requirements of this Act shall not apply to any individual or entity licensed as an insurance producer in this State.

(b) Pursuant to the authority granted by this Act, the Director may adopt rules as may be necessary or appropriate for the administration and enforcement of this Act.

Section 97. Severability. The provisions of this Act are severable under Section 1.31 of the Statute on Statutes.

Section 99. Effective date. This Act takes effect upon becoming law.".