Section 4515.10  Purpose

 

The purpose of this Part is to establish certification criteria for Navigator, In-Person Counselor or Certified Application Counselor certification; establish pre-certification education requirements for applicants for Navigators, In-Person Counselors or Certified Application Counselors certification; and establish continuing education requirements for Navigators, In-Person Counselors or Certified Application Counselors. Additionally, this Part establishes disqualification and non-compliance penalty provisions and disqualifying offense review standards for Navigators, In-Person Counselors or Certified Application Counselors regardless of residency.

 

(Source:  Amended at 43 Ill. Reg. 422, effective December 21, 2018)

 

Section 4515.20  Definitions

 

"Certification" means the issuance by the Director of a license or authorization pursuant to this Part.

 

"Certified Application Counselor" means any employee or volunteer of a Certified Application Counselor Organization that enters into an agreement with the Marketplace to have its employees or volunteers provide information to individuals and employees about insurance affordability programs and qualified health plan coverage options; assist individuals and employees to apply for coverage in a qualified health plan through the Marketplace and for insurance affordability programs; and help to facilitate enrollment of eligible individuals in qualified health plans and insurance affordability programs.

 

"Certified Application Counselor Organization" means any organization designated by the Marketplace to certify its staff members or volunteers to act as certified application counselors and includes those organizations described in 45 CFR 155.225.

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Course" means any course of study certified to the Director that meets the requirements of this Part, including but not limited to seminar, classroom, and self-study formats.

 

"Department" means the Illinois Department of Insurance.

 

"Director" means the Director of the Illinois Department of Insurance or anyone to whom the Director's responsibilities and authority are lawfully delegated.

 

"In-Person Counselor" means any individual or entity who receives grant funds from the State of Illinois to perform the activities and duties identified in 45 CFR 155.205 or is described or designated by a Marketplace, the State, or the United States Department of Health and Human Services, or could reasonably be described or designated as "non-Navigator assistance personnel" as described in 45 CFR 155.215.  An In-Person Counselor would engage in the activities and meet the standards described in 45 CFR 155.215, including, but not limited to:

 

conduct public education activities to raise awareness of the availability of qualified health plans;

 

distribute fair and impartial information concerning enrollment in qualified health plans, and the availability of premium tax credits under 26 USC 36B and cost-sharing reductions under 42 USC 18071;

 

facilitate enrollment in qualified health plans;

 

provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health Services Act (42 USC 300gg-93), or any other appropriate State agency or agencies, for any enrollee with a grievance, complaint, or question regarding his or her health plan, coverage, or a determination under a plan or coverage; and

 

provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Marketplace.

 

"Marketplace" means any health benefit exchange authorized under the federal Patient Protection and Affordable Care Act and established or operating in this State, including any exchange established or operated by the United States Department of Health and Human Services.

 

"Navigator" means any individual or entity who is certified as a "Navigator" under the federal Patient Protection and Affordable Care Act, and means any individual or entity, other than an insurance producer licensed by the Department, who receives grant funds from the United States Department of Health and Human Services to perform any of the activities and duties identified in 42 USC 18031(i)(3) or is described or designated by a Marketplace, the State, or the United States Department of Health and Human Services, or could reasonably be described or designated, as Navigators, as described in 45 CFR 155.210.  A Navigator would engage in the activities and meet the standards described in 45 CFR 155.210 and 45 CFR 155.215, including, but not limited to:

 

conduct public education activities to raise awareness of the availability of qualified health plans;

 

distribute fair and impartial information concerning enrollment in qualified health plans, and the availability of premium tax credits under 26 USC 36B and cost-sharing reductions under 42 USC 18071;

 

facilitate enrollment in qualified health plans;

 

provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health Services Act (42 USC 300gg-93), or any other appropriate State agency or agencies, for any enrollee with a grievance, complaint, or question regarding his or her health plan, coverage, or a determination under a plan or coverage; and

 

provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Marketplace.

 

"Qualified health plan" has the meaning given that term in 42 USC 18021(a).

 

(Source:  Amended at 43 Ill. Reg. 422, effective December 21, 2018)

 

Section 4515.30  Certification Required

 

a)                  No individual or entity shall act as, offer to act as, or advertise any service as a Navigator, In-Person Counselor, Certified Application Counselor or Certified Application Counselor Organization in this State unless the individual or entity is certified by the Department pursuant to this Part.

 

b)                  The Director shall determine the length, no less than 12 months, of the effectiveness of any certification issued pursuant to this Part.

 

Section 4515.40  Exemption from Certification

 

a)         Government employees and their agents performing activities related to the Marketplace are exempt from certification. Those individuals and entities may not engage in Navigator, In-Person Counselor and Certified Application Counselor prohibited conduct.

 

b)         The distribution of educational and informational materials relating to the Marketplace authored or provided by a governmental authority is exempt from certification.

 

c)         The collection from the public of requests for information or assistance relating to the Marketplace in a manner approved by a governmental authority or a certified Navigator, In-Person Counselor, Certified Application Counselor or Certified Application Counselor Organization is exempt from certification.

 

d)         The referral of inquiries from the public relating to the Marketplace to an appropriate governmental authority or certified Navigator, In-Person Counselor, Certified Application Counselor or Certified Application Counselor Organization is exempt from certification.

 

e)         The exercise in good faith by journalists and persons other than a certified Navigator, In-Person Counselor or Certified Application Counselor of such person's U.S. and Illinois constitutional right to speak, write and publish freely with regard to the Marketplace is exempt from certification. The rights of a certified Navigator, In-Person Counselor or Certified Application Counselor to engage in Navigator, In-Person Counselor and Certified Application Counselor prohibited conduct are expressly restricted.

 

Section 4515.50  Application for Certification

 

a)         An individual applying for a Navigator, In-Person Counselor or Certified Application Counselor certification shall make application to the Department on a form developed or accepted by the Director and declare under penalty of refusal, suspension, or revocation of the certification 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)         Maintains his or her principal place of business in the State;

 

3)         Is not disqualified for having committed any act that would be a ground for denial, suspension, or revocation of a certification;

 

4)         Has not had an insurance producer license, Navigator certification, In-Person Counselor certification, or Certified Application Counselor certification, or equivalent license or certification denied, suspended, or revoked in any state, province, district, or territory or by the United States Department of Health and Human Services;

 

5)         Has successfully passed the applicable federal training program for Navigators, In-Person Counselors or Certified Application Counselors;

 

6)         Unless otherwise determined by the Director, other than an applicant for Certified Application Counselor certification, has submitted a full set of fingerprints to the Department and successfully completed a criminal background check in a manner prescribed by the Director. The Director may accept an equivalent criminal background check performed by the Navigator entity, In-Person Counselor entity or Certified Application Counselor Organization;

 

7)         When applicable, has the written consent of the Director pursuant to 18 USC 1033 or any successor statute regulating crimes by or affecting persons engaged in the business of insurance whose activities affect interstate commerce;

 

8)         Possesses the requisite character and integrity; and

 

9)         Has identified the entity with which the individual is affiliated and supervised, if any.

 

b)         An entity that acts as a Navigator, supervises or is responsible for the activities of individual Navigators, or receives funding to perform those activities shall obtain a Navigator entity certification. An entity applying for Navigator entity certification shall:

 

1)         Make application on a form containing the information prescribed by the Director; and

 

2)         Designate an individual registered as a Navigator to be responsible for the entity's compliance with this Chapter.

 

c)         An entity that acts as an In-Person Counselor, supervises or is responsible for the activities of individual In-Person Counselors, or receives funding to perform these activities shall obtain an In-Person Counselor entity certification. An entity applying for In-Person Counselor entity certification shall:

 

1)         Make application on a form containing the information prescribed by the Director; and

 

2)         Designate an individual registered as an In-Person Counselor to be responsible for the entity's compliance with this Chapter.

 

d)         An entity that acts as a Certified Application Counselor Organization, supervises or is responsible for the activities of individual Certified Application Counselors, or receives funding to perform those activities shall obtain a Certified Application Counselor certification.  An entity applying for a Certified Application Counselor certification shall:

 

1)         Make application on a form containing the information prescribed by the Director; and

 

2)         Designate an individual registered as a Certified Application Counselor to be responsible for the entity's compliance with this Chapter.

 

e)         The Director may require any documents deemed necessary to verify the information contained in an application submitted.

 

f)         Entities certified as Navigators, In-Person Counselors or Certified Application Counselor Organizations shall, in a manner prescribed by the Director, provide the Director with a list of all individual Navigators, In-Person Counselors or Certified Application Counselors that it employs, supervises, or is affiliated with on a quarterly basis.

 

(Source:  Amended at 43 Ill. Reg. 422, effective December 21, 2018)

 

Section 4515.60  Certification Renewal

 

a)         A Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization certification shall be valid for one year. A Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization certification shall expire 12 months after certification.

 

b)         Thirty days prior to the end of the 12 month period, a Navigator, In-Person Counselor, Certified Application Counselor or Certified Application Counselor Organization may file an application for renewal on the application prescribed by the Director.

 

c)         Prior to the filing date for application for renewal of a certification, an individual Navigator, In-Person Counselor and Certified Application Counselor shall complete the applicable federal training course curriculum for recertification as provided in Section 4515.100(b). The individual, at the time of application, shall file with the Director, by a method prescribed by the Director, proof of passing the applicable federal training course curriculum. Any failure to fulfill the ongoing continuing education requirements shall result in the expiration of the certification. Individual Navigators, In-Person Counselors or Certified Application Counselors whose certification has expired for failing to complete the continuing education requirements may not apply for a certification until they have provided satisfactory proof to the Director that they have completed the required continuing education requirements and have filed an application for certification.

 

(Source:  Amended at 43 Ill. Reg. 422, effective December 21, 2018)

 

Section 4515.70  Navigator, In-Person Counselor and Certified Application Counselor Prohibited Conduct

 

a)                   A Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization may not:

 

1)         sell, solicit, or negotiate, as these terms are defined in Section 500-10 of the Illinois Insurance Code, any of the classes of insurance enumerated in Section 4 of the Illinois Insurance Code;

 

2)         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 insurance products not offered in the exchange, except for health care providers when furnishing information or services related to a patient's existing health benefit plan or other existing health insurance coverage;

 

5)         accept any compensation or consideration, directly or indirectly, from any issuer of accident and health insurance or stop-loss insurance that is dependent, in whole or in part, on whether a person enrolls in or purchases a particular private health benefit plan; or

 

6)         engage in any unfair method of competition or any fraudulent, deceptive or dishonest act or practice with respect to the Marketplace or with respect to that individual's or entity's absence of a conflict of interest in connection with the enrollment of any individuals or employees in a particular private health benefit plan.

 

b)                  Subsections (a)(1) through (a)(5) do not apply to Navigators, In-Person Counselors, Certified Application Counselors or Certified Application Counselor Organizations when assisting individuals with the enrollment process in the State Medicaid program or other public programs.

 

c)                  A Navigator or In-Person Counselor may not:

 

1)                  Be a health insurance issuer or issuer of stop-loss insurance;

 

2)                  Be a subsidiary of a health insurance issuer or issuer of stop-loss insurance;

 

3)                  Be an association that includes members of, or lobbies on behalf of, the insurance industry; or

 

4)                  Receive any consideration directly or indirectly from any health insurance issuer or issuer of stop-loss insurance in connection with the enrollment of any individuals or employees in a Qualified Health Plan or Non-Qualified Health Plan.

 

Section 4515.80  Reporting to the Director

 

a)         Each certified Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization shall report to the Director any administrative action taken by a governmental agency against that person in this State or in any other jurisdiction within 30 calendar days after the final disposition of the matter. This report shall include a copy of the order, consent order, or other relevant legal documents.

 

b)         Each certified Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization shall immediately report to the Director any criminal prosecution of that person 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. Failure to report within 30 days following the hearing date shall be considered a violation of this Section.

 

c)         An entity certified under this Part as a Navigator, In-Person Counselor or Certified Application Counselor Organization that terminates the employment, engagement, affiliation, or other relationship with an individual Navigator, In-Person Counselor or Certified Application Counselor 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 Section 4515.70 or 4515.120, or the entity has knowledge the navigator or certified application counselor was found by a court or government body to have engaged in any of the activities in Section 4515.70 or  4515.120. 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 4515.90  Training Provider Responsibilities (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 422, effective December 21, 2018)

 

Section 4515.100  Responsibilities of the Applicant for the Navigator, In-Person Counselor or Certified Application Counselor Certification

 

a)         Prior to receiving approval for a Navigator, In-Person Counselor or Certified Application Counselor certification, the applicant must complete approved federal training courses prescribed by the Director.  Initial courses for Navigators, In-Person Counselors and Certified Application Counselors will be provided online.  An applicant for a Navigator, In-Person Counselor or Certified Application Counselor must complete the Director prescribed federal training courses within 12 months prior to certification.

 

b)         Certified Navigator, In-Person Counselor or Certified Application Counselor

 

1)         Each Navigator or In-Person Counselor shall complete 2 approved federal training courses prescribed by the Director to satisfy continuing education requirements prior to requesting a renewal of a certification.  The training courses will be provided online.

 

2)         Each Certified Application Counselor shall complete the same approved federal training courses that are prescribed by the Director as initial courses to satisfy continuing education requirements prior to requesting a renewal of a certification. The training courses will be provided online.

 

c)         Each Navigator, In-Person Counselor or Certified Application Counselor shall maintain a record of each course completed for 3 years from the date of completion.  The record shall include the name of the provider of the continuing education course, the course title, and the date of completion. Courses initiated or completed prior to the original issue date of the certificate shall not be used to meet continuing education requirements.

 

(Source:  Amended at 43 Ill. Reg. 422, effective December 21, 2018)

 

Section 4515.110  Continuing Education Course Design (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 422, effective December 21, 2018)

 

Section 4515.120  Certification Denial, Nonrenewal or Revocation

 

a)         The Director may place on probation, suspend, revoke, or refuse to issue or renew a Navigator, In-Person Counselor or Certified Application Counselor's certificate or may levy a civil penalty in accordance with this Section or take any combination of actions, for any one or more of the following causes:

 

1)         Providing incorrect, misleading, incomplete, or materially untrue information in the certificate application;

 

2)         Violating any insurance laws, or violating any rule, subpoena, or order of the Director or of another state's insurance Director;

 

3)         Obtaining or attempting to obtain a certificate through misrepresentation or fraud; 

 

4)         Obtaining or attempting to obtain any monies or properties from Illinois consumers while conducting navigator business;

 

5)         Intentionally misrepresenting the terms of an actual or proposed insurance contract;

 

6)         Having been convicted of a felony;

 

7)         Having admitted or been found to have committed any insurance unfair trade practice or fraud;

 

8)         Using fraudulent, coercive, or dishonest practices, or demonstrating incompetence, untrustworthiness or financial irresponsibility in the conduct of business in this State or elsewhere;

 

9)         Having a Navigator, In-Person Counselor or Certified Application Counselor certificate, or its equivalent, denied, suspended, or revoked in any other state, province, district or territory;

 

10)       Forging a name to an application for insurance or to a document related to an insurance transaction;

 

11)       Failing to comply with an administrative or court order imposing a child support obligation;

 

12)       Failing to pay Illinois state income tax or penalty or interest or comply with any administrative or court order directing payment of Illinois state income tax or failing to file a return or to pay any final assessment of any tax due to the Illinois Department of Revenue; or

 

13)       Failing to make satisfactory repayment to the Illinois Student Assistance Commission for a delinquent or defaulted student loan.

 

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 50 Ill. Adm. Code 2402.

 

c)         In addition to, or instead of, any applicable denial, suspension or revocation, a person may be subject to a civil penalty of up to $10,000 for each cause for denial, suspension or revocation; however, the civil penalty may total no more than $100,000.

 

Section 4515.130  Regulatory Examinations

 

a)         The Director may examine any applicant for or holder of a Navigator, In-person Counselor or Certified Application Counselor certificate or Navigator or In-Person Counselor entity certificate.

 

b)         All Navigators, In-Person Counselors or Certified Application Counselors being examined must provide to the Director convenient and free access, at all reasonable hours, at their offices, and/or comply with any requests, to all books, records, documents and other papers relating to the persons' navigator business affairs.  The Navigator, In-Person Counselor or Certified Application Counselor and employees must facilitate and aid the Director in the examinations, as much as it is in their power to do so.

 

c)         The Director may designate an examiner or examiners to conduct any examination under this Section.  The Director or his or her designee may administer oaths and examine under oath any individual relative to the business of the person being examined.

 

d)         The examiners designated by the Director under this Section may make reports to the Director.  A report alleging substantive violations of Illinois insurance laws, this Part or any rules prescribed by the Director must be in writing and be based upon facts ascertained from the books, records, documents, papers, and other evidence obtained by the examiners or from sworn or affirmed testimony of or written affidavits from the Navigator, In-Person Counselor or Certified Application Counselor employees or other individuals, as given to the examiners.  The report of an examination must be verified by the examiners.

 

Section 4515.140  Disqualifying Offense Review

 

Review Standards

Section 30(a) of the Illinois Navigator Act allows the Director to place on probation, suspend, revoke or refuse to issue or renew a Navigator, In-Person Counselor and Certified Application Counselor certification, levy a civil penalty, or take any combination of the preceding actions as established by rule.  Section 4515.120 of this Part allows the Director to place on probation, suspend, revoke, or refuse to issue or renew a Navigator, In-Person Counselor or Certified Application Counselor's certificate or levy a civil penalty or take any combination of these actions, when the Navigator, In-Person Counselor, Certified Application Counselor or applicant has been convicted of a felony. (See Section 4515.120(a)(6).) When reviewing Navigator, In-Person Counselor and Certified Application Counselor certifications or applications involving Navigators, In-Person Counselors or Certified Application Counselors who have been convicted of a felony, the Director shall consider the following factors in determining the appropriate action:

 

a)         Nature and severity of the criminal activity.  Violent criminals or sex offenders may be denied certification privileges, as well as those convicted of crimes which are insurance related and/or involve untrustworthiness;

 

b)         Time elapsed since the prior criminal conduct.  The greater the time period since the criminal conduct, the more leniency is appropriate.  When making this determination, the duration since the criminal activity should be proportionate to the severity of the criminal conduct;

 

c)         Absence of additional criminal conduct since the reported felony.  Continued criminal conduct of a lesser or greater nature should not be tolerated;

 

d)         Multiple offenses or pattern of criminal conduct.  Those engaged in repeated criminal conduct are a greater risk to the public;

 

e)         Restitution.  Payment to the victim of the felony is necessary to both satisfy the court order and to demonstrate penitence;

 

f)         Proper disclosure.  Failure to fully cooperate or properly report the criminal activity to the Department does not reflect favorably on the applicant's character;

 

g)         Satisfactory completion of sentence and probationary period.  The debt to society must be fully satisfied before the applicant is granted any further privileges;

 

h)         Rehabilitation.  Post-conviction community service or charitable activity may serve as evidence of rehabilitation;

 

i)          Nature of work performed.  There is less risk when the work to be performed does not involve money transactions or direct contact with the public; and

 

j)          Any other facts or circumstances deemed relevant by the Director.  Letters of recommendation addressed to the Director attesting to the character and reputation of the applicant or certificate holder may be considered by the Director.