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

 

"Act" means the Navigator Certification Act [215 ILCS 121].

 

"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 (Apr. 27, 2023) (no later editions or amendments).

 

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

 

"Federal training curriculum" means the curriculum implemented by the United States Department of Health and Human Services under 45 C.F.R. 155.215(b) (Apr. 25, 2019) (no later editions or amendments).

 

"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 (May 5, 2021) (no later editions or amendments) 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 U.S.C. 36B and cost-sharing reductions under 42 U.S.C. 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 U.S.C. 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 U.S.C. 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 (Apr. 27, 2023) (no later editions or amendments).  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 U.S.C. 36B and cost-sharing reductions under 42 U.S.C. 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 U.S.C. 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 U.S.C. 18021(a).

 

(Source:  Amended at 48 Ill. Reg. 12343, effective August 1, 2024)

 

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 must make an 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 must find that the individual:

 

1)         Is at least 18 years of age;

 

2)         Maintains a 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 curriculum 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 U.S.C. 1033 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 I.

 

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 I.

 

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 48 Ill. Reg. 12343, effective August 1, 2024)

 

Section 4515.60  Certification Renewal

 

a)         A Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization certification shall be valid, through October 31 of the plan year for which the certificate holder successfully completed the applicable federal training curriculum.

 

b)         Sixty days before the end of the certification 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)         Before the filing date for application for renewal of a certification, an individual Navigator, In-Person Counselor and Certified Application Counselor must complete the applicable federal training curriculum for recertification as provided in Section 4515.100. The individual, at the time of application, must file with the Director, by a method prescribed by the Director, proof of passing the applicable training course curriculum. Any failure to fulfill the ongoing continuing education requirements will 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 48 Ill. Reg. 12343, effective August 1, 2024)

 

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 or Renewal

 

a)         Before 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's prescribed federal training courses within 12 months prior to certification.

 

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

 

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

 

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

 

c)         Each Navigator, In-Person Counselor, or Certified Application Counselor must retain the certificate of completion from each course or federal training curriculum completed for 3 years from the date of completion.   Courses initiated or completed before the original issue or most recent renewal date of the Navigator, In-Person Counselor or Certified Application Counselor certificate cannot be used to meet continuing education requirements.

 

d)         For certificates to perform Navigator or Certified Application Counselor activities in a State-based Exchange on the Federal Platform or a Federally-facilitated Exchange, an applicant or certificate holder must use the online federal training curriculum to satisfy their pre-certification and continuing education requirements.  Applicants and certificate holders must register for the Marketplace Learning Management System (MLMS) application at https://portal.cms.gov and must successfully complete the HHS-approved training modules prescribed in MLMS for the applicable certification. 

 

(Source:  Amended at 48 Ill. Reg. 12343, effective August 1, 2024)

 

Section 4515.110  Continuing Education Course Design (Repealed)

 

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

 

Section 4515.120  Certification Denial, Suspension, Nonrenewal, Probation, 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 law, or violating any administrative 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 property 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, unless the individual demonstrates to the Director sufficient rehabilitation to warrant the public trust in accordance with Section 4515.140;

 

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 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, revoke, or deny a certificate or to place an applicant or certificate holder on probation, then the Director will notify the applicant or certificate holder and advise, in writing, the applicant or certificate holder of the reason for the suspension, revocation, denial, nonrenewal, or probation 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 will be held within not fewer than 20 days nor more than 30 days after the mailing of the notice of hearing and will 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.

 

(Source:  Amended at 48 Ill. Reg. 12343, effective August 1, 2024)

 

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  Felony Offense Review

 

a)         The Director and the Department will not require applicants or certificate holders to report the following information and will not collect and consider the following criminal history records in connection with a certificate under this Part:

 

1)         Juvenile adjudications of delinquent minors as defined in Section 5-105 of the Juvenile Court Act of 1987, subject to the restrictions set forth in Section 5-130 of that Act;

 

2)         Law enforcement records, court records, and conviction records of an individual who was 17 years old at the time of the offense and before January 1, 2014, unless the nature of the offense required the individual to be tried as an adult;

 

3)         Records of arrest not followed by a charge or conviction;

 

4)         Records of arrest where charges were dismissed unless related to the duties and responsibilities of a Navigator, Certified Application Counselor, or In-Person Counselor. However, individuals will not be asked to report any arrests, and any arrest not followed by a conviction will not be the basis of disciplinary action by the Director and may be used only to assess an individual's rehabilitation.  Nothing in this subsection relieves a Navigator or Certified Application Counselor certificate holder of the requirement to report any criminal prosecution taken in any jurisdiction to the extent provided in Section 35 of the Act;

 

5)         Convictions overturned by a higher court;

 

6)         Convictions or arrests that have been sealed or expunged.

 

b)         The Director, upon a finding that an individual was previously convicted of a felony, will consider any mitigating factors and evidence of rehabilitation contained in the individual's record, including any of the following factors and evidence, to determine if a certificate may be denied, suspended, or revoked because the prior conviction will impair the individual's ability to engage in the position for which a certificate is sought:

 

1)         the bearing, if any, of the offense for which the individual was previously convicted on the duties and functions of the position for which a certificate is sought;

 

2)         whether the conviction suggests a future propensity to endanger the safety and property of others while performing the duties and responsibilities for which a certificate is sought;

 

3)         whether 5 years since a felony conviction or 3 years since release from confinement for the conviction, whichever is later, have passed without a subsequent conviction;

 

4)         if the individual was previously certified or employed in this State or other states or jurisdictions, then the lack of prior misconduct arising from or related to the certified position or position of employment;

 

5)         the individual's age at the time of the criminal offense;

 

6)         successful completion of sentence and, for individuals serving a term of parole or probation, a progress report provided by the individual's probation or parole officer that documents the individual's compliance with conditions of supervision;

 

7)         evidence of the individual's present fitness and professional character;

 

8)         evidence of rehabilitation or rehabilitative effort during or after incarceration or during or after a term of supervision, including, but not limited to, a certificate of good conduct under Section 5-5.5-25 of the Unified Code of Corrections or certificate of relief from disabilities under Section 5-5.5-10 of the Unified Code of Corrections; and

 

9)         any other mitigating factors that contribute to the person's potential and current ability to perform the duties and responsibilities of a certificate holder.

 

c)         If the Director denies, suspends, or revokes a certificate based upon a conviction or convictions in whole or in part, then the Director will notify the applicant of the disciplinary action in writing with the following included in the notice:

 

1)         a statement about the decision to deny, suspend, or revoke the certificate;

 

2)         a list of convictions that the Director determined will impair the individual's ability to engage in the position for which the certificate is sought;

 

3)         a list of the convictions that were the sole or partial basis for the disciplinary action; and

 

4)         a summary of the appeal process or the earliest the individual may reapply for a certificate, whichever applies.

 

(Source:  Amended at 48 Ill. Reg. 12343, effective August 1, 2024)