Chapter 628

REGULATION OF NAVIGATORS

628.90 628.90 Definitions. In this subchapter:

628.90(1) (1) “Exchange” means the American health benefit exchange, as described in 42 USC 18031.

628.90(2) (2) “Health benefit plan” has the meaning given in s. 632.745 (11).

628.90(3) (3) 

628.90(3)(a) (a) Except as provided in par. (b), “navigator” means a natural person, or an entity that supervises or employs a natural person, who does all of the following:

628.90(3)(a)1. 1. Performs any of the activities and duties identified in 42 USC 18031 (i) and 45 CFR 155.210 on behalf of the exchange.

628.90(3)(a)2. 2. Receives funding to perform any of the activities and duties identified in 42 USC 18031 (i) and 45 CFR 155.210 on behalf of the exchange.

628.90(3)(b) (b) “Navigator” does not include a person acting as an insurance intermediary licensed under subch. II, but an insurance intermediary may apply to be licensed as a navigator under this subchapter.

628.90(4) (4) “Nonnavigator assister” means a natural person who has been designated by the exchange, or could reasonably be described as working at the behest of the exchange, as a nonnavigator assister, including an in-person assister, enrollment assister, application assister, or certified application counselor.

628.90 History History: 2013 a. 20.

628.91 628.91 Requirement of licensure or registration. No natural person or entity may act as a navigator in this state unless licensed or registered as a navigator under s. 628.92.

628.91 History History: 2013 a. 20.

628.92 628.92 Issuance of license and registration.

628.92(1) (1) Individual license. A natural person applying for a navigator license shall make application to the commissioner on a form developed by the commissioner and shall declare under penalty of refusal, suspension, or revocation of the license 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 commissioner shall find that the person satisfies all of the following:

628.92(1)(a) (a) Is at least 18 years of age.

628.92(1)(b) (b) Resides in this state or maintains his or her principal place of business in this state.

628.92(1)(c) (c) Has completed the training and course of study requirements under sub. (7) and any training and course of study requirements mandated by the exchange.

628.92(1)(d) (d) Has successfully passed a written examination approved by the commissioner under sub. (7) that tests the applicant’s knowledge concerning the duties and responsibilities of a navigator, the insurance laws and regulations of this state, and state public assistance programs and eligibility.

628.92(1)(e) (e) Has submitted a full set of fingerprints to the commissioner and successfully completed a regulatory and criminal history background investigation in a manner prescribed by the commissioner under sub. (6).

628.92(1)(f) (f) Possesses the requisite character, integrity, competency, and trustworthiness as determined in accordance with the criteria under the rules promulgated under s. 628.04.

628.92(1)(g) (g) Has not committed any act that the commissioner finds would warrant the denial, suspension, or revocation of a license under this subchapter.

628.92(1)(h) (h) Has identified the entity with which he or she is, or will be, affiliated and by which he or she is, or will be, supervised, if any.

628.92(1)(i) (i) Has paid the applicable licensing fee as set forth in s. 601.31 (1) (nm).

628.92(2) (2) Entity registration. An entity that acts or intends to operate as a navigator, supervises the activities of individual navigators, or receives funding to perform such activities shall first register as a navigator entity with the commissioner. This registration shall be on an application form developed by the commissioner, which shall include such documentation as the commissioner determines is necessary and appropriate. Before the commissioner may register the entity, the entity must establish to the satisfaction of the commissioner that it satisfies all of the following:

628.92(2)(a) (a) The entity has policies and procedures in place to ensure that all acts that may be performed only by a navigator or licensed intermediary are performed by persons who are appropriately licensed under this subchapter or subch. II, or both.

628.92(2)(b) (b) The entity will assume full legal responsibility for the acts of the individual navigators that it employs, supervises, or is affiliated with that are performed in this state and that are within the scope of the navigator’s apparent authority.

628.92(2)(c) (c) The entity is sound, reliable, and entitled to public confidence.

628.92(2)(d) (d) The entity has paid the applicable registration fee as set forth in s. 601.31 (1) (np).

628.92(2)(e) (e) The entity has identified on the registration form a designated responsible individual navigator who is licensed under this subchapter.

628.92(3) (3) Documentation. The commissioner may require any documents necessary to verify the information contained in an application submitted under sub. (1) or (2).

628.92(4) (4) List of individual navigators. Upon initial registration, navigator entities shall, in a manner prescribed by the commissioner, provide the commissioner with a list of all individual navigators that it employs, supervises, or is affiliated with. Thereafter, the navigator entity shall provide updates, if any, to the list of individual navigators on a monthly basis. A navigator entity is bound by the acts of each individual navigator who has been, or should have been, reported under this subsection that are performed in this state and that are within the scope of the individual navigator’s apparent authority.

628.92(6) (6) Fingerprints and criminal and regulatory background check. Each applicant for licensure as an individual navigator shall provide fingerprints in a format specified by the commissioner and complete a criminal and regulatory background check as a condition for being granted a license to act as a navigator. The commissioner shall use the fingerprints to conduct a state criminal history background investigation of the applicant and a national criminal history background investigation of the applicant with the federal bureau of investigation.

628.92(7) (7) Training and examination. An individual navigator shall complete at least 16 hours of prelicensing training and satisfactorily complete an approved written examination for navigators before applying for an individual navigator’s license. After licensure, an individual navigator shall complete a course of study of at least 8 hours of approved training every one-year period. The commissioner may approve and designate courses and programs that an applicant for a navigator’s license may complete to fulfill the prelicensing training requirement or that a licensed navigator may complete to fulfill the annual training requirement. The commissioner may make arrangements, including contracting with an outside testing service or other appropriate entity, to administer examinations and collect fees.

628.92 History History: 2013 a. 20; 2023 a. 212.

628.93 628.93 Other applicable provisions.

628.93(1) (1) Social security and federal employer identification numbers on applications or at time of fee payment. Applicants for individual navigator licensure and navigator entity registration are subject to s. 628.095.

628.93(2) (2) Refusal to issue license; failure to pay support or to comply with subpoena or warrant; delinquent taxes or unemployment insurance contributions. Applicants for individual navigator licensure and navigator entity registration are subject to s. 628.097.

628.93(3) (3) Termination of license. Individual navigator licenses are subject to s. 628.10.

628.93 History History: 2013 a. 20, 276.

628.95 628.95 Navigator and nonnavigator assister conduct.

628.95(1) (1) General. For purposes of this subchapter, a navigator or nonnavigator assister, in the performance of its duties, shall be considered to be transacting the business of insurance.

628.95(2) (2) Prohibited practices. A navigator or nonnavigator assister may not do any of the following:

628.95(2)(a) (a) Receive compensation from an insurer who offers a health benefit plan or stop loss insurance or from a 3rd-party administrator.

628.95(2)(b) (b) Provide any information or services related to enrollment in health benefit plans or other insurance products not offered in the exchange.

628.95(2)(c) (c) Make or cause to be made any communication relating to the exchange, health benefit plans, an insurance contract, the insurance business, any insurer, any navigator, any nonnavigator assister, or any intermediary that contains false, deceptive, or misleading information, including information that is misleading because of incompleteness.

628.95(2)(d) (d) Provide advice about which health benefit plan is better or worse for a particular individual or employer.

628.95(2)(e) (e) Recommend a particular health benefit plan or insurer or advise consumers about which health benefit plan to choose.

628.95(2)(f) (f) Engage in any unfair method of competition or any other unfair, fraudulent, deceptive, or dishonest act or practice.

628.95(2)(g) (g) Receive compensation that is dependent, in whole or in part, on whether an individual enrolls in or renews a health benefit plan.

628.95(3) (3) Restitution. The commissioner may require that any person that violates this subchapter make restitution to any individual who suffers financial injury because of the violation of this subchapter.

628.95 History History: 2013 a. 20.

628.96 628.96 Nonnavigator assisters.

628.96(1) (1) Registration required. Any entity that employs one or more nonnavigator assisters shall, in a manner prescribed by the commissioner, provide the commissioner with a list of all nonnavigator assisters that it employs, supervises, or is affiliated with upon the nonnavigator assisters first becoming authorized by the exchange to provide nonnavigator assistance. Thereafter, the entity shall provide updates, if any, to the list of nonnavigator assisters on a monthly basis. No nonnavigator assister may act as a nonnavigator assister in this state until registered with the commissioner. The commissioner may refuse to register any nonnavigator assister to which any of the following applies:

628.96(1)(a) (a) The nonnavigator assister does not possess the requisite character, integrity, competency, and trustworthiness as determined in accordance with the criteria under the rules promulgated under s. 628.04.

628.96(1)(b) (b) The nonnavigator assister has committed any act that the commissioner finds would warrant the denial, suspension, or revocation of a license or registration under this subchapter.

628.96(2) (2) Application counselors. In addition to the requirements of this section, certified application counselors, as established by 45 CFR 155.225, shall be required to meet the training and examination requirements set forth in s. 628.92 (7). Certified application counselors may also become licensed as individual navigators.

628.96(3) (3) Entity liability. An entity that employs, supervises, or is formally affiliated with a nonnavigator assister assumes legal responsibility for the acts of the nonnavigator assister that are performed in this state and that are within the scope of the nonnavigator assister’s apparent authority to act as a nonnavigator assister on behalf of that entity.

628.96(4) (4) Exemption for government entities. This section does not apply to any government entity or any person acting on behalf of a government entity.

628.96 History History: 2013 a. 20.

628.98 628.98 Rules. The commissioner may promulgate any rules necessary to carry out the purposes of this subchapter. Notwithstanding s. 227.24 (1) (a) and (3), the commissioner may promulgate rules under this section as emergency rules under s. 227.24 without providing evidence that promulgating a rule under this section as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and without a finding of emergency.

628.98 History History: 2013 a. 20.