Health Insurance Agent vs. Navigator: What’s the Difference?

Shopping for health insurance can be a confusing process. You may need some assistance in choosing the right options, getting the subsidies you are entitled to receive, and enrolling in a health plan. You may be able to get the help you need through either a health insurance agent or a navigator. Although both agents and navigators can help you enroll in a health plan, there are significant differences between the two.

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What Is the Role of a Health Insurance Agent?

A licensed health insurance agent can serve as a personal shopper for health insurance – with expertise. Agents can explain plan details and help determine if you are eligible for subsidies or Medicaid. Unlike navigators, they can also recommend a particular plan based on your circumstances. An agent can also continue to assist you after you purchase a health plan with questions or problems regarding utilization, medical claims, billing, or appeals. Health insurance agents are not only certified by the government exchange but also licensed by a state department of insurance. They must receive specialized training about the products they sell from both the insurance companies they represent and state regulatory agencies.

What Is the Role of an Exchange Navigator?

The purpose of a health insurance navigator is to provide individuals with impartial education about exchanges and health plans. Navigators also help applicants determine if they qualify for Medicaid or subsidies and help them enroll if they do. In addition, navigators have certain optional duties. These include:

Helping people file eligibility appeals (although they cannot represent an individual in an appeal)
Assisting with post-enrollment coverage issues
Providing information about premium tax credits
Assisting with filing for shared responsibility exemptions
Educating individuals on basic concepts regarding use of their health coverage
Providing targeted assistance to underserved or vulnerable populations

What Are the Similarities and Differences Between Agents and Navigators?

Health insurance agents and navigators can both help you use the government exchange to enroll in health insurance, and there is no charge for their services. They can also assist you with applying for subsidies to lower your health insurance costs. Both have some training and are certified as guides for the state exchange. Along with the similarities, there are some significant differences between agents and navigators:

Only a health insurance agent can recommend a plan based on your needs and budget. Navigators are not allowed to make plan recommendations.
Navigators have not been around as long as agents. Their role only came into existence in 2013. For this reason, agents may have more experience than navigators.
Agents are licensed by state departments of insurance. They complete ongoing insurance training and pass examinations, ensuring their knowledge of health insurance is current. Navigators may be volunteers working for non-profit organizations who only help people with insurance matters during open enrollment. They do not have the same education requirements as agents.
Health insurance agents are qualified and authorized to help you understand health plans that are not on a government exchange. Navigators are not.
If you have a problem with your health insurance company, an agent can act as your advocate. A navigator cannot deal with the insurance company on your behalf.