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But even with its product renaissance, Lincoln lags in eighth place among luxury and premium brands in the U. Lincoln's design team ditched the giant gull-wing doors that debuted on the concept version of the Navigator revealed a year ago in New York. On the interior, design director David Woodhouse said Lincoln used "horizontal layering to imbue a sense of equilibrium and calmness and balance. Lincoln has changed direction several times in recent years with the design of its front grille but has now settled on a mesh grille with a Lincoln logo in the center. That grille debuted in on the MKZ and also is on the recently launched Continental.

The shape of each opening in the grille is an outline of the Lincoln star. The front end also has two layers of LED headlights that will give the Navigator a distinctive look at night. The Navigator is a big vehicle and pretty much all of its features, including the center console and storage space, are big as well. The center storage compartment between the front seats is downright table-like with bleached teak wood serving as storage compartment doors that can be opened with push-buttons. Easy-to-reach USB charging ports are located inside one of the compartments.

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Drivers will put the car into drive using a horizontally designed set of keys reminiscent of piano keys — a design element that Lincoln says will appear in other future models. The Navigator offers four different driving modes that can be changed by turning a dial. They are: conserve, slippery, deep conditions and excite. The seats in the Navigator have a horizontal ribbing that provide added comfort and fit in with the overall design theme.


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Atop the center console is a inch infotainment screen that looks more like a small TV or an iPad than a normal vehicle display. In addition, certified application counselors cannot charge consumers for their services, as provided in this final rule. The primary differences between the existing and proposed standards for Navigators and non-Navigator assistance programs, and the proposed standards for certifying certified application counselors in all Exchanges, which we finalize in this rulemaking, relate to the requirement that Navigators and non-Navigator assistance personnel perform public outreach and comply with detailed conflict of interest standards, eligibility requirements and prerequisites, as well as CLAS and disability access standards.

Comment: A number of commenters requested that HHS clarify in the regulations that the nondiscrimination provisions applicable to the Exchanges apply to all consumer assistance programs, including Navigators, non-Navigator assistance personnel, and certified application counselors.

Therefore, in order for an Exchange to comply with these nondiscrimination provisions, it must ensure that its Navigators, any activities authorized under See 77 FR at Comment: One commenter explained that it is critical that no barriers are imposed that would disrupt the enrollment assistance relationships that Indian health providers have with consumers, and urged us not to create standards so onerous that they cannot be met by volunteers.

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Response: Nothing in this final rulemaking requires Indian health providers to change their current relationships with the consumers they serve. This regulation does not require them to be trained or registered as non-Navigator assistance personnel, Navigators, or certified application counselors in order to continue their existing work. Comment: Some commenters observed that general rules regarding non-discrimination are often translated into a requirement to serve anyone who seeks the service.

However, Exchange Navigator, non-Navigator assistance, and certified application counselor services are not Indian health programs or benefits authorized by the Indian Health Care Improvement Act, so the same limitation does not apply to them. As we stated in the preamble to the proposed rule, while Navigators and non-Navigator assistance personnel should have the ability to help any individual who presents him or herself for assistance, there may be some instances where a Navigator or non-Navigator assistance personnel lacks the immediate capacity to help an individual.

In such cases, the Navigator or non-Navigator assistance personnel should be capable of providing assistance in a timely manner but must also refer consumers seeking assistance to other Exchange resources, such as the toll-free Exchange call center, or to another Navigator or non-Navigator assistance personnel in the same Exchange who might have better capacity to serve that individual more effectively. The same principle would apply to certified application counselor services. Comment: A number of commenters requested that all individuals providing consumer assistance be required to provide equal access to individuals with limited English proficiency and individuals with disabilities.

Response: Sections These standards will apply to Navigators and non-Navigator assistance personnel in all Federally-facilitated Exchanges, including State Partnership Exchanges, and to non-Navigator assistance personnel in State Exchanges that are funded with a Exchange Establishment grants. Comment: One commenter asked that consumer assistance be available to those who wish to apply via paper application rather than electronically.

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Response: While we strongly encourage all types of assistance personnel to help consumers apply for and enroll in coverage electronically, we also expect all types of assistance personnel to help consumers who wish to apply on paper. Comment: Several commenters asked HHS to encourage states to have a single training program for all Exchange consumer assistance programs, with one commenter recommending that HHS clarify that states may develop a single set of training materials for Navigators, non-Navigator assistance personnel, and certified application counselors, as stated in the preamble to the proposed certified application counselor rule.


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Response: Section These standards do not apply to certified application counselors. State Exchanges may, at their option, base their own training programs for Navigators, for other kinds of non-Navigator assistance personnel and for certified application counselors on these standards, or they may adopt the Federal standards and training materials.

State Exchanges may use their Navigator training for non-Navigator personnel funded through a grants if the training meets the standards in the final rule. State Exchanges are encouraged to have the same training across all of their programs. A few commenters suggested that non-Navigator assistance personnel be trained on how to address the concerns of mixed-status immigrant families to encourage enrollment by eligible members of those families.

However, we encourage knowledgeable assistance personnel to help consumers access other programs, such as drug assistance programs and Ryan White programs. This amendment clarifies that Consumer Assistance Programs established under section of the Public Health Service Act are an available and appropriate resource in many states to which Navigators, non-Navigator assistance programs, and certified application counselors can refer consumers for additional assistance.

Moreover, we expect that the entities specified in this provision are able and willing to provide assistance and accept referrals. The provisions and amendments discussed in this section were proposed in the April 5, proposed rule 78 FR In addition, holding an agent or broker license is neither necessary, nor by itself sufficient, to perform the duties of a Navigator, as these licenses generally do not address areas in which Navigators need expertise, including the public coverage options that will be available to some consumers. Comment: Generally, commenters supported the proposed amendment to 45 CFR Some commenters requested additional guidance on what types of state requirements would and would not be preempted under this provision; for example, whether a state requirement that Navigators obtain a surety bond would be preempted by this provision.

Other commenters requested we extend this provision to apply to non-Navigator assistance personnel as well. We are monitoring relevant state legislation and will work with states to help ensure that state legislation does not prevent the application of a provision of title I of the Affordable Care Act and the federal regulations implementing it. We are adopting the proposed amendment without modification. While we are not including parallel provisions applicable to non-Navigator assistance personnel and certified application counselors in this final rule, we note that Affordable Care Act section d also applies to those programs.

Comment: Some commenters raised concerns about the impact of Navigator and non-Navigator assistance programs on the business of licensed agents and brokers. Some commenters believed the requirements for these programs would prevent agents and brokers from participating. Response: Licensed agents or brokers are eligible to serve as Navigators or non-Navigator assistance personnel as long as they meet the applicable requirements; however, during their term as Navigators or non-Navigator assistance personnel, they would not be permitted to receive any direct or indirect consideration from a health insurance or stop loss insurance issuer in connection with the enrollment of any individuals or employees in QHPs or non-QHPs.

In addition, subject to applicable state law, agents and brokers are not otherwise prohibited from assisting consumers with enrollment both inside and outside of the Exchanges. We expect that agents and brokers will continue to play an important role in educating consumers about their health coverage options and, unlike Navigators and non-Navigator assistance personnel, will also be able to sell consumers health insurance coverage.

In addition, many states are expecting that small businesses seeking enrollment assistance in the Small Business Health Options SHOP Exchange will continue to use agents and brokers as their primary resource, subject to applicable state law. We proposed to amend section Section i of the Affordable Care Act requires a Navigator to distribute fair and impartial information concerning enrollment in QHPs, to be free from conflicts of interest, and directs that standards be established to ensure that those requirements are met.

Existing regulations at 45 CFR Taken together, these provisions indicate that, with respect to the assistance offered by a Navigator to a small employer, a Navigator should not have a personal interest in whether a small employer chooses to self-insure its employee health plan, or chooses to enroll in fully-insured coverage inside or outside the Exchange. In the proposed rule, we explained that these amendments would help ensure that Navigators provide any small employer that requests help from a Navigator with information and services in a fair, accurate, and impartial manner, as such information would facilitate small employers' selection of QHPs in Small Business Health Options SHOP Exchanges, if they choose to enroll in such coverage.

We solicited public comments on this proposal. Comment: CMS received comments supporting the addition of stop loss insurance issuers and their subsidiaries to the provisions at 45 CFR One commenter requested clarification regarding the definition of stop loss insurance.

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Response: The proposed rule did not define stop loss insurance or stop loss insurance issuer and we are not adding a definition of stop loss insurance or stop loss insurance issuer to the final rule. See 77 FR That RFI describes stop loss insurance as designed to protect against health insurance claims that are catastrophic or unpredictable in nature, and as providing coverage to self-insured group health plans once a certain level of risk has been absorbed by the plan.

For purposes of this final rule, we continue to interpret the terms stop loss insurance and stop loss insurance issuer as having meanings consistent with the discussion in the RFI. Comment: A few commenters requested guidance on whether selling other insurance products, such as Medicare health plans, accident plans, cancer-only or other dread disease plans, hospital expense, or critical illness plans, would be a prohibited conflict of interest making someone ineligible to be a Navigator or non-Navigator assistance personnel. Such term does not include a group health plan.


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If an entity or one of its corporate affiliates is required to be licensed to engage in the business of insurance in a state and is subject to state law that regulates insurance, it might be a health insurance issuer or stop loss issuer or have a relationship with a health insurance issuer or stop loss issuer that would prohibit it from becoming non-Navigator assistance personnel. Within the Federally-facilitated Exchanges, CMS will evaluate specific corporate structures on a case by case basis. Comment: Commenters requested clarification that a health care provider's contract with a health plan including a QHP to provide health services as part of the plan network would not preclude the provider from being eligible to be a Navigator or non-Navigator assistance personnel.

Some commenters noted that this relationship should still be disclosed as a non-prohibited conflict of interest. Commenters also requested clarification that a grant offered by a plan for a restricted purpose, such as in support of providing services to the uninsured or to help finance a program or capital project, does not constitute consideration directly or indirectly for enrollment of individuals into a QHP or non-QHP. Commenters also noted that some health centers may receive federal grants under section of the Public Health Service Act that can be used to plan and develop a managed care network plan.

Response: We are finalizing without change the proposed amendment to 45 CFR We interpret the prohibition on receiving direct or indirect consideration from a health insurance or stop loss insurance issuer to apply to consideration received for enrolling individuals or employees in health insurance plans or stop loss insurance inside or outside the Exchanges; it does not apply to consideration received by a provider to support specific activities, such as the provision of medical services, that are not connected to the enrollment of individuals or employees in QHPs.

It is possible that a provider would be required to disclose to the Exchange and consumers receiving application assistance from staff serving as Navigators or non-Navigator assistance personnel, the fact that it receives issuer funds that are unrelated to the enrollment of individuals or employees into health insurance plans, but this would not be a bar to serving as a Navigator or non-Navigator assistance personnel. Such disclosure would not Start Printed Page include proprietary information about reimbursements received from issuers. Similarly, an entity that receives a grant or other funding from a health insurance or stop loss insurance issuer would not be prohibited from serving as a Navigator or non-Navigator assistance personnel unless such grant or funding is related to the enrollment of individuals or employees in a QHP or non-QHP.

However, the entity would need to disclose the receipt of the grant or funding from the issuer to the Exchange and consumers receiving application assistance. With respect to health centers that may receive federal grants under section of the Public Health Service Act that can be used to plan and develop a managed care network plan, as stated earlier, whether or not an entity is or is not a health insurance issuer is determined by state law.

If these health centers would not be required to be licensed to engage in the business of insurance in a state or subject to state law that regulates insurance, then the health center would not be ineligible to serve as a Navigator or non-Navigator assistance personnel, assuming all other eligibility criteria are also satisfied.

Comment: Some commenters requested guidance regarding the situation where a large organization, such as a hospital, has some but not all employees serving as Navigators or non-Navigator assistance personnel. In this situation, commenters requested clarification about whether all employees of the organization need to be free of prohibited conflicts of interest, or whether only the employees providing Navigator or non-Navigator assistance personnel services need to be free of prohibited conflicts of interest.

Response: Only the Navigator grantee and the staff members and volunteers who work on the Navigator program or perform Navigator services under the grant are required to be free of prohibited conflicts of interest. Therefore, staff or employees of a Navigator grantee who are in no way involved in the Navigator program are not required to comply with the conflict of interest standards that are applicable to the Navigator program staff.

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Section i 4 of the Affordable Care Act directs the Secretary to establish standards for Navigators, including provisions to avoid conflicts of interest. We have explained that having a conflict of interest means having a private or personal interest sufficient to influence, or appear to influence, the objective exercise of a Navigator's official duties 77 FR through We solicited public comments on the proposal to require Navigators to submit an attestation regarding eligibility.

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We stated that this would be particularly important for those Navigator grantees that may have a changing workforce, and might thus utilize new or different staff or employees during the term of a Navigator grant. We solicited public comments on the proposed requirement to submit a written plan to remain free of conflicts of interest, including comments on the form of and content for the plan. The requirement that an Exchange develop standards to minimize and mitigate conflicts of interests suggests that some conflicts of interest would not be absolute bars to service as a Navigator, provided that the conflict of interest would not ultimately prevent the entity or individual from providing information and services in a fair, accurate, and impartial manner.

Striking this balance will allow for a robust pool of Navigators while ensuring all Navigators have the Start Printed Page integrity, fairness, and impartiality to carry out their duties appropriately. In order to mitigate conflicts of interest, we proposed three types of information that Navigators, including Navigator staff, must disclose to the Exchange and to their consumers.

First, Navigators would be required to disclose to the Exchange and to each consumer who receives application assistance from the Navigator entity or individual, any lines of insurance business, other than health insurance or stop loss insurance, which the Navigator intends to sell while serving as a Navigator. In addition, we proposed to require disclosure of two other types of indirect financial conflicts of interest.

We stated that Navigators and their staff members would be required to disclose to the Exchange and each consumer receiving application assistance, any existing and former employment relationships they have had within the last five years with any issuer of health insurance or stop loss insurance, or subsidiaries of such issuers. We specified that Navigators and their staff must also disclose any existing employment relationships between any health insurance issuer or stop-loss insurance issuer, or subsidiary of such issuers, and the Navigator or staff member's spouse or domestic partner.

Navigators and their staff members would also be required to disclose to the Exchange, and to each consumer receiving application assistance, any existing or anticipated financial, business, or contractual relationships with one or more issuers of health insurance or stop loss insurance or subsidiaries of such issuers.