Finding Local Help: Navigators vs. Brokers for Marketplace Enrollment

Last updated 2 days ago. Our resources are updated regularly but please keep in mind that links, programs, policies, and contact information do change.

The Health Insurance Marketplace, established by the Affordable Care Act (ACA), serves as a central hub for individuals and families to find, compare, and enroll in health insurance coverage. Many people can also access financial assistance, such as premium tax credits and cost-sharing reductions, through the Marketplace to make coverage more affordable. While the Marketplace aims to simplify shopping for health insurance, the process can still feel complex, with numerous plan options, eligibility rules, and financial considerations.

Fortunately, individuals seeking coverage are not alone. Various types of free or expert assistance are available to help navigate the application and enrollment process. Two primary sources of help are Health Insurance Navigators and licensed Health Insurance Brokers (often called Agents). Understanding the distinct roles, responsibilities, and limitations of these helpers is crucial for choosing the support that best fits an individual’s needs.

This guide provides a thorough comparison of Navigators and Brokers to help consumers make an informed decision when seeking assistance with Marketplace enrollment. The existence of different types of assistance programs itself underscores the recognized complexity of the health insurance landscape and the varied needs of consumers trying to secure coverage. Government resources like the “Find Local Help” tool are specifically designed to connect people with these different support options.

What is a Health Insurance Navigator?

Role and Responsibilities

Health Insurance Navigators are individuals or organizations specifically created by the Affordable Care Act under Section 1311(i) to provide impartial assistance to consumers enrolling in health coverage through the Marketplace. The Navigator role was first implemented in the fall of 2013 when the Marketplaces initially opened. Navigators work for community-based organizations, non-profits, or other entities that receive federal or state grants specifically designated for Navigator activities.

Their core duties encompass a wide range of support activities designed to help consumers understand their options and successfully enroll:

• Outreach and Education: Navigators conduct public education activities to raise awareness about the Health Insurance Marketplace, available coverage options, and the importance of health insurance. This outreach is often targeted toward communities that historically face barriers to coverage.
• Eligibility Assessment: They assist consumers in understanding their eligibility for various programs, including private health plans offered through the Marketplace (Qualified Health Plans or QHPs), financial assistance like premium tax credits and cost-sharing reductions, and public programs like Medicaid and the Children’s Health Insurance Program (CHIP).
• Application and Enrollment Assistance: Navigators provide hands-on help with completing and submitting Marketplace applications and enrolling in selected health plans.
• Serving Underserved Populations: A key focus of the Navigator program is providing targeted assistance to underserved, vulnerable, and uninsured populations. This includes individuals with limited English proficiency, those without internet access at home, people with disabilities, racial and ethnic minorities, LGBTQ individuals, the elderly, individuals experiencing homelessness, and families with mixed immigration statuses. Navigators are often embedded in communities and build trust to effectively reach these groups.
• Post-Enrollment Support: Unlike many other types of assistance, Navigators are explicitly required to offer help after enrollment. This critical function includes assisting consumers with:
  • Understanding how to use their health insurance (e.g., finding in-network providers, understanding cost-sharing like deductibles and copays, knowing when to seek primary vs. emergency care)
  • Navigating eligibility appeals if the Marketplace determination seems incorrect
  • Understanding the process for reconciling premium tax credits when filing federal taxes
  • Addressing issues with premium payments
  • Helping with appeals related to claim denials or pre-authorization denials
  This post-enrollment support is vital for ensuring that having an insurance card translates into actual access to healthcare, particularly for individuals new to insurance or facing systemic barriers.
• Referrals: Navigators can refer consumers to appropriate consumer assistance programs or health insurance ombudsman offices for help with grievances or complaints beyond their scope.
• Initiating Contact (Rule Change): Federal regulations updated for 2024 allow Navigators in federally-run Marketplaces to initiate direct contact with potential enrollees (e.g., following up after an outreach event) and provide enrollment assistance immediately. Previously, they had to wait for the consumer to re-initiate contact specifically for enrollment help after an initial outreach contact. This change aims to help Navigators reach and enroll more consumers efficiently.

It’s important to note that while the term “patient navigator” is used more broadly in healthcare, often referring to individuals (like nurses or social workers) who help patients navigate complex care systems, particularly for conditions like cancer, ACA Marketplace Navigators have a distinct role defined by federal and state law, focused specifically on Marketplace, Medicaid, and CHIP enrollment and related support, operating under specific funding and impartiality rules.

Training, Certification, and Impartiality

To ensure they provide accurate and unbiased assistance, Navigators must meet specific training and certification requirements.

• Training and Certification: Standards are established either by the federal government (the Centers for Medicare & Medicaid Services, CMS) for Navigators operating in states using the federal HealthCare.gov platform, or by the individual states that run their own Marketplaces. Federal regulations outline the minimum standards (found in Title 45 of the Code of Federal Regulations, specifically sections 155.210 and 155.215). Training covers topics such as eligibility rules, plan options, insurance affordability programs, privacy and security standards, cultural competency, and the needs of diverse populations. Federal training can involve 5 to 20 hours annually, plus certification exams. Annual recertification and ongoing training are typically required to keep Navigators updated.
• State-Specific Requirements: Some states may impose additional requirements beyond the federal minimums. For instance, states like Florida, Indiana, and Georgia require Navigators to also register or obtain a state-specific license.
• Impartiality Mandate: A cornerstone of the Navigator program is the requirement for impartiality. Navigators must provide information that is fair, accurate, and unbiased. They are strictly prohibited from:
  • Recommending specific health plans or telling consumers which plan to choose
  • Steering consumers toward particular plans or insurance companies
  • Receiving any compensation or payment (direct or indirect) from health insurance companies in connection with enrolling individuals
• Disclosure: Navigators must disclose certain relationships they might have with health insurance issuers or insurance affordability programs.

How Navigators Are Funded

Navigator programs are funded through grants awarded by either the federal government (CMS) for states using HealthCare.gov, or by the state government for states operating their own Marketplaces. These grants are awarded to specific organizations, known as Navigator grantees. Individuals serving as Navigators must be affiliated with one of these grant-receiving organizations.

Funding levels for the federal Navigator program have experienced significant volatility over the years. After peaking in earlier years, funding was drastically reduced to approximately $10 million per year nationwide from 2018 through 2020 under the Trump administration. Funding was substantially increased under the Biden administration, reaching roughly $100 million per year for the 2022 through 2025 plan years. However, sharp cuts have been announced again, with federal funding projected to fall back to $10 million per year starting with the 2026 plan year.

Such dramatic fluctuations in funding can create instability for Navigator organizations, potentially impacting their ability to retain staff, maintain consistent service hours, and reach all geographic areas within their mandate. Given that Navigators play a crucial role in assisting hard-to-reach and vulnerable populations, funding reductions may disproportionately affect access to enrollment help for those who need impartial, free assistance the most. This instability can hinder progress toward reducing uninsurance rates and achieving health equity goals.

Key Limitation: Cannot Recommend Specific Plans

It is essential for consumers to understand that Navigators, while knowledgeable about plan options, cannot tell them which specific health plan to purchase. Their mandate for impartiality and the fact that they are not licensed insurance producers prevent them from making personalized plan recommendations. They provide comprehensive information about available plans, subsidies, and program eligibility, empowering consumers to make their own informed decisions based on their individual needs and preferences.

Cost to You: Free

The assistance provided by Health Insurance Navigators is offered at no cost to consumers. Their services are paid for by the federal or state grants received by their affiliated organizations.

What is a Health Insurance Broker (or Agent)?

Role and Responsibilities

Health Insurance Brokers, often also referred to as Agents, are licensed insurance professionals who assist individuals, families, and small businesses with selecting and enrolling in health insurance coverage. While the terms are often used interchangeably in the context of Marketplace assistance, technically, an “agent” might represent one or a limited number of insurance companies (either captive or independent), whereas a “broker” typically represents the consumer and works with multiple insurance companies. Both agents and brokers operating in the Marketplace must meet state licensing and Marketplace registration requirements.

Their core duties include:

• Needs Assessment and Plan Comparison: Helping consumers understand their health insurance needs, compare costs, benefits, and provider networks across different plans. They often possess detailed knowledge of local healthcare provider networks.
• Eligibility and Enrollment: Assisting consumers with determining eligibility for Marketplace coverage, applying for financial assistance (premium tax credits and cost-sharing reductions), and completing the enrollment process.
• Off-Exchange Plan Assistance: Unlike Navigators, brokers can also help consumers enroll in health plans directly from insurance companies, outside of the official Marketplace (known as “off-exchange” plans). These plans do not qualify for Marketplace subsidies.
• Small Business (SHOP) Assistance: Brokers play a critical role in helping small employers navigate the Small Business Health Options Program (SHOP) Marketplace, including determining eligibility for the Small Business Health Care Tax Credit, comparing group plans, and enrolling employees. In states using the federal platform for SHOP, enrollment must generally go through a SHOP-registered agent, broker, or insurer.
• Ongoing Support: Brokers often provide year-round service to their clients, helping with plan renewals, reporting life changes that affect eligibility or coverage (like income changes or adding a family member), and answering questions about using the coverage. Tools like Enhanced Direct Enrollment (EDE) allow brokers with approved technology platforms to directly manage applications, eligibility determinations, plan selections, and post-enrollment updates for their clients within the Marketplace system.

Brokers enroll a substantial portion of Marketplace consumers, particularly on the federal platform, where they consistently account for nearly half of all enrollments. This high volume is partly due to their ability to serve broader market segments, including those seeking off-exchange plans or small group coverage through SHOP, areas where Navigators typically do not operate.

Training, Licensing, and Compensation

Brokers operate under a different regulatory and compensation structure than Navigators.

• State Licensing: Brokers must hold an active insurance producer license issued by the insurance department in each state where they conduct business. State licensing involves specific pre-licensing education, examinations, background checks, and continuing education requirements.
• Marketplace Registration and Training: In addition to state licensure, brokers who wish to sell Marketplace plans must complete annual registration and training specific to the Marketplace (either federal or state-based). This training covers Marketplace rules, eligibility for subsidies, plan categories, and enrollment procedures. Training can be completed through CMS directly (which does not offer continuing education units, or CEUs) or through CMS-approved private vendors (which may offer CEUs).
• Compensation (Commissions): Unlike Navigators, brokers are typically compensated through commissions paid by the health insurance companies whose plans they sell. Importantly, the commission amount is generally based on the full monthly premium of the plan, even if the consumer receives premium tax credits that significantly lower their actual payment. Brokers must be formally contracted and appointed by an insurance company to receive commissions for selling its plans.

Key Advantage: Can Recommend Specific Plans

The most significant difference between brokers and Navigators/CACs is that licensed brokers are permitted to provide specific plan recommendations. Based on an assessment of a consumer’s health needs, budget, provider preferences, and other factors, a broker can analyze the available options and suggest the particular plan(s) they believe offer the best fit. This expert guidance can be valuable for consumers feeling overwhelmed by the choices in a complex market.

Potential Bias vs. Acting in Your Best Interest

The commission-based compensation model inherently creates a potential conflict of interest for brokers. Since they are paid by insurers, there could be an incentive to recommend plans that offer higher commissions or to only show plans from companies they are contracted with. Some brokers may represent many insurance companies, while others might represent only a few or even just one.

However, several factors work to mitigate this potential bias. Many states impose regulations requiring brokers to act in the consumer’s best interest, putting the client’s needs ahead of their own financial gain. Furthermore, brokers often rely on building long-term client relationships and maintaining a positive reputation within their community. Additionally, a specific category known as “web-brokers” – agents or brokers who operate their own enrollment websites that interface with the Marketplace – are federally required to display all available Qualified Health Plans (QHPs) in the consumer’s service area on their sites. The value of a broker’s recommendation should thus be considered alongside an understanding of their compensation structure and the range of plans they represent.

Cost to You: Services are Typically Free; Premiums are the Same

Using a broker to help with Marketplace enrollment generally does not cost the consumer anything directly. The broker’s commission is paid by the insurance company whose plan is chosen. Critically, the monthly premium a consumer pays for a specific health plan is exactly the same whether they enroll through a broker, a Navigator, a CAC, or directly on their own through the Marketplace website. Using a broker does not increase the cost of the insurance plan itself.

Navigator vs. Broker: Key Differences at a Glance

Understanding the fundamental distinctions between Navigators and Brokers is key to choosing the right type of assistance.

Comparison Table

The following table summarizes the primary differences discussed:

Deeper Dive into Differences

• Impartiality vs. Recommendation: This is the core philosophical difference. Navigators are bound by impartiality rules and funded by grants to provide unbiased information and enrollment assistance. Brokers, funded by commissions, can provide advice and specific plan recommendations but may face potential conflicts of interest. Consumers must weigh the value of guaranteed impartiality against the desire for a personalized plan suggestion.
• Populations Served: While there is overlap, data suggests Navigators and brokers often serve different primary populations. Surveys indicate Navigators are significantly more likely than brokers to assist individuals who were previously uninsured, have limited English proficiency, lack internet access at home, or need help applying for Medicaid or CHIP. Brokers, while serving diverse clients, enroll a much larger volume of Marketplace consumers overall. CMS data, often cited to highlight broker efficiency based on enrollment volume and cost-per-enrollment, may not fully capture the unique role Navigators play in reaching specific vulnerable groups targeted by the ACA. Some analyses suggest CMS enrollment data might undercount the number of consumers assisted by Navigators. This difference in focus highlights that the programs, while overlapping, are not truly interchangeable. Policy decisions regarding funding and emphasis may depend on whether the primary goal is maximizing total enrollment numbers or ensuring equitable access for the hardest-to-reach populations.
• Scope of Services: The range of services differs significantly. Navigators concentrate on Marketplace, Medicaid, and CHIP enrollment, with a mandated focus on outreach, education, and post-enrollment support like navigating appeals and understanding how to use coverage. Brokers have a wider scope regarding plan types, covering Marketplace, off-exchange private plans (often for those ineligible for subsidies), and the SHOP Marketplace for small businesses. While brokers offer ongoing service, their focus may be less intensive on Medicaid/CHIP applications or the specific types of post-enrollment utilization support Navigators are required to provide.

What About Certified Application Counselors (CACs)?

Besides Navigators and Brokers, consumers might also encounter Certified Application Counselors (CACs) when seeking help. CACs represent a third category of free, impartial assistance available through the Marketplace.

Key differences distinguish CACs from Navigators:

• Funding: CACs are typically staff members or volunteers associated with organizations known as Certified Application Counselor Designated Organizations (CDOs). These CDOs (which might be community health centers, hospitals, or social service agencies) participate voluntarily in the Marketplace and, unlike Navigator grantees, do not receive specific federal or state grant funding for providing CAC services.
• Scope of Duties: The primary required function of CACs is to assist consumers with the eligibility and enrollment process for Marketplace plans and affordability programs. While they must provide fair and impartial information and cannot recommend plans, they are generally not required to conduct the broader outreach, education, or post-enrollment support activities mandated for Navigators.
• Regulation and Oversight: While CACs must complete training and adhere to privacy and impartiality standards, Navigators are generally held to a “higher regulatory standard”. CACs are certified and overseen by their respective CDOs, which have agreements with the Marketplace.

Consumers are likely to find CACs working within healthcare settings like community clinics and hospitals, or at local social service agencies. Understanding their role helps clarify the spectrum of free, impartial assistance available.

Which Type of Help is Right for You?

The choice between a Navigator, Broker, or CAC depends entirely on an individual’s specific needs, preferences, and circumstances. There is no single “best” option for everyone. Consider these scenarios:

• If you want someone to recommend the “best” plan for you: A licensed Broker is the only professional authorized to provide specific plan recommendations. Remember to ask about the range of plans they offer and be aware of the commission-based compensation structure.
• If your top priority is guaranteed impartial information: A Navigator or CAC is the best choice. They will provide comprehensive information about all your options without bias, but the final decision about which plan to enroll in rests with the consumer.
• If you think you might qualify for Medicaid or CHIP: Navigators and CACs typically have significant expertise and focus on assisting with applications for these programs. While Brokers can refer individuals to Medicaid/CHIP agencies, they are generally less likely to specialize in these applications.
• If you anticipate needing help after enrollment (understanding bills, filing appeals, learning how to use your coverage): Navigators are explicitly tasked with providing post-enrollment support and utilization assistance. While many Brokers offer ongoing client service, the nature and depth of post-enrollment help may differ.
• If you have a complex situation (e.g., fluctuating income, disability, limited English proficiency, first-time enrollee): Navigators are specifically trained, funded, and mandated to assist underserved and vulnerable populations facing barriers to enrollment and understanding coverage. While Brokers also serve diverse clients, Navigators have a dedicated focus on these needs.
• If you are a small business owner seeking group coverage: You will generally need to work with a SHOP-registered Broker.
• If you want to explore plans sold outside the Marketplace (off-exchange): Only a Broker can assist with enrolling in off-exchange plans.

By considering these factors, consumers can better identify which type of assistance aligns with their personal situation and priorities.

How to Find Local Help

Once an individual decides which type of assistance they prefer, several resources are available to locate help in their community.

HealthCare.gov Resources

For residents in states using the federal HealthCare.gov platform, the primary resource is the official website:

• “Find Local Help” Tool: This online directory is the main portal for locating nearby assistance. The direct URL is: https://www.healthcare.gov/find-local-help/. Users can search by entering their ZIP code or city and state. The search results will list both “Assisters” (which includes Navigators and Certified Application Counselors) and “Agents/Brokers” who are registered with the Marketplace. Listings often include contact information (phone, email), office addresses, hours of operation, languages spoken, and whether they offer in-person or remote assistance. It’s important for users to examine the listings to identify the type of helper (Assister vs. Agent/Broker) based on their needs determined earlier. Agents and brokers must actively opt-in through their Marketplace Learning Management System (MLMS) profile and meet licensing and training requirements to appear in the tool. The underlying data for this tool is updated frequently, often daily.
• “Help On Demand” Service: This is a separate feature offered through HealthCare.gov that specifically connects consumers seeking assistance with Marketplace-registered agents and brokers. Consumers provide their contact information, and an available agent or broker is expected to respond quickly, often within 15 minutes. This service is free for both consumers and participating agents/brokers.
• Marketplace Call Center: Consumers can always contact the general Marketplace Call Center (1-800-318-2596) for assistance over the phone. (Note: The call center for the SHOP Marketplace has a different number: 1-800-706-7893).

The usability of the “Find Local Help” tool depends on the accuracy and completeness of the information provided by the assister organizations and agents/brokers themselves. Understanding the distinction between the broad “Assister” category and “Agent/Broker” in the results is crucial for finding the desired type of help.

State-Based Marketplace Resources

It is crucial to recognize that not all states use the federal HealthCare.gov platform. Many states operate their own State-Based Marketplaces (SBMs) with their own websites, branding, and enrollment systems. Examples include New York (NY State of Health), Oregon (OregonHealthCare.gov), Georgia (Georgia Access), and Illinois (Get Covered Illinois).

Residents of these states must use their state’s official Marketplace website to apply for coverage and find local assistance programs specific to their state. State-run Marketplaces will have their own versions of the “Find Local Help” tool and may have different designations or specific programs for Navigators, CACs, or other assisters operating within that state. The main HealthCare.gov website provides a tool to identify whether a state uses the federal platform or runs its own Marketplace: https://www.healthcare.gov/marketplace-in-your-state/. Using the correct state-specific resource is essential for residents in SBM states.

Other Community Resources

Beyond the official Marketplace websites, consumers may also find Navigators or CACs located at various community organizations, such as:

• Community health centers
• Hospitals and other healthcare providers
• Local libraries
• Non-profit organizations
• Social service agencies

These organizations often serve as trusted resources within the community and may host enrollment events or offer appointments for assistance. The “Find Local Help” tool often includes listings for assisters based at these types of community locations.

Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.