In order to effectively engage with payer customers around the topic of health insurance Exchanges, you’ll need to be up to date on how Exchanges work and how stakeholders are impacted. This newsletter contains a brief over
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By the end of 2012, states had to determine whether they would establish their own state-run Exchange. If a state opted to run its own Exchange, it had to submit its proposal and obtain final approval from the HHS.
Then, in February 2013, the remaining states had to decide whether they would partner with the federal government in setting up a Marketplace. After both deadlines passed, any states that were left would have their Marketplaces run by the federal government. Here’s how things looked after the February 2013 deadline.
A state that fully implements its own Exchange will complete all activities to build and run the Marketplace, including establishing the IT infrastructure and providing consumer outreach and assistance. States are also responsible for choosing, certifying, recertifying, and decertifying (if needed) qualified health plans (QHPs).
A QHP is a plan that has all the features required by the ACA and that meets all state requirements.
Because the Department of Health and Human Services (HHS) knew that some states would be unable or unwilling to create a state health Exchange by the specified deadline, states have the option of creating a state-federal partnership. This partnership is generally flexible: States can choose what parts of their Marketplace they want to operate, and the Exchange is designed to be fully converted to a state-run Marketplace in the future. In this model, the state would still choose and certify QHPs, but HHS would help oversee the process and resolve any issues.
Most states are having their Exchange run by the federal government. Some states simply did not make a decision and defaulted to this option. Other states specifically chose the federal option because of timing or budget issues. For these states, HHS operates a state’s Exchange, but engages state health agencies to help with consumer assistance and coordinating Medicaid administration.
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Overall, the population using the Exchanges is projected to be slightly older, less educated, have lower income, and be more racially diverse than current privately insured populations. According to a health industry report by PricewaterhouseCooper (PwC), those who will enroll in the Exchanges break down as follows:
Select a category to view the statistics. (Viewing on a tablet? Feel free to swipe through this content.)
According to ACA, individuals purchasing a health plan on the Exchange can receive a premium subsidy if they earn 100% to 400% of the FPL.
I may be able to get
a subsidy on my health insurance if
I go through the Marketplace
Any payer designing individual or small-group health plans, whether or not they are for an Exchange, will need to adhere to the Essential Health Benefit (EHB) categories defined by ACA. Although some state-level mandates existed prior to ACA, the goal of the EHBs is to make sure all individuals throughout the country have access to a baseline level of care.
The ACA mandates that people who purchase a plan on the Exchange must be offered coverage in these 10 Essential Health Benefit categories:
Ambulatory patient services
Maternity and newborn care
Mental health and substance
use disorder services, including
behavioral health treatment
Rehabilitative and habilitative
services and devices
Preventive and wellness services
and chronic disease management
Pediatric services, including oral and vision care