One of the most significant changes to the health system to come out of the Affordable Care Act (ACA) is the establishment of State Insurance Exchanges for new individual and small group insurance plans in every state and the District of Columbia.
The Exchange (sometimes called a “marketplace”) is simply the market forum within a state. Insurance companies will offer various plans within the markets, all variable in price and in benefits
States were given the option to develop their own state-administered Insurance Exchange, or by default, to allow the Federal Government to establish a federally-facilitated exchange (FFE). Another option was for states to join into a federal-state partnership to develop the exchange.
State planning grants were offered to the state to make this determination, and states had to declare their intent to HHS by November, 2012, and those wishing to establish their own exchange had to submit a blue print to HHS for approval by December 2012.
18 states will have a state-run exchange: California, Colorado, Connecticut, District of Columbia, Hawaii, Idaho, Kentucky, Maryland, Vermont, Massachusetts, Minnesota, Nevada, New Mexico, New York, Oregon, Rhode Island, Utah, Washington.
7 states will have an Exchange run via state-federal partnership: Arkansas, Illinois, Michigan, West Virginia, Delaware, Iowa, New Hampshire.
26 states will have a Federally-facilitated Exchange (FFE): Alaska, Alabama, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Virginia, Wisconsin,Wyoming.
Plans in the Exchanges:
Plans for both individuals and small groups will be available in the exchange.
Plans in the Exchanges must meet a range of criteria in order to be designed “Qualified Health Plans” (QHPs).
Plans in the Exchanges have requirements for Pricing.
Every health plan offered in the Exchanges is required to offer certain basic benefits required by the ACA, called the Essential Health Benefits (EHBs).
Plans in the Exchanges must contract with Essential Community Providers.
Patients Purchasing Insurance Coverage:
Under the ACA, individuals are required to obtain insurance coverage beginning in 2014 or face tax penalties. This includes both adults and children who are legal US citizens. This provision is often referred to as the “individual mandate.” Those currently uninsured, without employer-based insurance or other coverage and ineligible for public programs, will be required to attain coverage, and will be able to do so through the State Insurance Exchanges.
Tax Credits are available to individuals of low to middle income levels who are purchasing insurance in the Exchanges.
Patients will have easy access to enroll in the Exchanges through a variety of ACA provisions, like a single uniform enrollment form to determine eligibility, and both electronic and paper applications, as well as in-person, phone, and internet options.
States are required to set up resources to help consumers with selection and enrollment in plans. Other specific personnel will help consumers prepare electronic and paper applications to establish eligibility and enroll in coverage through the Marketplace as well as providing general outreach, education, and referrals. Some of the patient assistors are: Patient Navigators, Certified application counselors, in-person assistance personnel.
It is crucial for the HIV community to keep abreast of the developments in your state because each state determines the structure of their exchange individually. Below are some tools for advocates on the State Insurance Exchanges: