The Affordable Care Act (ACA), established State Insurance Exchanges in every state where individuals who lack health coverage can shop for “Qualified Health Plans” (QHPs).
Background
The ACA created State Insurance Exchanges (Marketplaces) in each state. In these marketplaces, insurers can offer “Qualified Health Plans” (QHPs) for purchase by individuals who lack insurance coverage through their employer and do not qualify for other government programs.
QHPs Requirements
The plans must meet certain requirements in order to be certified as “Qualified Health Plans” (QHPs). Among them:
Non–Discrimination
Plans are not allowed to discriminate against individuals based on their health status, according to the Patient Protections required under the ACA.
Offer Real Options
Qualified Health Plans must offer a range of options to consumers that plans are meaningfully different from one another.
Cover Essential Health Benefits
Qualified Health Plans must cover all of the Essential Health Benefits
required under the ACA.
Prescription Drug Coverage
Qualified Health Plans are required to cover at least the same number of drugs per United States Pharmacopeia category and class as the state’s Benchmark Plan. QHPs also must list their formulary of covered drugs online so that patients can utilize it in making informed choices.
QHPs must also have an appeals process and an exceptions process to ensure access to clinically appropriate drugs not included on a plan’s formulary.
Contract with Essential Community Providers
Qualified Health Plans are required to include a sufficient number of Essential Community Providers (ECPs) in their plan networks to ensure access to care for low-income and vulnerable populations. ECPs include Ryan White Program providers as well as other safety net providers such as Federally Qualified Health Centers.
Provider Directory
Plans are required to make their provider directories available for online publication. The directory should include information about provider specialty, location, institutional affiliations, languages spoken, and provider credentials.
Grandfathered Plans:
Some health insurance plans that were in existence before the passage of the ACA will also be included in the Exchanges, they are referred to as “grandfathered plans.” However, they may not have some of the benefits and protections that other (new) plans will have.
Grandfathered plans must maintain the same patient protections required by the ACA, such as no lifetime limits on coverage, no arbitrary cancelations of coverage, covering adult children, providing easy-to-read summaries of benefits and coverage.
However, grandfathered plans do not have to cover preventive care for free, protect patient choice of providers, or access to emergency care. They also are not held accountable for excessive premium increases through rate reviews.
These plans must disclose that they are grandfathered plans in all materials describing plan benefits.
Oversight
The ACA also created the new Center for Consumer Information & Insurance Oversight (CCIIO), under the Centers for Medicare and Medicaid Services (CMS) at the federal Department of Health and Human Services.
CCIIO exists to certify and monitor the plans in the federally-facilitated Exchanges and the state-federal partnership Exchanges.
However, state-based exchanges are responsible for designing their own similar plan certification criteria and processes. For all states, the state Insurance Commissioner is primarily responsible for oversight of all insurance plans sold within the state.
Selecting & Purchasing Qualified Health Plans:
Qualified Health Plans for sale in the State Insurance Exchanges have requirements for value and pricing that is structured into categories named after metals: there are “bronze,” “silver,” “gold,” and “platinum” level plans. Each of these plans has different values within its category, and offers different prices and benefits to consumers.
Learn More: Plan Premiums and Pricing
Tax Credits / Premium Subsidies
Tax Credits are available to individuals of low- to middle-income levels who are purchasing Qualified Health Plans in the Exchanges. These credits take the form of subsidies which are applied to the plan premium cost (or “premium subsidies”).
Learn More: Tax Credits (Premium Subsidies)
Patient Enrollment
Patients are able to in the State Insurance Exchange, and determine their eligibility for Premium Subsidy Assistance through a variety of methods, including both electronic and paper applications, as well as in-person, phone, and internet options.
Learn More: Patient Enrollment
Navigators
States also offer a variety resources to help consumers with selection of Qualified Health Plans. In some states, specific personnel can 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.
These patient assistors are called: Patient Navigators, Certified application counselors, and in-person assistance personnel.
Learn More: Patient Navigators
Additional Information:
Qualified Health Plans – Center for Consumer Information & Insurance Oversight (CCIIO)
Plan Certification Criteria for Qualified Health Plans – NASTAD
Grandfathered Health Plans – Healthcare.gov
Q&A: When will prices be available for Marketplace insurance plans?– Healthcare.gov
Marketplace Health Plans Assessment Workbook and Worksheet- Center for Health Law and Policy Innovation at Harvard Law School