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 in every state and the District of Columbia.
A State Insurance Exchange (sometimes called a “Marketplace”) is simply a market forum where insurance companies offer various health insurance plans for individuals to purchase for themselves or their family.
The plans offered in the Exchange are called Qualified Health Plans (QPHs) and must meet certain requirements in terms of the benefits they offer, under the ACA law.
Background
Under the ACA, states were given the option to develop their own state-administered Insurance Exchange, or to allow the Federal Government to establish a federally-facilitated Exchange (FFE). States could also partner with the federal government in establishing their Exchange through a federal-state partnership. In any state that did not take action to establish an exchange, the federal government established one for the state by default.
Plans in the Exchanges
Insurers will offer a variety of insurance plans for sale in the state exchange (marketplace) that cover individuals, families, and small groups.
Qualified Health Plans
In order to qualify for participation in the exchange, these plans in the must meet a range of criteria required by the ACA, and be designed “Qualified Health Plans” (QHPs).
Learn More: Qualified Health Plans
Essential Health Benefits
Every health plan offered in the Exchanges (QHP) is required to offer certain basic benefits required by the ACA, called the Essential Health Benefits (EHBs).
Learn More: Essential Health Benefits
Essential Community Providers
Plans in the Exchanges must contract with certain types of providers in their networks under the law. These providers are called the “Essential Community Providers” and should include most HIV providers.
Learn More: Essential Community Providers
Actuarial Value and Pricing
Plans in the Exchanges have requirements for value and pricing that is structured into categories named after metals: the “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
Patients Purchasing Insurance Coverage:
Individual Mandate
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.
Learn More: Individual Mandate
Tax Credits
Tax Credits are available to individuals of low-to middle-income levels who are purchasing insurance in the Exchanges. These credits take the form of subsidies which are applied to the plan premium (or “premium subsidies”).
Learn More: Tax Credits (Premium Subsidies)
Patient Enrollment
Patients are able to enroll in the Exchanges through a variety of methods, including both electronic and paper applications, as well as in-person, phone, and internet options. Patients also have the benefit of a single enrollment process to determine their eligibility for all ACA options.
Learn More: Patient Enrollment
Navigator Program
States offer a variety resources to help consumers with selection and enrollment in 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 Resources
State Insurance Exchanges – State Profiles – Kaiser Family Foundation
Private Insurance Markets – Kaiser Family Foundation
Issue Brief: Review of Premium Assistance Options– Manatt Health Solutions
Health Insurance Marketplace Guide– Centers for Medicare and Medicaid Services