Starting in 2014, every state will have a State Insurance Exchange (Marketplace) where patients who lack health coverage will be able to purchase it.
Each state’s exchange will be different, with different insurers participating in it and offering Qualified Health Plans that are different then those offered in others states. So, it is important to learn about the specifics of your state’s Exchange, and the insurers participating in it.
See: Health Reform in My State
Provider Participation/ Contracting
Providers must contract with the the insurers offering plans in the marketplace individually to be included in their provider networks, and have access to their patients.
This process is similar to contracting with employer-based insurance companies and plans, or managed care organization provider networks.
The HIV Medicine Association (HIVMA) has developed detailed guidance for HIV providers on contracting with the insurers offering Qualified Health Plans in the exchanges.
Download: Strategies for HIV Medical Providers: Contracting with Health Insurers - HIVMA
The “Essential Community Provider” Designation
As an HIV provider, you may qualify for designation as an “Essential Community Provider (ECP)” that will assist you in contracting with insurers participating in the state insurance exchange.
ECPs are providers with experience caring for medically underserved populations or low-income populations. In states with a federally-facilitated Exchange, this includes: Ryan White HIV/AIDS providers, Federally Qualified Health Centers (FQHCs), Title X family planning clinics, Indian providers, Safety-net hospitals, STD Clinics, providers who qualify for 340B drug purchase prices, and more. In states with a State-run Exchange, the state will determine the definition of an ECP.
The Qualified Health Plans participating in the Exchange (Marketplace) are required to contract with a sufficient number and georgraphic distribution of ECPs and Specialistsin order to demonstrate network adequacy. At least 20% of available ECPs in the plan’s service area must be included in the provider network, including at least one ECP per type, per county.
Most plans are currently involved in efforts to build their provider networks.
When contacting plans in an effort to contract with their networks, HIV providers should indicate that you might be able to help them meet their ECP requirement.
AAHIVM has prepared the following document to provide assistance in contacting insurers that are offering plans in the States Insurance Exchange (Marketplace) about contracting with their provider network.
Download: Connecting My Practice to the Qualified Health Plans in the State Insurance Exchanges: A Guide for Providers - AAHIVM
The Qualified Health Plans participating in the Exchange (Marketplace) also need demonstrate network sufficiency through including adequate numbers of Specialists in their plans network to serve the needs of the population in the state.
Infectious Disease Specialists should inform plans of their medical specialty.
While state and federal definitions do not recognize HIV care as a medical specialty, providers with any advanced certifications or credentials, such as an AAHIVM HIV Specialist (AAHIVS), should also inform plans of this certification.
Plans In Your State
AAHIVM is keeping track of the insurers participating in the Exchange (Marketplace) in your state, and providing specific contact information to assist you in connecting to them.
The AAHIVM Health Reform in My State resource offers contact information for all insurers operating in each state insurance exchange.
See: Health Reform in My State
AAHIVM has prepared the following document to provide assistance in contacting plans in the States Insurance Exchanges about contracting with their provider networks.
Download: Connecting My Practice to the Qualified Health Plans in the State Insurance Exchanges: A Guide for Providers
Health Care Reform & Essential Community Providers: Information for Ryan White Providers - HIVMA