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State Insurance Exchange (Marketplace)


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.

 

Learn More: Background On Establishing The Exchanges

 

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 MoreQualified 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 MoreEssential 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 MoreEssential 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 MoreIndividual 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 MoreTax 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 MorePatient 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 MorePatient Navigators

 

Additional Resources:

 

Health Reform in My State- AAHIVM

 

Establishing Health Insurance Exchanges: An Overview of State Efforts – Kaiser Family Foundation

 

State Insurance Exchanges – State Profiles – Kaiser Family Foundation

 

Private Insurance Markets – Kaiser Family Foundation

 

Health Insurance Marketplace Training Website- DHHS

 

Tools for HIV Service Providers: Tools for the Ryan White Community - HRSA HIV/AIDS Bureau

 

Issue Brief: Cost-sharing and Tax Credit Guide for Assistors- State Health Reform Assistance Network

 

Issue Brief: Review of Premium Assistance Options- Manatt Health Solutions

 

Health Insurance Marketplace Guide- Centers for Medicare and Medicaid Services

 

Provider Marketplace Toolkit: ACA and HRSA Programs- HRSA

 

List of Marketplace Resources with links - CMS

 

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