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 each state.
These exchanges are the vehicle by which health insurance will expand to cover millions of individuals.
The exchange is simply the market forum, and private insurers will develop and offer various plans within the markets, all variable in price and in benefits
A key element of this provision is the requirement for uninsured individuals to purchase insurance beginning in 2014, often referred to as the “individual mandate.”
All 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.
By November 16, 2012 states are required to declare to the federal government, their intent to either establish a state-based insurance exchange, or to defer to a federally-facilitated exchange (FFE) or, to establish a shared partnership model.
For states that choose to establish a state-based insurance exchange, the state must submit a blueprint of their plan for creating and implementing the exchange by November 16, 2012.
For states that delayed in their decision making, the timeline is quite short for these determinations. Most state legislatures are now out of session, so creating the legal authority for an exchange could require a special legislative session or an executive order from the governor.
Recently, HHS announced a new funding opportunity that states can apply for, so that they can receive funding through 2014. However, by 2015, all state exchanges must be self-sustaining.
Below are some of the key decisions being made by states:
Small Business Health Options Program (SHOP) Exchange
States can either combine the markets for the small-business and individual plans, or keep them separate. This choice determines much about the risk-pool for the two markets.
States are required to set up a program to help consumers with selection and enrollment in plans, called the Navigator Program. Organizations providing unbiased information to consumers on health insurance, qualified health plans, public programs (Medicaid, CHIP, etc), and the Health Insurance Marketplace are called Patient Navigators. They will play a large part in enrolling all the newly eligible in the Marketplace. They 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. Millions of Americans will become eligible for new types of health insurance coverage under the ACA in 2014. A variety of challenges including a limited knowledge of health insurance, language barriers, and disability will face new enrollees and there will be a great need for assistance. These Navigators will function much like case managers in many AIDS service organizations, but will instead focus on ensuring access to health insurance for all who are eligible. Programs like Ryan White already cover many navigation services provided to people living with HIV.
Agents and brokers may enroll consumers in Marketplace coverage where permitted by the state and will be compensated by the issuer in accordance with state law. Certified application counselors have been proposed by HHS as a third option for educating consumers and assisting with the application process. Where there is a State-based marketplace, in-person assistance personnel (or non-Navigator assistance personnel) will operate as navigators while the state launches and develops its Marketplace.
On April 9, 2013 the Centers for Medicare & Medicaid Services (CMS) announced opportunities for grant awards to fund Navigator programs in both state partnership and federally –facilitated insurance marketplaces. A total of $54 million will be dedicated to hiring and training Patient Navigators in 33 states. Grants may be awarded to public organizations (national, regional, or state-based), private entities, and self-employed individuals to serve as Navigators.
October 1, 2013- Open enrollment in the Marketplace. Consumers in all states will have new affordable health insurance options.
January 1, 2014- Coverage begins
All state exchanges are required to be self-sustaining by 2015. However, money is available to states in the short term to help develop and build their exchanges.
Essential Health Benefits
In addition to the establishment of the exchanges, state lawmakers are also determining the basic benefits that will be offered in the insurance states in each state, through the development of the Essential Health Benefits (EHBs) package. States have a wide range of determination over the level and scope of coverage that will be offered. Visit the Essential Health Benefits page in the Health Reform section to learn more.
To learn more about where your state is in each of these decisions and determinations, see the resources below.
Status of State Action Toward Creating Health Insurance Exchanges – as of 08/2012
State Exchange Decisions – as of 07/2012
State Planning Grants Awarded – as of 2012
Establishing Health Insurance Exchanges: An Overview of State Efforts
Health Insurance Exchange Development: Innovation in the States
State Insurance Exchanges – State Profiles
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:
Making the Federally Facilitated Exchanges Work for People with HIV
The Hidden Gem of the ACA: the Basic Health Program