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HIV and Enteropathy
Qualified Health Plans

 By 2014, individuals who lack insurance will be able to shop for “Qualified Health Plans” (QHPs) in the State Insurance Exchanges.

These plans have certain requirements under the Affordable Care Act (ACA), including contracting with HIV service providers.
The ACA created Health Insurance Exchanges (marketplaces) in each state that will begin to enroll patients by January 2014. The marketplaces will offer “Qualified Health Plans” (QHPs) for individuals who lack insurance to purchase.
The ACA also created the new Center for Consumer Information & Insurance Oversight (CCIIO), under the Centers for Medicare and Medicaid Services (CMS) and the federal Department of Health and Human Services. CCIIO will certify and monitor the plans in the federally-facilitated Exchanges and the state-federal partnership Exchanges.
State-based exchanges are responsible for designing their own similar plan certification criteria and processes.
QHPs Requirements
The plans must meet certain requirements in order to be certified as “Qualified Health Plans” (QHPs). Among them:
  • Contract with Essential Community Providers
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 will be required to make their provider directories available for online publication. The directory will include information about provider specialty, location, institutional affiliations, languages spoken, and provider credentials.
  • Cover Essential Health Benefits
Plans must cover the Essential Health Benefits required under the ACA.
  • Non–Discrimination
To ensure that plan designs do not discriminate against people based on their health status, CCIIO will review cost sharing for specific services – including specialist visits and prescription drugs – and identify outliers (those plans charging significantly higher cost sharing).
  • Offer Real Options
To allow consumers to make informed choices about their plan options, CCIIO will review plans to ensure that plans are meaningfully different from one another.
  • Prescription Drug Coverage
Plans will be required to cover at least the same number of drugs per United States Pharmacopeia category and class as the state’s benchmark plan. Plans must also include an exceptions process to ensure access to clinically appropriate drugs not included on a plan’s formulary. However, the guidance does not include information about how combination drugs are captured in this process.
Grandfathered Plans
Some health 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.
Under the ACA, all health plans (including grandfathered plans) must maintain certain patient protections such as no lifetime limits on coverage, no arbitrary cancelations of coverage, covering adult children, provding 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.
Learn More:
Qualified Health Plans - Center for Consumer Information & Insurance Oversight (CCIIO)
Grandfathered Health Plans –

Marketplace Health Plans Assessment Workbook and Worksheet- Center for Health Law and Policy Innovation at Harvard Law School
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