The Affordable Care Act (ACA) requires all states to establish a Health Insurance Exchange (HIE). Exchanges will be competitive, regulated marketplaces for individuals and small businesses to purchase health insurance plans with standardized, comprehensive benefits. •
Each state must establish an exchange by 2014. The Department of Health and Human Services (HHS) must sign off on plans by January 1, 2013. If states do not have a plan, the federal government will establish an exchange in that state or partner with the state.
All exchanges will offer “qualified health plans.” • All insurance market reforms will apply to QHPs. -‐ Meet out-‐of-‐pocket limits: about $6,000 for individuals and $12,000 for families -‐ Essential Health Benefits -‐ No lifetime or annual limits -‐ No pre-‐existing conditions exclusions • Requirements for “network adequacy” to ensure that plans don’t use network design to exclude patients. ACA requires that QHPs contract with “essential community providers” that serve predominantly low-‐income, medically underserved individuals. These providers include those who participate in the 340(b) drug pricing program and those eligible for Section 1927 “nominal drug pricing.” • QHPs do not have to contract with them for any specific medical procedures. • Every essential community provider does not have to be included in the network. How will the essential community provider provision be implemented? • Likely to be left to state discretion as they build exchanges. • Maryland recently recommended that insurers contract with essential community providers for all services for which they can be credentialed, but they must be willing to accept Medicaid rates. Where are the states now?
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org
• • •
As of July 27, 13 states had signaled their intent to operate a state exchange: CA, CO, CT, MD, HI, KY, MA, MN, NY, OR, RI, UT, WA As of September 24, 24 states had done some degree of exchange planning: AR, CA, CO, CT, DC, HI, IL, IN, KY, MA, MN, MS, NC, ND, NV, NY, OR, RI, TN, UT, VT, WA, WV 35 states have received exchange establishment grants.
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org