Defining the Impending Role of Exchanges
2/22/2012 3:32 PM
Beginning in 2014, health care exchanges are expected - indeed mandated – to play a key role in the implementation of reform legislation. Exchanges are intended to serve and address consumers who don’t have employer-sponsored coverage or cannot afford employer-sponsored coverage. The basic concept of the exchange is to facilitate the interaction between insurance companies and consumers, using a common platform for comparison of qualified health plans.
Below is a basic explanation of the roles and responsibilities of the exchanges.
Health Plan Review and Certification
Exchanges will be charged with certifying qualified health plans. As part of the process, exchanges must review the premium changes of qualified health plans. They are also expected to rate qualified health plans based on their quality and price.
Exchanges will maintain a toll-free telephone help line to respond to requests for assistance, as well as a website for comparison of qualified health plans. They are expected to provide comparison information on qualified health plans in a standardized format, including Summary of Benefits and Coverage (SBC) documentation.
Exchanges will review eligibility in Medicaid, Children’s Health Insurance Program (CHIP), and applicable state or local public programs. They will be charged with certifying individuals for government subsidies and determining exemptions from the individual mandate, or from penalties for failure to maintain minimum essential coverage.
For individuals eligible for Medicaid, CHIP or applicable state or local public programs, exchanges will enroll the individuals, as well as provide initial, annual and special enrollment periods for the qualified health plans.
The actual implementation of the exchanges will occur on a state-by-state basis. Under the health care reform law, each state is authorized to establish an exchange, which can be administered by either a state governmental agency or a nonprofit organization.
Although the exchanges won’t be available to consumers and small businesses until 2014, the clock is ticking for states to lay the groundwork for their respective exchanges. If the Department of Health and Human Services (HHS) determines that a state hasn’t made sufficient progress toward establishing an exchange by January 1, 2013, or if a state chooses not to establish an exchange, HHS will step in and administer that state’s exchange.