Skip to Main Content
Don't have an account? Create Account

Requirements Health Plans Must Meet to Participate in Marketplaces



This week in Washington—outlining requirements for qualified health plans sold through the exchange. You are tuning in to the health policy update from America’s Essential Hospitals for the week of Aug. 12.

Throughout our last several podcasts we have focused on what health insurance plans look like for consumers—we have discussed the benefits they include and the costs associated with different plans. There are many other requirements, though, that health plans must meet to sell health insurance through the exchanges. And these requirements fall in various categories.

The Affordable Care Act (ACA) requires that all plans sold through the exchanges must be certified as qualified health plans (QHPs). Depending on whether the exchange is a state-based, partnership, or federally-facilitated exchange, the state or the federal government will review applications from plans wishing to sell insurance through the exchange. If the plan meets certain requirements, it will be certified as a QHP for that exchange.

We have discussed some of these requirements in previous weeks, including the defined essential health benefits and cost-sharing limits for deductibles, copayments and out-of-pocket maximum amounts. Qualified health plans must comply with a variety of additional requirements. First, the issuer selling the plan has to be licensed and in good standing with the state. In terms of cost, issuers must charge the same premium rate for each plan and sell at least one plan at the silver level and gold level of coverage—you may remember we mentioned these plan levels last week.

Plans also must meet several requirements related to quality. Plans must be accredited with respect to local performance in clinical quality measures, they must implement quality improvement strategies, and they must provide information to consumers that explain quality data.

In terms of provider networks, plans must meet specific adequacy requirements, including contracting with essential community providers, which we will discuss in more detail next week.

To streamline the enrollment process, qualified health plans must use a standardized enrollment form and standard format for presenting health benefit and plan options.

Plans also are responsible for ensuring that diverse populations and people with significant health needs are not discouraged from enrolling. While all of these requirements will be important to ensure that people are able to enroll in quality, affordable health plans, this last requirement will be particularly important for vulnerable patients.

In fact, the non-discrimination requirement will help people who have low-incomes and who are of minority backgrounds overcome some of the obstacles they currently face in obtaining health insurance. As a result, many people who were previously excluded from enrolling in health insurance will have access to coverage. This not only helps people obtain health services, but also helps essential hospitals, as treating high volumes of uninsured patients puts significant strains on essential hospitals’ resources.

To ensure that the non-discrimination requirement is implemented in a manner that achieves its stated goal, the U.S. Department of Health and Human Services is seeking information through a notice of proposed rulemaking. The agency is soliciting information from providers who work with vulnerable patients about their experience with discrimination in health programs. Those providers can offer input until Sept. 30 to help inform the rulemaking process that will later determine how the non-discrimination requirement in the ACA is implemented.

Thanks for listening to another edition of This Week in Washington. I’m Erin Richardson; join us next week as we continue our discussion of health insurance exchanges.


About the Author

Dedicated staff at America's Essential Hospitals work together to produce high-quality, reliable content. Please view the about section for more details about staff.

Previous Next
Test Caption
Test Description goes like this