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Series Explores ACA Health Insurance Exchanges



This week in Washington—Open enrollment in health insurance exchanges begins Oct. 1. In preparation, This Week in Washington will devote the next 11 podcasts to exchange-related issues. You are tuning in to America’s Essential Hospitals’ health policy update for the week of July 15, 2013.

The Affordable Care Act (ACA) requires all states to establish a health insurance marketplace, also referred to as a health insurance exchange, where people can obtain affordable health insurance coverage. The ACA requires that exchanges in each state offer plans for individual coverage and group coverage for small businesses. A single exchange may offer both types of insurance, or two separate exchanges may be established for individuals and small businesses, respectively.

Exchanges may be established by states or through a partnership between a state and the federal government. The federal government will establish exchanges in states that do not establish their own. No matter who is running the exchange, they all will generally perform the same functions.

States, or in some cases the U.S. Department of Health and Human Services, are responsible for determining what health plans are qualified to be sold in the exchange by assessing benefits offered; cost-sharing requirements such as deductibles, copayments, and out-of-pocket maximums; and the number and type of providers included in a plan. Qualified health plans must contract with essential community providers who serve predominantly low-income, medically underserved populations. As essential community providers, members of America’s Essential Hospitals should be included in plan networks and continue to care for many patients who become eligible for exchange plans. We will discuss this issue in detail in coming weeks.

Plans that are certified as qualified health plans may offer four levels of coverage (bronze, silver, gold and platinum). The levels of coverage will differ depending on the level of cost-sharing required. Platinum plans provide the most coverage, with benefits equal to 90 percent of health care costs. Gold plans cover 80 percent of health care costs, silver plans will include benefits equal to 70 percent of health care costs, and bronze plans will include benefits equal to 60 percent of health care costs, requiring the consumer to pay about 40 percent out-of-pocket costs.

All plans will cover 10 categories of essential health benefits, which include: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health benefits and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.

Exchanges are also required to hire a navigator to help people understand these health plans and how to enroll in them. These navigators will support new programs designed to inform people about coverage offered in their exchange and eligibility requirements for public programs like Medicaid and the Children’s Health Insurance Program. Programming will also cover information about eligibility for premium tax credits to reduce the cost of premiums and subsides to reduce cost-sharing for consumers.

We will continue to explore exchanges over the next few months, focusing on financial support for coverage, coverage levels and benefits, qualified health plans and provider networks, potential challenges, profiles of different types of exchanges, and outreach and enrollment strategies.

Thanks for listening to another edition of This Week in Washington. I’m Erin Richardson; join us next week for another update.



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