Under the Affordable Care Act, Health Insurance Exchanges, whether state or federally operated, must manage several core functions starting in 2014. The functions include pre-screening for Medicaid or CHIP coverage, federal subsidy eligibility determination, consumer assistance, management and oversight of qualified health plans (QHPs), financial management, and enrollment of individuals or small group employees in qualified health coverage or connection with CHIP and Medicaid.
Management of QHPs entails a complex range of new functions, including certification of health plans, rate and benefit review, quality rating, marketing regulation, compliance monitoring, and open enrollment administration. In some states, the Health Insurance Exchange (HIX) may also decide to collect premiums centrally. Like other Exchange functions, states may take on these responsibilities or defer them to the Centers for Medicare and Medicaid Services as part of a federal-run HIX (federally facilitated exchange or FFE in federal parlance). In other cases, the state and CMS may partner and share in HIX management.
Plan Management: Issues for State, Partnership and Federally Facilitated Health Insurance Exchanges – a research paper from the Center on Health Insurance Reforms at Georgetown University’s Health Policy Institute – drills in on key aspects of the plan management responsibilities of Health Insurance Exchanges, most notably, licensure confirmation and solvency, rate and benefit review, marketing regulation, quality improvement, and ongoing oversight. The findings draw upon a review of current plan regulation within Medicaid programs and state commercial marketplaces, with additional regulatory structure evaluation conducted in six states: Arizona, Minnesota, New York, Tennessee, Washington, and Wisconsin.
The researchers found that state insurer oversight notably increases with new exchange plan management obligations, though existing infrastructure likely exists to ensure exchange officials would not need to create a plan management infrastructure from the ground up. Medicare Advantage provides the Centers for Medicare and Medicaid Services with some infrastructure, which may be used in plan management operation for FFEs. However, differences remain in current and potential regulatory approaches. While the bulk of plan regulatory and purchasing experience resides in states, the report says collaboration among state regulators and CMS could prove beneficial.
The research paper was released by the National Academy of Social Insurance and authored by Sabrina Corlette, JD, JoAnn Volk, MA, and Kevin Lucia, JD, MHP, all from the Center on Health Insurance Reforms at Georgetown.
To read or download the full paper, click here (PDF).