Demystifying State Health Insurance Marketplaces

By Hahn, Joyce A.; Sheingold, Brenda Helen et al. | Nursing Economics, May/June 2013 | Go to article overview

Demystifying State Health Insurance Marketplaces


Hahn, Joyce A., Sheingold, Brenda Helen, Ott, Karen M., Nursing Economics


The Patient Protection and Affordable Care Act (2010) and the health care provi- sions of the Health Care and Education Reconciliation Act (2010), mandated that by law, each state will establish and oper- ate a health insurance exchange for individual and small business health insurance coverage begin- ning January 1, 2014. The Affor- dable Care Act, or ACA, has become the accepted term for the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act combined. The ACA sets federal minimum standards and aims to achieve quality and affordable near-universal health insurance coverage through shared federal, state, employer, and individual responsibilities (see Table 1). As ACA rolls out to meet the timetable included within the leg- islation, the Department of Health and Human Services (HHS, 2013a) rules and grants are providing additional direction and guidance for implementing these new affordable insurance market- places. For example, HHS award- ed $1.5 billion on January 17, 2013 to 11 states to support the development of health care cover- age for their respective residents (HHS, 2013b). Health care law im- plementation is a work in progress and this article is written to pres- ent the state health insurance exchange information and dynam- ics as currently known and illus- trated through tables, a glossary, and discussion of the topic to in- clude the description of how these exchanges impact nursing prac- tice.

State Health Insurance Exchange Marketplaces

States are authorized under ACA to develop an insurance mar- ketplace by establishing an indi- vidual state exchange market- place, participate in a federal part- nership exchange marketplace, or become part of a Federally Facili- tated Exchange marketplace. States had until December 14, 2012 to submit applications to HHS to operate their own state health insurance exchange marketplace or until February 15, 2013 to sub- mit applications to participate in a federal-state exchange market- place. Creation of state health in- surance exchanges is a key com- ponent of the small group and individual health insurance mar- ket reforms in ACA. Health insur- ance exchanges will create a mar- ketplace where individuals and small businesses will choose affordable, comprehensive health coverage that meets or exceeds a set of minimum benefit standards (ACA, 2010; Rosenbaum, Lopez, Burke, & Dorley, 2013). State ex- changes will determine the health insurers and health plans that will participate in their exchange (qualified health plans) and pro- vide employers, consumers, insur- ance brokers, and others an online view of the competing health plans comparing benefits, costs, provider networks, quality re- ports, and other provided features. Exchanges will also provide "pa- tient navigators" to educate, an- swer questions, and guide con- sumers through the process. ACA also mandates exchanges to pro- vide a seamless streamlined pro- cess for consumers in determining eligibility for Medicaid, CHIP ben- efits, premium subsidies, or tax credits for eligible small benefits. States have the ability to create a separate exchange for the Small Business Health Options Program or they may incorporate the small businesses into the individual con- sumer exchange (Henry J. Kaiser Family Foundation, 2012a).

Inside and Outside the Exchange

The newly formed state health insurance exchanges will provide choices for health insurance for consumers and small businesses inside the exchange. Existing health plans can continue to oper- ate outside the exchange inde- pendently from the state exchange or may choose to operate both in- side and outside the state ex- change. All Qualified Health Benefit Plans operating inside and/or outside the state exchanges are required to meet the minimum benefit provisions outlining the cost-sharing levels of participating plans (Piper, 2013; Rosenbaum, 2011).

Cost Sharing and Benefits

Under ACA legislation, state insurance exchange plans must cover a portfolio of mandatory benefits, also referred to as "essen- tial health benefits" (see Table 2). …

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