It's been a couple of weeks since I posted about health care reform, but now it's time to roll up our sleeves and get our hands dirty. Yup, we've reached the part in the book about health insurance exchanges, starting with Section 1311, Affordable Choices of Health Benefit Plans.
Assistance to States
The federal Department of Health and Human Services can award grants to the states to help cover the costs of setting up the exchanges, which the law refers to as "American Health Benefit Exchanges." HHS determines the amounts of the grants at the start of each fiscal year. A state that receives a grant in one year can receive a grant renewal the next year if HHS determines that it is making progress toward establishing its exchange, is implementing the coverage and market reforms we've already discussed, and is meeting other benchmarks HHS has set. The grant program expires in 2015. HHS must assist states to help small businesses participate in Small Business Health Options Program (SHOP) exchanges (I'll get into them later.)
By January 1, 2014, each state must establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans, creates a SHOP exchanges to help small employers enroll their employees in qualified small group plans, and that meets a number of requirements that I'll discuss in a bit. States can combine the regular and SHOP exchanges if they have the resources to assist both individuals and employers in one exchange.
HHS must issue regulations that create criteria for certifying health plans as "qualified." To get that certification, a plan must at minimum:
- Meet marketing requirements and not covertly discourage people with significant health needs from enrolling
- Ensure a sufficient choice of providers and provide information to current and prospective enrollees on the available of in- and out-of-network providers
- Include in its network available providers who serve low-income, medically-underserved people (however, this does not require a plan to cover any specific medical procedure)
- Be accredited by entities recognized by HHS; accreditation will be with respect to local performance on clinical quality measures, patient experience ratings, consumer access, utilization management, quality assurance, and other areas. Alternatively, it must receive accreditation applicable to all plans in the exchange
- Implement a quality improvement strategy
- Use a uniform enrollment form for individuals and employers to complete; this form must take into account criteria that the NAIC will develop and submit to HHS
- Use the standard format for presenting health benefits plan options
- Provide information to current and prospective enrollees and to the exchanges on any quality measures for health plan performance.
Plans do not have to contract with a health care provider who refuses to accept the plan's "generally applicable payment rates."
HHS must create a rating system to rate qualified health plans offered through an exchange on relative quality and price for each benefits level. The exchange must make the ratings publically available on an Internet portal. HHS must develop an enrollee satisfaction survey system to measure satisfaction with any qualified health plan that had more than 500 enrollees the previous year. The exchange must include the satisfaction information on the Internet portal and make it easy for individuals to compare plans on this basis.
Speaking of Internet portals, HHS must continue to operate the site currently known as HealthCare.gov, help states get their own portals up and running, and make a model template for a portal available to the exchanges for their use. The exchanges can use the portal to direct individuals and employers to qualified health plans, help them determine their eligibility for the exchange or for premium tax credits or reduced cost-sharing, and to present standardized information to make it easier to choose a plan. The template must include access to a uniform outline of coverage for each plan and to a copy of each plan's policy.
HHS must require an exchange to provide for
- An initial open enrollment
- Annual open enrollment periods thereafter
- Special enrollment periods as set by the tax and Social Security laws
- Special monthly enrollment periods for Indians.
In my next post, I'll get into the requirements exchanges must meet.