Picking up our examination of the forthcoming health insurance exchanges, let's look at the provisions on consumer choice.
Qualified individuals may enroll in any available exchange-offered plan for which that person is eligible. Qualified employers may select any coverage level to offer employees. If an employer specifies a coverage level, its employees may enroll in any available plan that offers coverage at that level. The covered person may pay any applicable premium to the health insurance carrier.
Single Risk Pools
A health insurance carrier must consider everyone enrolled in its individual health plan to be members of a single risk pool. This pool includes both people who buy from an exchange and those who buy outside the exchange. The same applies to everyone enrolled in plans the carrier offers in the small group market. If they decide it's appropriate, states have the authority to require carriers to merge the two markets.
The law clarifies that carriers can offer plans to individuals and employers outside the exchanges, and individuals and employers are free to choose non-exchange plans. It also states that it does not override any state laws governing required benefits for plans offered outside an exchange. Individuals are free to enroll or to not enroll in exchange plans, and the government cannot compel them to enroll in them. Qualified individuals (see below) may enroll in any available exchange plan, but they must be eligible to enroll in a catastrophic plan before they can choose one. The federal government will be able to offer to members of Congress and congressional staff (both in Washington and in district offices) only plans created under the health care reform law or plans offered through an exchange. Individuals can cancel their enrollment in an exchange plan without penalty if they become eligible for coverage elsewhere or if that coverage becomes affordable to them mid-term.
Agents and Brokers
The federal Department of Health and Human Services must create procedures for states to allow agents and brokers to:
- Enroll individuals and employers in exchange plans as soon as they become available through the exchanges in their states
- Help individuals in applying for premium tax credits and cost-sharing reductions for exchange plans.
Qualified Individuals and Employers
Individuals must be residents of the state that established an exchange in order to seek individual coverage from it. They are not eligible if they are incarcerated and not awaiting the disposition of charges. Small employers are initially eligible to buy coverage through the exchanges, but states may allow carriers to offer large group plans through the exchanges starting in 2017. Carriers will not be required to offer large group plans through the exchanges. If a state elects to do this, large employers will then become eligible. Exchange plans will not be available to non-citizens who are not "lawfully present" in the U.S.
Next time: Financial integrity provisions.