Health Insurance Exchanges: What You Need to Know

By Andrew Slavik, DC, and Kara Webb

One term that has been used with frequency since the passage of the Patient Protection and Affordable Care Act (PPACA) is “state insurance exchange.” Many are confused about what exactly state insurance exchanges will do and what impact they will have on doctors of chiropractic (DCs). Here we provide DCs with the knowledge needed to fully understand insurance exchanges and to help them become involved in ensuring that their patients are well served by their state’s insurance exchange.

Exchanges Defined
Health insurance exchanges will be marketplaces where consumers can compare and purchase health insurance. The exchanges will operate websites, toll-free phone lines and physical offices to provide information about the available health plans and to help consumers enroll in coverage. Many believe that having the ability to more easily review and purchase health care coverage will create a more competitive marketplace for buying health insurance.Insurance plans offered for purchase on the exchanges will be required to conform to certain standards laid out by the federal government. Many of these standards have not yet been finalized. However, some basic requirements for exchanges were specifically delineated in PPACA.

Each state is required to develop and have a functioning insurance exchange operating by 2014. If a state chooses not to develop an exchange or does not develop an adequate exchange, the federal government will come in and develop and operate that state’s exchange. Initially, not all consumers will be able to purchase insurance through a health insurance exchange. In 2014, exchanges will serve individuals who are buying insurance independently and small businesses that have up to 100 employees. In future years, states will have the option of allowing businesses with greater numbers of employees to purchase insurance through the exchange.

Health insurance plans sold on the exchanges also will be required to cover certain health care services. The benefits that are required to be covered are called “essential health benefits.” The Department of Health and Human Services (HHS) has called on the Institute of Medicine (IOM) to help develop criteria for determining essential health benefits. The IOM is expected to release its report to HHS in the fall of 2011. After review of the report, HHS will issue proposed regulations giving more information about the required essential benefits. ACA has been actively involved in ensuring that the services provided by DCs are recognized as essential.

In January 2011, ACA was invited to offer testimony to the IOM on how to define essential benefits. ACA stands ready to launch a strong response to any proposed regulations regarding the definition of essential health benefits.

What DCs Can Do
As of July 2011, 15 states already had established health insurance exchanges: California, Colorado, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Nevada, North Dakota, Oregon, Utah, Vermont, Virginia, Washington and West Virginia. Some states have deferred to their next legislative session the development of insurance exchange legislation. It is critical that the chiropractic profession be involved in the development and actions of the exchanges. Below is a list of actions that DCs and state organizations should take to become involved in the development and roll out of state health insurance exchanges.

  • Determine if your state is planning to develop an exchange, or if it is deferring to the federal government to develop the exchange.
  • If your state is developing the exchange, determine if legislation has been passed regarding the creation and monitoring of the state exchange. A great resource for checking on the status of insurance exchange development is accessible at http://statehealthfacts.kff.org/ healthreformsource.jsp.
  • If legislation has not yet been passed, meet with legislators in your state to gather more information about where the legislature may be going with respect to exchange development. Communicate the chiropractic profession’s desire to be involved in exchange development. For health care reform lobbying resources visit www.acatoday.org/hcr and click on “Health Care Reform Survival Kit.”
  • If legislation is pending, review the legislation. One major issue to look for in draft legislation is whether the opportunity exists for health care provider involvement in any board or committee that oversees the actions of the exchange.
  • If legislation is pending, meet with key contacts to communicate the chiropractic profession’s desire to be involved in exchange development. ACA has a resource to guide you through this process with information to leave with key contacts. (Refer to “Case for Full Inclusion” for talking points to use while meeting with policy makers.)
  • Determine if any of your state representatives participate on the White House Work Group on Health Care Reform. (This list is accessible in the Health Care Reform Survival Kit noted above.) If a work group participant is active in your state, consider meeting with him or her to discuss exchange development. These individuals are key players in health care reform.
  • If legislation has passed regarding the development and operation of the exchange in your state, review the legislation and determine any approaches to become involved in exchange Activities and oversight. If health care provider representation on any boards or committees has been delegated to one specific provider organization or specific individuals or groups, reach out to those individuals to discuss issues of mutual interest regarding exchange development and oversight.
  • If legislation has passed regarding the development and operation of the exchange in your state, it is very likely that the legislation will need to be amended to ensure it is consistent with the federal regulations governing exchanges. Those regulations should be finalized by the end of 2011. If exchange legislation is revisited, contact your legislators to gather information about potential changes, and get involved in any meeting on exchange development.
  • Ensure that your state organization is represented at any public meetings regarding exchanges.

The development of insurance exchanges and defining essential health benefits are ongoing efforts that require the full engagement of DCs across the country. ACA is fully engaged on the federal level to preserve, promote and protect the chiropractic profession in the changing health care environment. We need the support of the states and DCs across the country to ensure our success. If you have any questions about this article or how to get involved, please contact gr@acatoday.org.

In addition to lobbying on behalf of all DCs, ACA is constantly updating and providing resources related to health care reform and meeting with local liaisons in 26 states on a monthly basis through the local liaison program (LLP). During these meetings, liaisons strategize with ACA regarding insurance problems, legislation and general concepts related to reimbursement of chiropractic services, as well as health care reform. Liaisons will be receiving specialized training in aspects of health care reform in order to be well versed in the concepts of new payment methods and delivery systems such as accountable care organizations. To find out if your state currently participates in this valuable program, visit www.acatoday.org/ LLP. To find out more about the local liaison program, email LLPInfo@acatoday.org.


REGULATORY UPDATE

  • In July 2011, HHS released a proposed rule regarding the operation and oversight of health insurance exchanges.
  • ACA strongly supports the many instances in the rule in which HHS proposed to limit the role that health insurers can play in the development, oversight and operation of exchanges.
  • ACA would like to see HHS allow even more health care provider involvement in the oversight of health insurance exchanges.
  • Read ACA’s comments on the proposed rule at www.acatoday.org/hcr.
  • Please note the comments given are in response to proposed regulations. ACA will keep the profession informed of the final regulations.