Question

Discuss what the functions and requirements are for insurance exchanges since the implementation of the ACA, what is the structure of governance, and management in payer organizations?

Answer 1

Affordable care act has dramatically changed the health insurance market.

• prohibiting insurers from considering subscribers’ health status or risk
• providing substantial subsidies to purchase individual purchase
• creating an “exchange” structure that facilitates comparison shopping.

?Insurance exchange is designed to make health insurance coverage accessible and affordable for individuals and small employer groups. It offers a special marketplace where individuals and small employers can buy coverage and in which federal coverage subsidies (through premium tax credits) can be secured. Insurance exchange works in accordance with requirements related to enrollment, eligibility determinations, consumer and patient assistance through the use of Navigators, transparency, QHP (qualified health plan) certification and oversight. Exchange functions:

• perform eligibility determinations of those seeking to buy coverage in the Exchange
• if eligible, enroll those qualified individuals in QHPs
• conduct plan management functions, including QHP certification
• provide numerous consumer assistance services
• perform financial management functions.

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