Question

How many kinds of marketplaces/exchanges are there in each State? What kinds of health insurance customers does each type of exchange aim to help?

Answer 1

A Health Insurance Marketplace (formerly called an Exchange) is a virtual marketplace where “qualified individuals” or “small” employers can compare and purchase health insurance policies (called “qualified health plans” or QHPs), either online or by calling in to a customer service center. January 1, 2014 is the earliest date coverage will be effective if purchased in a Marketplace. There are two types of Marketplaces:

• An Individual Marketplace – where individuals can buy health insurance policies for themselves and/or family members and where individuals can possibly receive federal subsidies to help pay for such coverage
• A Small Business Health Options Program (SHOP) Marketplace – where small employers (up to 50 employees in 2014 and 2015) can buy group health insurance policies or allow their eligible employees to select from among different group health plan options

PPACA allows three different types of Marketplaces: State-run, Federally-facilitated and State-Federal Partnerships. A fourth hybrid option has since been added as well. In enacting PPACA, Congress thought most states would want to establish State-run Marketplaces, and the Federally-facilitated Marketplaces were to be the default for those states that did not get state Marketplaces established in time to be operational for the October 1, 2013 enrollment start date. For a number of reasons—the primary two being partisan politics and lack of specific timely guidance from the federal government—twenty-six states have elected to have federally-facilitated Marketplaces in 2014, and only fifteen states and the District of Columbia will have State-based Marketplaces. Seven states will have State-Federal partnerships, and two states (Utah and New Mexico) will have State-run SHOP Marketplaces and Federally-facilitated individual Marketplaces.

EHBs—listed below—are 10 core health benefits items and services the Institute of Medicine (IOM) and the federal government have determined all individual and small group health insurance policies should provide. Most large group health plans already provided at least eight or nine of these 10 services (many did not include pediatric dental or vision, or habilitative care).

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care