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Health Care Reform FAQ

What is a health exchange or a marketplace?

Essentially, exchanges are websites that will sell insurance. The intent of the exchange will be to assist consumers with the education and purchase of health insurance. The ACA requires a health exchange to be operating in every state by January 2014. Beginning in January 2013, the United States Department of Health and Human Services (HHS) began referring to exchanges as marketplaces.

My state has decided against setting up a health exchange. What happens now?

States that decide not to create a state-based exchange or a state/federal exchange are ceding authority to the Federal Government. The U.S. Department of Health and Human Services (HHS) will create and implement a Federally Facilitated Exchange (FFE) in your state. The FFE in your state will provide the same function as any other exchange, but will be run, overwhelmingly, by the Federal Government. HHS will try to coordinate as much as possible with your state in areas like plan certification, consumer assistance, and Medicaid services. Despite an FFE being implemented, a state may still apply in the future to establish its own state-based exchange. The role of the agent/broker is still being determined; PIA is currently involved in that dialogue. We expect to learn a lot more about these exchanges in the coming months.

What is a SHOP exchange?

Beginning in January 2014, Small Business Health Options Program (SHOP) exchanges will be available for small businesses. SHOP exchanges may operate separate from the individual exchanges or may be merged into one larger exchange that serves both market segments. Businesses up to 100 employees may purchase coverage through a SHOP exchange, although states may limit that number to 50 employees until 2016. Plans offered through a SHOP exchange will have to meet certain federal and state standards. The U.S. Department of Health and Human Services (HHS) has indicated that they envision robust agent participation in a Federally Facilitated SHOP. PIA is working on those details now.

What are Essential Health Benefits?

The Affordable Care Act (ACA) requires each individual and small group plan to offer a series of basic coverages called Essential Health Benefits (EHBs). Each plan must include coverage for the following ten categories:

  • 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

Each state is required to establish an EHB benchmark plan from the above list to serve as the benefit standard for the state. If a state doesn’t submit a benchmark plan, then the Federal Government will do so for the state. If a benchmark plan doesn’t include all the coverage categories, as listed above, then the state will be required to supplement the benefits.

What is a Qualified Health Plan?

Starting in 2014, a health insurance plan offered through an exchange must be certified as a Qualified Health Plan (QHP). These plans must meet certain requirements that include marketing standards, providing essential health benefits, utilization of a standard format for presenting coverage options and a limitation on cost-sharing (deductible, copayments, etc.). Each QHP must be certified by each exchange in which it is sold.

What new ACA provisions will be implemented this year?

To view PIA’s timeline of the ACA implementation, visit www.pianet.com/health and click ACA Timeline.

Can agents be part of the health exchange?

Yes, licensed agents and brokers can be part of the health exchange. The federal regulations make it clear that, with proper training, agents and brokers can enroll individuals, employers and employees in Qualified Health Plans (QHPs) through an exchange, as well as outside the exchange. In fact, in some states agents are represented on the governing board of the exchange.

Agents and brokers who assist consumers with an exchange must have entered into an agreement with the exchange that requires the agent or broker to, at a minimum:

  • Register with the exchange in advance of assisting qualified individuals enrolling in QHPs through the exchange;
  • Receive training in the range of QHP options and insurance affordability programs;
  • Comply with the exchange’s privacy and security standards.

Regulations allow agents or brokers to use their own website to complete the selection of a plan inside an exchange, as long as the website:

  • Meets all the standards for disclosure and display of QHP information set out in law and regulations;
  • Provides consumers the ability to view all QHPs offered through the exchange;
  • Does not provide financial incentives, such as rebates or giveaways;
  • Displays all the QHP data provided by the exchange;
  • Maintains audit trails and records in an electronic format for a minimum of 10 years;
  • Provides consumers with the ability to withdraw from the process and use the exchange website.

Additional details, including that of compensation, are still being worked out. PIA is working to ensure agents earn fair and just compensation.

What is a "navigator?"

Federal law requires exchanges to establish a navigator program. Responsibilities of a navigator include:

  • Conduct public education;
  • Distribute fair and impartial information;
  • Facilitate enrollment in QHPs;
  • Provide referrals to the appropriate entity for an enrollee with a grievance, complaint or question;
  • Provide information that is both “culturally and linguistically appropriate”.

Exchanges may require that navigators meet additional standards and carry out additional duties consistent with the listed minimum duties.

The ACA and regulations list the types of entities that may be navigators. The regulations clarify that the exchange must select entities from at least two of the following categories to serve as navigators:

  • A community- and consumer-focused nonprofit group;
  • A trade, industry or professional association;
  • A commercial fishing industry, ranching or farming organization;
  • Chambers of commerce;
  • Unions;
  • Resource partners of the Small Business Administration;
  • Licensed agents and brokers.

Federal regulation states that navigators cannot be forced to hold a producer license or carry errors and omissions insurance.

What is an "assister?"

The Affordable Care Act (ACA), along with subsequent regulations from the U.S. Department of Health and Human Services (HHS), provides relatively detailed guidance on the role of navigators but leaves wide discretion to the states on the role of other “facilitators” or “assisters.” Some states plan to utilize navigators and assisters quite extensively, while other states plan to continue to utilize licensed agents and brokers to assist consumers with choosing a health plan that is right for them.

For example, in California certified “Application Assisters” are people who have been trained, passed a certification test and provide application assistance to consumers applying for certain state health programs.

In Arkansas, the state is considering an “In-Person Assister” program. These assisters may be very similar to a navigator and assist with education efforts and enrollment in a Qualified Health Plan. The state is considering allowing agents and brokers to become an “In-Person Assister,” though restrictions may be placed on how they are compensated.