Healthcare Insurance Exchanges represent a new marketplace. They are intended to play a significant role in healthcare reform. Given the success of web-based commerce, they stand a good chance of succeeding. As part of the larger government healthcare reform initiative, there are challenges! www.healthcaremedicalpharmaceuticaldirectory.com John G. Baresky

1. “A Conversation About
Healthcare Insurance Exchanges”
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2. “A Conversation About
Healthcare Insurance Exchanges”
www.HealthcareMedicalPharmaceuticalDirectory.com
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3. What is the purpose of the exchanges?
• Exchanges are intended to make buying health insurance
easier and more affordable, they are essentially virtual
stores for selling health insurance
• Their goal is to help individuals and small businesses:
– Compare health plans
– Get answers to questions
– Find out if they are eligible for tax credits for private insurance
or health programs like Children’s Health Insurance
Programs(CHIPs)
– Enroll in/purchase health insurance

4. What will each exchange provide?
• A website and 1-800 hotline to ask questions and
purchase insurance
• Standardized plan descriptions for easy comparison by
consumers and small businesses
• Websites will feature a calculator to determine costs
• Plans will be pre-ranked according to price, coverage and
other variables

5. Who is eligible to use the exchanges?
• The Accountable Care Act (ACA) requires:
– Employers with more than 50 full-time workers to offer health insurance for
employees and their families
– Each exchange to offer plans for consumer and small businesses (up to 100
employees)
– The plans offered to feature a minimum set of benefits or pay a tax of
$2,000 per employee for failing to do so (the tax will not apply to the first 30
workers)
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6. What types of plans will exchanges offer?
• Commercial plans will be available through:
– Insurers
– Licensed insurance agents
– Insurance brokers
• Government plans will also be featured:
– Medicaid
– CHIPs (Children’s Health Insurance Program)
– Other

7. How are plans chosen for exchanges?
• Plan coverages and other features are reviewed by
federal and state governments for the exchanges:
– These are referred to as “Qualified Health Plans” or
“QHPs”
– Plans will be accepted, assessed and renewed upon
review approval on an ongoing basis

8. What will commercial plans provide?
• Ambulatory patient care
• Emergency medical services
• Hospitalization
• Maternity / newborn care
• Mental health, behavioral health and substance abuse
care
• Prescription medications
• Rehabilitative services, devices, patient care
• Laboratory testing services
• Preventative, wellness and chronic disease services
• Pediatric care that also features oral and vision care

9. What will state government plans provide?
• Medicaid and CHIPs plans differ from state to state
• Some states have more than one type of Medicaid
and/or CHIPs plans to better serve different needs
• Coverage will vary between states and the plans they
offer
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10. How will exchange users choose a plan?
• They may choose by cost based on several variables
including age, employment status and income
• Some persons may qualify for a plan from a commercial
provider (Aetna, BlueCross BlueShield, Human, United
Healthcare, etc.)
• Other will be directed to Medicaid or other government-
sponsored plans

11. Can applicants be refused coverage?
• Yes, applicants may be denied, eligibility/coverage is not
automatic
• A formal appeal process will be available for exchange
customers
– More detailed guidelines are being developed for acceptance,
denial and appeal decisions

12. Who will operate the exchanges?
• Some exchanges will be run by individual states
• States may partner with the Federal government to jointly setup
and operate an exchange
• A state may opt out of the program and the Federal government
will operate one on their behalf
• Exchanges operated by the Federal government are expected to be
operated by the states at a later date
• After the election, U.S. Secretary of Health and Human Services,
Kathleen Sebelius, extended a January, 2013 deadline to February
14th, 2013 for states to choose which option to choose

13. When will the exchanges be open?
• Exchanges will become operational 10/1/2013
– Consumers and small businesses can begin reviewing and
choosing plans
– Active coverage for beneficiaries will be effective 1/1/2014
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14. Is use of the exchanges mandatory?
• Individuals and small businesses can obtain health
insurance from any source they prefer
• The exchanges are intended to provide easily accessible,
comparative healthcare insurance information to
evaluate / purchase health insurance
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15. Why is Information Technology important?
• Exchange customer information will be cross-referenced
with data on file in state Medicaid and Children’s Health
Insurance Program (CHIP) plans to
• Consumer income will be verified through state-based
data sources
• Application information will be matched with plans
offered in the exchange to determine which ones best
align to the exchange customer’s needs

16. Who is paying for the exchanges?
• Federal funding is covering much of the startup expenses
• By November, 2012, over $2 billion has been allocated to
support state activities to develop websites,
enrollment/eligibility management systems, etc.
• By 2014 the exchanges must be self-supporting through
fees collected from insurers using the exchanges to
market their plans
• For plans sold through federal exchanges, insurers will
pay HHS 3.5% of the premium to support exchange costs

17. What are some concerns?
• Will exchanges be used by enough customers to remain
viable over time?
• Can exchanges be adequately funded over the long term?
• If insurers withdraw from offering plans on an exchange,
will remaining ones offer competitive rates?
• As small businesses grow beyond 100 employees, how
can they economically migrate to a non-exchange plan?
• How can coverage/cost issues be minimized when
beneficiaries move to other states?
• Can federal and state government adequately oversee
the exchanges, plan providers and service levels for
consumers/small businesses?

18. Summary
• Health insurance exchanges are a key component of
healthcare reform
• Significant cost, management and technology challenges
remain ahead for federal and state governments in
launching /maintaining the exchanges
• Internal and external web-based technology will play a
pivotal role in the functionality of all exchanges
• Affordability and coverage issues are a concern for
potential consumer and small business customers

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