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Qualified Health Plans


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QHP is an insurance plan certified by the Health Insurance Marketplace. The whitepaper expounds the guidelines for payers to avail of Qualified Health Plans.

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Qualified Health Plans

  1. 1. Payer Guidelines for a Qualified Health Plan Payer Guidelines for a Qualified Health Plan Thejesh Kumar C. is a Solutions Consultant with 13 years of experience in US Healthcare across different functional areas. Apart from being a certified RCM, AHM, PAHM, CMS and AHIP professional, he also has vast experience in Claim benefit management, ANSI X12 transactions, HL7, Medicare & Medicaid solutions, Enrolment and other key areas. Thejesh Kumar C
  2. 2. What is QHP? QHPs offer the same core set of benefits, including preventive services, mental health and substance abuse services, emergen- cy services, prescription drugs and hospitalization. Some plans include benefits beyond the core set. QHPs are categorized and labeled by a standard coverage level to help consumers compare plans. The four standard coverage levels which are also known as metallic tiers are: Platinum: the plan must cover 90% of expected costs for the average individual Gold: the plan must cover 80% of expected costs for the average individual Silver: the plan must cover 70% of expected costs for the average individual Bronze: the plan must cover 60% of expected costs for the average individual There are also catastrophic plans. Catastrophic plans have high deductibles and offer less coverage than the metal level plans. Premium tax credits could not be used with these plans. Consumers must be under 30 or meet other criteria to be eligible to purchase a catastrophic plan. As defined in the Afford- able Care Act (ACA), a QHP is an insurance plan certi- fied by the Health Insur- ance Marketplace. It pro- vides Essential Health Benefits (EHBs), follows established limits on cost sharing, and meets other requirements outlined in the application process. Monthly Cost Cost when you get Care Good option if you... Platinum Gold Silver Bronze $$$$ $$$ $$ $ $ $$ $$$ $$$$ Plan to use alot of medical care services Want to save on the monthly premi- um, while keeping your out-of-po cket costs low Need to balance your monthly cost with your out-of-po cket costs Don,t plan on needing a lot of medical care services Source: fied-health-plan-qhp 1 Copyright © 2018 Nalashaa
  3. 3. Conclusion The process of certification of a QHP plan will have a huge impact on payer business. The processes involved like monitoring the quality and defining quality metrics, defining rates, designing plans, SHOPs and Exchange need a comprehensive strategy of solution. Business process, policy, and system change impacts need to be identified, assessed, planned, and ana- lyzed before going live. Nalashaa has great exposure in Health Insurance Exchange and creating benefits for health plans, which will help assist in smooth delivery of QHP related services. If you would like to bounce off your thoughts on this, let’s have a conversation. Connect with the experts! At Nalashaa, we partner with healthcare organizations of all stages, from startups to established firms, and work with them to build engaging user experiences that reduce organziational cost and risk. Our healthcare and technology expertise, along with our flexible engagement models, make us a great fit for developing the quality technology while reducing time to market and engineering costs. About Us 555 US Highway 1 South, Suite 170, Iselin, NJ 08830, USA 732-602-2560 X 200 Reach Us: