A Qualified Health Plan (QHP) is an insurance plan certified by the Health Insurance Marketplace that provides essential health benefits and follows cost sharing limits. QHPs are categorized into platinum, gold, silver, and bronze tiers based on the percentage of expected health care costs covered. The document discusses the benefits and costs associated with each metal tier and concludes that Nalashaa can assist payers in smoothly implementing QHP certification requirements and processes.

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. 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: https://www.peoplekeep.com/blog/faq-what-is-a-quali-
fied-health-plan-qhp
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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.
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let’s have a conversation.
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