1. T HE A FFORDABLE C ARE A CT:
T HE E XCHANGES

2. O VERVIEW
• Affordable Care Act
• The Exchange Program
• Employer Provided Insurance
• Legal Opt-Out Options
• Penalties
• Key Exchange Implementation Dates
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3. A FFORDABLE C ARE A CT
•
• Healthcare Insurance Exchanges will allow
individuals and employers to shop, compare,
and enroll affordable insurance plans
• Effective: January 1, 2014
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4. A FFORDABLE C ARE A CT:
H IGHLIGHTED C HANGES TO
H EALTHCARE C OVERAGE
• Individuals with pre-existing conditions are no longer denied
coverage, nor can they be dropped when diagnosed with a
serious illness/disability
• Eligibility requirements and covered healthcare services are
expanded
• Lifetime insurance limits on essential services are prohibited
• Small businesses may qualify for a tax credit
• Employers will be penalized for providing inadequate coverage
or for not providing coverage at all
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5. A MERICAN H EALTH B ENEFIT
E XCHANGE (E XCHANGE )
• ACA §1311 requires each state to have an Exchange program
available for consumers to both compare and purchase
healthcare coverage
• The primary format of an Exchange will be via website
o Until all state Exchanges are up and running, consumers can find
available healthcare options via the ACA website at
http://finder.healthcare.gov/
• Exchanges will also be available via toll-free hotline, by mail, and
through in-person assistance locations
o Set up of in-person assistance programs will be optional for states
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6. E XCHANGE A SSISTANCE
• Each Exchange will be required to set up Navigator programs
• Navigators are to provide impartial information, assistance to
consumers, and help with the appeal process
• Navigators can be in the form of different professional or
community based organizations
o At least one Navigator program within the state must be from the
community/consumer non-profit group
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7. T HE E XCHANGE P ROGRAM :
Q UALIFIED H EALTH P LANS (QHP S )
• A Qualified Health Plan is an insurance plan that is
certified to operate within an Exchange
• QHPs can be offered at four different levels of
coverage
• QHPs can also be in the form of Child-only or
Catastrophic plans
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8. T HE E XCHANGE P ROGRAM
Main functions of an Exchange will be to:
• Allow for comparison of QHPs
• Assist applicants with applications and enrollment
• Administer QHP certification process
• Monitor QHPs for compliance
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9. T HE E XCHANGE P ROGRAM :
Q UALIFIED H EALTH P LANS (QHP S )
A QHP must offer the following 10 essential health
benefits, per ACA §1302:
1. Ambulatory patient services
2. Hospitalization
3. Mental health & substance use disorder services
4. Rehabilitative & habilitative services
5. Preventative & wellness services
6. Emergency services
7. Maternity & newborn care
8. Prescription drugs
9. Laboratory services
10. Pediatric services
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10. T HE E XCHANGE P ROGRAM :
E XCHANGE S ET -U P
There are three Exchange types: a State-Based Exchange, a State-
Partnership Exchange, and a Federally-Facilitated Exchange
To set-up an Exchange, a state must submit a Declaration Letter
and Exchange Application to the Centers for Medicare and
Medicaid Services (CMS):
• Must be submitted November 16, 2012
• If nothing is received, the Department of Health and
Human Services (HHS) declare that the state is operating
as a Federally-Facilitated Exchange
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11. T HE E XCHANGE P ROGRAM :
E XCHANGE T YPES
State-Based Exchange
• The state conducts all of its Exchange program activities
• The state may elect the government to perform tasks such as:
o Applicant tax benefits Exemptions
o Risk adjustment program
o Reinsurance program
State-Partnership Exchange
• The state partners with HHS to operate Exchange
o States perform services for plan management, consumer
assistance, or both
o HHS performs services for reinsurance programs, eligibility
for Medicaid/CHIP and tax credits, and ensures the Exchange
meets its required functions
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12. T HE E XCHANGE P ROGRAM :
E XCHANGE T YPES
Federally-Facilitated Exchange
• HHS performs all Exchange activities for the state
• HHS will coordinate with the state to operate a
successful Exchange
If HHS determines that a state’s Exchange program is
non-compliant, it can change the state’s Exchange to a
Federally-Facilitated Exchange program
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13. T HE E XCHANGE P ROGRAM :
T YPES OF E XCHANGE F UNDING
State Planning Grant
• Aids state in beginning development of its Exchange
program
Early Innovator Grant
• Awarded to states that developed a working Exchange
program that is transferrable to other states to use
Level One Establishment Grant
• Provides funding for one year to start an Exchange Plan
Level Two Establishment Grant
• Helps states continue Exchange development after one year,
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provided certain criteria is met

14. T HE E XCHANGE P ROGRAM :
E XCHANGE C OMPLIANCE
Exchanges are responsible for implementing a
compliance monitoring and recertification system for
QHPs
The Secretary of HHS will conduct annual reviews to
ensure the Exchange complies with:
• Eligibility verification requirements
• Federal funds usage requirements
• Quality and performance standards
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15. L EGAL O PT -O UT O PTIONS
States – can opt-out of implementing its Exchange;
HHS will then implement a Federally-Facilitated
Exchange
QHPs – can opt-out of providing abortion related
coverage
Individuals – can opt-out of automatic enrollment in
employer provided insurance plans and individual
coverage, if applicable
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16. L EGAL O PT -O UT O PTIONS :
I NDIVIDUAL E XEMPTIONS
Individuals that fall under the following classifications are
exempt from the individual insurance mandate:
• Members of religious sects/healthcare sharing
ministries
• American Indians
• Individuals with financial hardships
Incarcerated individuals not pending charges and
undocumented immigrants are not eligible for coverage
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17. U PCOMING I MPLEMENTATION
K EY D ATES
The Consumer Operated & Oriented Advisory
Board establishes a plan that will allow the
creation of non-profit and member-run insurance.
Open enrollment period begins
ACA Exchanges are in
effect.
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18. R EED & A SSOCIATES , CPA S
For more information on Reed & Associates, CPAs please
contact us at:
inquire@reedassociatescpas.com
Phone: 860-395-1996
Or visit our website:
reedassociatescpas.com
PAGE 18
Quality. Integrity. Experience.