Health insurance marketplace
Health insurance marketplaces, also called Health Exchanges, are organizations set up to facilitate the purchase of health insurance in every state of the United States in accordance with Patient Protection and Affordable Care Act (Obamacare). Marketplaces provide a set of government-regulated and standardized health care plans from which individuals may purchase health insurance eligible for federal subsidies.
All health exchanges must be fully certified and operational by January 1, 2014, under federal law. Enrollment in the marketplaces started on October 1, 2013 and will continue for six months.
As of November 13, 2013 only 106,185 people have selected a health plan through the health insurance marketplaces.
- 1 Background
- 2 History
- 3 Economics of health insurance exchanges: the individual mandate
- 4 Acronym
- 5 Criticism and controversy
- 6 Private health insurance exchanges
- 7 See also
- 8 References
- 9 External links
Health insurance exchanges in the United States are intended to help insurers comply with consumer protection laws, compete in cost-efficient ways and expand insurance coverage to more people. Exchanges are not themselves insurers, so they do not bear risk themselves, but they do determine the insurance companies that are allowed to participate. An ideal exchange promotes insurance transparency and accountability, facilitates increased enrollment and delivery of subsidies, and helps spread risk to ensure that the costs associated with expensive medical treatments are shared more broadly across large groups of people rather than spread across just a few beneficiaries.
President Barack Obama promoted the concept of a health insurance exchange as a key component of his health care reform initiative. Obama stated that it should be "... a market where Americans can one-stop shop for a health care plan, compare benefits and prices, and choose the plan that's best for them, in the same way that Members of Congress and their families can. None of these plans should deny coverage on the basis of a pre-existing condition, and all of these plans should include an affordable basic benefit package that includes prevention, and protection against catastrophic costs. There are those who strongly believe that Americans should have the choice of a public health insurance option operating alongside private plans. The belief is that it will give them a better range of choices, make the health care market more competitive, and keep insurance companies honest." Although the House of Representatives had sought a single national exchange as well as a public option, the Patient Protection and Affordable Care Act (ACA) as passed used state-based exchanges, and the public option was ultimately dropped from the bill after it did not win filibuster-proof support in the Senate. States may choose to join together to run multi-state exchanges, or they may opt out of running their own exchange, in which case the federal government will step in to create an exchange for use by their citizens.
The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010. The Law requires that health insurance exchanges start commence operation in every state on October 1, 2013. In the first year of operation, open enrollment on the exchanges runs from October 1, 2013 to March 31, 2014, and insurance plans purchased by December 15, 2013 will begin coverage on January 1, 2014. In subsequent years, open enrollment will start on October 15 and end on December 7.
Implementation of the individual exchanges changes the practice of insuring individuals. The expansion of this market is a major focus of President Obama's Patient Protection and Affordable Care Act.
Patient Protection and Affordable Care Act regulations
- Insurers are prohibited from discriminating against or charging higher rates for any individual based on pre-existing medical conditions or gender.
- Insurers are prohibited from establishing annual spending caps of dollar amounts on essential health benefits.
- All private health insurance plans offered in the Marketplace must offer the following essential health benefits: Ambulatory care, Emergency services, Hospitalization (such as surgery), Maternity and newborn care, Mental health and substance use disorder services, Prescription drugs, Rehabilitative and habilitative services (services to help people with injuries, disabilities, or chronic conditions to recover), Laboratory services, Preventive and wellness services, Pediatric services.
- Under the individual mandate provision (sometimes called a "shared responsibility requirement" or "mandatory minimum coverage requirement"), individuals who are not covered by an acceptable health insurance policy will be charged an annual tax penalty of $95, or up to 1% of income over the filing minimum, whichever is greater; this will rise to a minimum of $695 ($2,085 for families), or 2.5% of income over the filing minimum, by 2016. The penalty is prorated, meaning that if a person or family has coverage for part of the year they won't be liable if they lack coverage for less than a three-month period during the year. Exemptions are permitted for religious reasons, members of health care sharing ministries, or for those for whom the least expensive policy would exceed 8% of their income. Also exempted are US citizens who qualify as residents of a foreign country under the IRS foreign earned income exclusion rule. In 2010, the Commissioner speculated that insurance providers would supply a form confirming essential coverage to both individuals and the IRS; individuals would attach this form to their Federal tax return. Those who aren't covered will be assessed the penalty on their Federal tax return. In the wording of the law, a taxpayer who fails to pay the penalty "shall not be subject to any criminal prosecution or penalty" and cannot have liens or levies placed on their property, but the IRS will be able to withhold future tax refunds from them.
|48 Contiguous States
- In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children. The law also provides for a 5% "income disregard", making the effective income eligibility limit 138% of the poverty line. States may choose to increase the income eligibility limit beyond this minimum requirement. As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that this withdrawal of funding was unconstitutionally coercive and that individual states had the right to opt out of the Medicaid expansion without losing pre-existing Medicaid funding from the federal government. For states that do expand Medicaid, the law provides that the federal government will pay for 100% of the expansion for the first three years, then gradually reduce its subsidy to 90% by 2020. As of April 25, 2013, fifteen states—Alaska, Alabama, Georgia, Idaho, Indiana, Iowa, Louisiana, Mississippi, Nebraska, North Carolina, Oklahoma, South Carolina, Texas, Wisconsin, and Virginia—were not participating in the Medicaid expansion, with ten more—Kansas, Maine, Michigan, Montana, Missouri, Ohio, Pennsylvania, South Dakota, Utah, and Wyoming—leaning towards not participating. (See: State rejections of Medicaid expansion).
- The Patient Protection and Affordable Care Act eliminates lifetime and annual limits from plans in the individual Health Benefits Exchanges. This effectively eliminates the ceiling on financial risk for individuals in the individual exchanges.
The subsidies for insurance premiums are given to individuals who buy a plan from an exchange and have a household income between 133% and 400% of the poverty line. Section 1401(36B) of PPACA explains that each subsidy will be provided as an advanceable, refundable tax credit and gives a formula for its calculation:
Except as provided in clause (ii), the applicable percentage with respect to any taxpayer for any taxable year is equal to 2.8 percent, increased by the number of percentage points (not greater than 7) which bears the same ratio to 7 percentage points as the taxpayer's household income for the taxable year in excess of 100 percent of the poverty line for a family of the size involved, bears to an amount equal to 200 percent of the poverty line for a family of the size involved. *(ii) SPECIAL RULE FOR TAXPAYERS UNDER 133 PERCENT OF POVERTY LINE- If a taxpayer's household income for the taxable year is in excess of 100 percent, but not more than 133 percent, of the poverty line for a family of the size involved, the taxpayer's applicable percentage shall be 2 percent.
- -- Patient Protection and Affordable Care Act: Title I: Subtitle E: Part I: Subpart A: Premium Calculation
A refundable tax credit is a way to provide government benefits to individuals who may have no tax liability (such as the earned income tax credit). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage. The U.S. Department of Health and Human Services (HHS) and Internal Revenue Service (IRS) on May 23, 2012, issued joint final rules regarding implementation of the new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits. Premium caps have been delayed for a year on group plans, to give employers time to arrange new accounting systems, but the caps are still planned to take effect on schedule for insurance plans on the exchanges; the HHS and the Congressional Research Service calculated what the income-based premium caps for a "silver" healthcare plan for a family of four would be in 2014:
|Income % of federal poverty level||Premium Cap as a Share of Income||Income $ (family of 4)a||Max Annual Out-of-Pocket Premium||Premium Savingsb||Additional Cost-Sharing Subsidy|
|133%||3% of income||$31,900||$992||$10,345||$5,040|
|150%||4% of income||$33,075||$1,323||$9,918||$5,040|
|200%||6.3% of income||$44,100||$2,778||$8,366||$4,000|
|250%||8.05% of income||$55,125||$4,438||$6,597||$1,930|
|300%||9.5% of income||$66,150||$6,284||$4,628||$1,480|
|350%||9.5% of income||$77,175||$7,332||$3,512||$1,480|
|400%||9.5% of income||$88,200||$8,379||$2,395||$1,480|
a.^ Note: In 2014, the FPL is projected to equal about $11,800 for a single person and about $24,000 for family of four. See Subsidy Calculator for specific dollar amount. b.^ DHHS and CBO estimate the average annual premium cost in 2014 will be $11,328 for a family of 4 without the reform.
In the individual market, sometimes thought of as the "residual market" of insurance, insurers have generally used a process called underwriting to ensure that each individual paid for his or her actuarial value or to deny coverage altogether. The House Committee on Energy and Commerce found that, between 2007 and 2009, the four largest for-profit insurance companies refused insurance to 651,000 people for previous medical conditions, a number that has increased significantly each year (49% increase in that time period). The same memorandum said that 212,800 claims had been refused payment due to pre-existing conditions and the insurance firms had business plans to limit money paid based on these pre-existing conditions. These persons who might not have received insurance under previous industry practices are guaranteed insurance coverage under the ACA. Hence, the insurance exchanges will shift a greater amount of financial risk to the insurers, but will help to share the cost of that risk among a larger pool of insured individuals.
The ACA's prohibition on denying coverage for pre-existing conditions will begin in 2014. Until that time, the ACA provides funds for state-run high-risk pools for those with previously existing conditions.
|Arkansas Health Connector||Connecticut (Access Health CT)|
|Covered California||District of Columbia (Health Link)|
|Connect for Health Colorado||Hawaii (Health Connector)|
|Kentucky Health Benefit Exchange||Idaho|
|Maryland Health Benefit Exchange||Massachusetts (Health Connector)|
|Cover Oregon||Minnesota (MNSURE)|
|Vermont Health Connect||Nevada (Health Link)|
|Washington Healthplanfinder||New York (Health Benefit Exchange)|
Limit to price variation
- Pricing Factors Allowed in the exchange under the ACA:
- Age: 3:1
- Smoking status: 1.5:1
Pricing variation will be allowed by area (within a state) and family composition ("tier") as well.
Comparable tiers of plans
Within the exchanges, insurance plans are to be offered in four tiers designated from lowest premium to highest premium: bronze, silver, gold, and platinum. The plans covered ranges from 60% to 90% of bills in increments of 10% for each plan. For those under 30 (and those with a hardship exemption), a fifth "catastrophic" tier is also available, with very high deductibles.
Insurance companies select the doctors and hospitals that are "in-network".
Proponents of health care reform believe that allowing comparable plans to compete for consumer business in one convenient location will drive prices down. Having a centralized location increases consumer knowledge of the market and allows for greater conformation to perfect competition. Each of these plans will also be limited in its out-of-pocket expenses at $6,350 for individuals and $12,700 for families.
Economics of health insurance exchanges: the individual mandate
The reason America's Health Insurance Plans were willing to accept these constraints on pricing, capping, and enrollment is the individual mandate: The individual mandate requires that all individuals purchase health insurance. This requirement of the ACA allows insurers to spread the financial risk of newly insured people with pre-existing conditions among a larger pool of individuals.
Additionally, a study done by Pauly and Herring estimates that individuals with pre-existing conditions in the 99th percentile of financial risk represented 3.95 times the average risk (mean). Figures from the House Committee on Energy and Commerce would indicate that approximately 1 million high-risk individuals will pursue insurance in the Health Benefits Exchanges. Congress has estimated that 22 million people will be newly insured in the Health Benefits Exchanges. Thus the high-risk individuals do not number in high enough quantities to increase the net risk per person from previous practice. It is thus theoretically profitable to accept the individual mandate in exchange for the requirements presented in the ACA.
HIX (Health Insurance Exchange) is emerging as the de facto acronym across state and federal government stakeholders, and the private sector technology and service providers that are helping states build their exchanges. The acronym HIX differentiates this topic from Health Information Exchange, which has been designated HIE.
The de facto acronym of HIX will be replaced in the soon (March 2013) to be released 3rd Edition of the HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations with HIEx. See more information on the HIMSS Dictionary at 2nd Edition of the HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations.
Criticism and controversy
- The system does not have a way for the user to update or even see a specific question. The user is forced to go through all sections in sequence and very often the previous data entered is not lost and the user has to select it again.
- Some users are unable to reset their lost or forgotten usernames/passwords, especially for the usernames created during the first week of operation.
- The system often does not give meaningful error messages and sometimes there are no error messages when an error occur.
- There were reports that some applications completed during the first week of operation are missing important data, so they are unable to be processed. The system has no updates as to why they are delayed or how to determine what is wrong.
- After a lot of complaints, the website was modified to allow people to view plans that are available in their areas without having to login or fill out an application. However, the cost estimate is not accurate, because it does not ask for age, income, number of children, smoking status, so the real cost may be higher, or lower if the premium subsidies apply. The search results does not contain important details, such as deductible cost, out-of-pocket maximum, co-pays, etc. Also, the search results can not be filtered or sorted by deductible amount, out-of-pocket maximum, co-pays, HMO, PPO, etc.
- The website does not provide the details on how exactly the premium and cost-sharing subsidies are calculated depending on family size, age, smoking size and income.
- The system sends users to the Kaiser Family Foundation's subsidy calculator to estimate the Marketplace health insurance costs and savings after the subsidies. It would make more sense to calculate the subsidies estimate without of leaving the main website.
- The system does not recognize addresses and every time an individual is added, the address selection list duplicates the same address again and the selection list grows with duplicate addresses.
- The system asks too many repeated questions such as how one family member is related to another one.
- The system does not save answers related to how siblings are related to each other.
First week of operation
"Please try again later" was the message that greeted many people who tried to view information on marketplace websites across the United States dring the first week of operation. Websites were reported to have either crashed or offer very sluggish response times. There was disagreement on whether the high volume of views (8.6 million people) was at the bottom of the problem or whether there were deeper technical issues involved.
Todd Park, U.S. chief technology officer, said that the glitches were caused by unexpected high volume at the federal health exchange (healthcare.gov) when the site drew 250 thousand visitors instead of the 50-60 thousand expected. He claimed that the site would have worked with less visitors. More than 8.1 million people visited the site from October 1–4, 2013.  The federal marketplace website was scheduled for maintenance on the weekend.
On the date of enactment of the Patient Protection and Affordable Care Act of 2010, only a few health insurance exchanges across the country were up and running. Among them were the Massachusetts Connector, the Utah Health Exchange, and HealthPass, a New York-based, non-profit exchange. Advocates claim that these exchanges make these "markets" more efficient, providing oversight and structure. Supporters argue that this is because current health insurance markets in the United States are not well-organized and have to deal with wide variations in coverages and requirements among different companies, employers, and policies.
It was unknown how many people in total successfully enrolled in the first week. The federal marketplace website was scheduled for maintenance on the weekend.  Some reporters have nicknamed the program "Slowbamacare". 
On October 1, 2013 the state-run marketplaces also opened to the public, and some of them reported first statistics. During the first week of enrollment:
- 28,699 people enrolled in the California health plan marketplace
- 17,300 people enrolled in the Kentucky health plan marketplace
- More than 40,000 people enrolled in the New York health plan marketplace
- On October 8, 2013, the Seattle Times reported that more than 9,400 people enrolled in the Washington health plan marketplace. However in a later report it was clarified that many of those who enrolled were Medicaid enrollees. By October 21, 2013, only 4,500 Washington residents had enrolled in private insurance through the state marketplace.
Postponement of tax penalty
- Many lower-income individuals excluded. NPR reported large numbers of low income people were excluded in states that did not offer Medicaid expansion to 133% of the poverty line.
- Moral and ethical concerns: Many varieties of libertarian ethical and political philosophy hold that it is wrong to require individuals to subsidize coverage of risks qualitatively different from and/or qualitatively greater than those that they impose; in other words, these schools of thought object to the governmentally mandated shift from risk-based pricing to community rating.
- Expansion of and increase in moral hazard: Economists worry that the prohibition of preexisting-condition exclusion will increase uninsured individuals' incentive to engage in risky behavior by removing the future unavailability of insurance as an ex ante incentive discouraging behavior that increases risks of developing those conditions. This moral hazard is independent of and in addition to the incentive toward risky behavior already existing among already-insured individuals.
- Premium cost too high for some people. Some speculation that for single people between the ages of 18-35 costs of insurance will rise
- Data security: Minnesota healthcare exchange, was reported to have accidentally emailed personal information of more than 2,400 insurance agents, according to the Minnesota Star Tribune.
- Employers dropping insurance for part-timers: According to NPR, some employers such as Trader Joe's and Home Depot have decided to terminate health insurance for their part-time workers.
- Scams: Scams were expected because of confusion over enrollment.
- Some exchanges have been criticized for offering health plans that necesssitate too many out-of-network claims. On October 5, 2013 Seattle Children's hospital had filed a lawsuit for "failure to ensure adequate network coverage" when only two insurers included Children's in their marketplace plan.
- "Cherry-picking" concern: The private health insurance industry fears that restricted eligibility and a market size that is too small could result in higher premiums, encourage "cherry-picking" of customers by insurers, and force a clearance of the exchange. That is what some believe will happen in Texas and California in their failed exchanges. One of these factors, "cherry-picking" of customers, will not be possible in the state-run exchanges mandated by the ACA, because all insurance plans will be guaranteed issue in 2014. Furthermore, the law will bring millions of new enrollees into the marketplace by way of the individual mandate requirement for all citizens to purchase health insurance and increase market size.
- Some marketplace web sites require enrollment as the first step to looking up any information.
Private health insurance exchanges
A private health insurance exchange is an exchange run by a private sector company or nonprofit. Health plans and insurance carriers in a private exchange must meet certain criteria defined by the exchange management. Private exchanges combine technology and human advocacy, and include online eligibility verification and mechanisms for allowing employers who connect their employees or retirees with exchanges to offer subsidies. They are designed to help consumers find plans personalized to their specific health conditions, preferred doctor/hospital networks, and budget. These exchanges are sometimes called marketplaces or intermediaries, and work directly with insurance carriers, effectively acting as an |extension of the carrier.
The idea of a health care exchange is not new. One example of an early health care exchange is International Medical Exchange (IMX) a company venture financed in Louisville, Kentucky by Standard Telephones and Cables, a large British technology company (now Nortel), to develop the exchange concept in the U.S. using on-line technology. The product was created in the mid-1980s. IMX developed an eligibility verification system, a claims management system, and a bank-based payments administration system that would manage payments between the patient, the employer, and the insurance carrier. Like proposed exchanges today, it focused on standards of care, utilization review by a third party, private insurer participation, and cost reduction for the health care system through product simplification. The focus was on creating local or regional exchanges that offered a series of standardized health care plans that reduced the complexity and cost of acquiring or understanding health care insurance, while simplifying claims administration. The system was modeled after the standardized stock exchange and banking industry back office processes. The major difference was IMX health care exchanges would provide their products through a national network of existing commercial banks rather than setting up a duplicate payment and administration systems network as proposed today. The IMX product rights were acquired shortly afterwards by Anthem (then Blue Cross and Blue Shield of Kentucky). The exchange product became the basis for inter-carrier claims settlement between commercial insurance carriers, and Blue Cross organizations. The founders of IMX were from top management at Humana, and top management of First Tennessee National Corp. (now First Horizon).
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