By Legal & Regulatory Affairs staff
In an effort to increase access to affordable health care coverage for millions of Americans, the Affordable Care Act creates a state-based health insurance marketplace, called the Affordable Insurance Exchange, where coverage plans for individuals and employees of small businesses are offered through a streamlined, online system. This system will allow for “one-stop shopping” as consumers will be able to compare plans, check eligibility for programs available through the exchange (including Medicaid and the Children’s Health Insurance Program (CHIP)) and for tax credits, and complete enrollment for coverage.
States that elect not to establish their own exchanges have three options:
Work with other states to develop regional exchanges;
Partner with the federal government to jointly manage an exchange; or
Allow the federal government to operate the exchange.
Exchanges Operated Solely By the Federal Government
Most of the state-based exchanges will be operated solely by the federal government, specifically the U.S. Department of Health and Human Services (HHS). These exchanges are known as federally-facilitated exchanges (FFE).
Whether HHS partners with the state to operate an exchange or operates the exchange on its own, HHS plans to coordinate with the state insurance departments to ensure that states retain their regulatory role of overseeing health plans. HHS must ensure that the FFE complies with existing state laws and programs.
Currently, HHS plans to operate FFEs in 26 states.1 In those states, HHS will be responsible for implementing and overseeing all exchange functions. This includes engaging with local stakeholders in the development of the FFE, overseeing certification of qualified health plans that will participate in the exchange, operating enrollment and eligibility functions and providing consumer and technical assistance.
With regard to consumer outreach, support and education, the FFEs will offer a website, a toll-free hotline and some kind of in-person assistance available to consumers with disabilities or limited English proficiency. There will also be a “Navigator” program in each state designed to assist consumers with participation in insurance exchanges and to provide consumer support.
Exchanges Operated by a Federal - State Partnership
To date, seven states are planning to partner with HHS in operating the exchange.2 In partnership arrangements, states will have the option to take primary responsibility for certain core functions in operating the exchange: plan management, consumer assistance and/or eligibility determinations. Under the partnership arrangement, states must agree to ensure that their insurance department, Medicaid and CHIP programs will coordinate with the business processes, systems, data/information and enforcement aspects of the exchange. Like the FFEs, state-based partnership exchanges will use centralized functions developed by HHS such as the website and the toll-free consumer hotline, as well as the Navigator program.
Issues for Psychologists
While the purpose of the health insurance exchanges is to benefit consumers, there are issues relating to the development and implementation of the exchange that impact psychologists and other health care providers. CMS is currently reviewing applications submitted by health insurance/managed care companies seeking certification of their plans as Qualified Health Plans (QHP), enabling those plans to be offered through the exchange. The companies must demonstrate that the plan maintains a network with a sufficient number and type of health care providers, including providers specializing in mental health and substance abuse services, to ensure that the plan offers benefits under all ten identified essential benefits categories.
As a result, psychologists who are in-network providers ought to consider the following issues:
Assignability provisions. Psychologists who are contracted with insurance companies as in-network providers should review their provider contract for an assignability provision. This kind of provision would allow the insurance company to assign you to another company’s network for specified reasons (for example, the company may agree to “lease” its network to another company, or if the company is acquired by or merges with another company). This provision would also mention whether the insurance company is required to notify you of this assignment and if so, what the notification requirements are.
Provider notifications. If you are an in-network provider, review any provider notifications that you receive either by U.S. mail or email to check for any changes to your contract as companies are currently in the process of participating in the QHP certification process. CMS is supposed to issue its final determinations on which plans can be certified as QHPs by Sept. 4, 2013.
Network directories. If you are currently an in-network provider, you should check to see if you are listed in the insurance company’s online provider directory and if so, whether your listing is accurate. If you had previously served on a network panel but no longer accept insurance, check that you are not still listed in the provider network directory. CMS expects the network directory to include contact information, location, specialty (if applicable) and any institutional affiliations for each provider in the network. It is hoped that QHPs will also include information about whether the provider is accepting new patients, provider credentials, language(s) spoken and whether the provider is an Indian (Native American) provider.
Cost-sharing requirements. As an in-network provider, it will be important to be aware of any cost-sharing requirements such as deductibles and co-payments as mental health services are a specified category that CMS will be evaluating for discriminatory practices.
Complaints and appeals processes. QHPs are required to comply with specific requirements governing internal claims and appeals and external review. Psychologists should review their provider contract and any addenda containing contract changes that may revise the appeals process. Also, it is important to note what kind of exchange will be established in your state to determine who or what agency will be responsible for addressing consumer complaints.
More information about the Qualified Health Plan certification process and other health insurance exchange implementation issues is available at HHS’s Center for Consumer Information and Insurance Oversight.
State-specific information about Essential Health Benefits and additional state coverage requirements can be found on the CMS website.
For more information, contact the Legal & Regulatory Affairs office in the Practice Directorate by email or by phone at (202) 336-5886.
1Alabama, Alaska, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Virginia, Wisconsin and Wyoming. Kaiser Family Foundation: State Decisions For Creating Health Insurance Exchanges, as of April 23, 2013.
2Arkansas, Delaware, Illinois, Iowa, Michigan, New Hampshire and West Virginia.Kaiser Family Foundation: State Decisions For Creating Health Insurance Exchanges, as of April 23, 2013.