Revisiting the ACA mandated SHOP exchange requirements

For the states that are forging ahead with their health insurance exchange and SHOP exchange implementation plans, possessing upfront complete clarity on the federal exchange requirements can help in ensuring swift and accurate designing of exchanges. While most health participants would already be aware of the important federal guidelines, we thought to revisit these exchange considerations to help stakeholders remain updated with the final requirements.

In March 2012, Maryland state listed several SHOP exchange specific considerations that Maryland exchange administrators were weighing to draw up a comprehensive and effective exchange business model.

Summary of Benefits & Coverage (SBCs) – Based on the recommendations of National Association of Insurance Commissioners (NAIC), the US Dept. of HHS, Labor & Treasury released standards for SBCs and Uniform Glossary documents that need to be issued by QHPs to consumers. The documents need to include premium details and employer & employee plan cost-sharing details etc., to help consumers make an informed decision while buying insurance.

Employer eligibility for exchange participation & tax credits – The federal ruling mandates that until 2017, only employers meeting the exchange criteria for small businesses would be allowed to purchase insurance off the exchange. Separate exchange eligibility rules may be identified for part-time or seasonal employees. It would be SHOP exchanges responsibility to inform small businesses if they are eligible for federal tax credits and other subsidies.

Health plan quality ratings: SHOP exchanges are required to display QHPs quality ratings to help guide consumers in their health plan purchase. Federally approved quality measuring standards laid down by National Committee for Quality Assurance (NCQA) etc., can be availed of.

Insurers metrics: SHOP exchanges would be required to gather and display insurers' actuals such as medical loss ratio (MLR) details, enrollment figures and other company metrics to help consumers gauge the quality of participating insures' services.

Consumer satisfaction index – To help incoming new exchange enrollees, Exchange can conduct and display consumer confidence surveys to help increase consumer awareness about plans and exchange administration.

Provider preferences – Exchanges need to provide consumers the facility to choose plans based on availability of specific provider(s) and or other network availability, within a plan.

Empowering employees – SHOP Exchanges must help employees in determining if the coverage offered by their employers can be considered as “affordable” and if the coverage fails to meet the affordability criteria, Exchange should make provision for employees to avail of other plan options or purchasing insurance off the health insurance Exchange.

Managing exchange data- The SHOP exchange, QHPs and web-portal vendors need to work in coalition to ensure that only the accurate information in line with the federal and exchange standards, is displayed on the exchange. Any discrepancies or errors in data should be quickly corrected and updated.

SHOP exchanges, once launched are likely to regulate the local insurance markets and help employers provide good quality & affordable care to their employees. Keeping the above suggested considerations can help administrators dispense best services to state residents.