Background:
It is estimated that 12 million people will begin purchasing health insurance through Health Insurance Marketplaces known as Health Insurance Exchanges or HIXs. These plans are being offered in accordance with Patient Protection and Affordable Care Act (Obamacare). HIXs provide a set of government-regulated and standardized health care plans from which individuals may purchase health insurance eligible for federal subsidies. Enrollment began October 1, 2013 for these plans. The HIX must be fully certified and operational by January 1, 2014. While enrollment begins today coverage is not effective until 1/1/14. No eta on the next open enrollment period.
Unanswered questions, challenges, and opportunities:
- Today no new commercial plans have been developed for the sole purpose of becoming an HIX. There may be some restructuring of how the State plans are structured.
- State plans, have several options ,briefly they can:
- Managed by the State
- Use the Federal Exchange to Manage the State plan
- Hybrid- The State did not set up their own Exchange and thus are using the Federal Exchange, but they still maintain some control over how the Exchange operates.
- Expand their Medicaid eligibility rules. So while some patients will get coverage through their state HIX, others may suddenly find themselves eligible for Medicaid due to the expanding eligibility requirements that some states will adopt (and get subsidized
- Most, if not all of the commercial payers will be offering a HIX.
- CMS has determined that the ASC X12 Standard with be the foundation of the Health Insurance Exchange The 834(enrollment) transaction is what is being used to enroll members.
- To date we are not aware of any plan that can generate a 270/271 that will not be including these members in their standard response.. Note, for hosted payer plans we will ask them to include these members in their files
- The plans have some questions of CMS as to how to handle a 90 day premium grace period. I was told this week by a payer that when they asked this question, the response they received from CMS was CMS did not know how to respond as they systems to handle these issues had not been built yet..
- No details of any data changes from what we see today in the CORE 271..
- We will monitor the271’s responses and look for ways to be able to identify members in the HIXs
