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October 2015 St@teside

Division of Labor for Qualified Health Plan Review

Before open enrollment begins, hard work is being done behind the scenes to make sure health plans meet the requirements for sale. While insurance departments have traditionally done much of the work necessary to guarantee plans meet the regulatory requirements in states, the opening of the exchanges created under the Affordable Care Act has often meant additional or shifted duties performed by the exchanges, insurance departments, and sometimes other agencies.

States have adopted a variety of approaches to handle the review and certification of qualified health plans (QHPs) before they can be sold on their state’s exchange. The Health Insurance Exchanges Research Group at the Leonard Davis Institute of Health Economics at Wharton (LDI) recently collected data from 30 states, and issued a data brief summarizing the various plan management and certification functions assumed by different state agencies across varying marketplace models. The dataset includes states with State Based Marketplaces (SBMs), State Partnership Marketplaces (SPMs), Supported State Based Marketplaces (SSBMs), and Federally Facilitated Marketplaces (FFMs) with state plan management. It also highlights the role CMS plays within each of the exchange plan management models.

Eight different types of reviews required for QHPs were included in this study: issuer solvency, network adequacy, essential community provider inclusion, geographic service areas, benefits, prescription drug formularies, non-discriminatory marketing practices, and rates. Among the states in the dataset, a majority of these functions continue to be the responsibility of the state insurance departments. While SBMs in four states performed reviews to ensure inclusion of essential community providers, most exchanges did not take an active role in the various reviews.

The full brief, dataset, and codebook, including definitions of each of the review functions and more detailed findings, are available on the State Network website.