State Insurance Exchanges

An insurance exchange is an organized marketplace through which individuals, families and small businesses can purchase health insurance coverage. A state exchange can be run by any of the following: state government, nonprofit or for-profit organization. However, if a state fails to establish an exchange, a federally-facilitated exchange will be established in that state by the federal government. Examples of existing insurance exchanges: Health Connector in Massachusetts and Utah Health Exchange.

• Subsidies — Since all individuals are required to purchase coverage, the legislation provides subsidies to help those who otherwise could not pay for it. Specifically, individuals and families with incomes between 133 and 400 percent of the federal poverty level will receive premium and cost-sharing subsidies if they cannot get coverage through their employer or any other source. The only way individuals and families can obtain subsidies is via state exchanges.



• Essential Health Benefits— To qualify as a plan offered via a state exchange, insurers will have to provide a minimum number of services referred to as Essential Health Benefits (EHB). The federal government sets loose standards regarding what must be included in the exchanges, but many of the specific benefits to be included will be determined by each state by choosing one plan to serve as a benchmark for others. In general, EHB must include items and services within at least the following 10 categories:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care
  
  

  One of the standards proposed by the federal government deals with the EHB prescriptions drug coverage. According to the proposed standard, EHB plans must only cover one drug per therapeutic category/class covered by a state benchmark plan.

  The AAN shares the concerns that such standard is inadequate to meet the complex needs of patients with chronic diseases. In collaboration with the Parkinson’s Action Network (PAN), the AAN signed a letter urging Department of Health and Human Services (HHS) to revise the proposed Essential Health Benefits (EHB) prescription drug coverage standards. The letter was signed by more than 100 organizations. Read the letter here.

  The AAN also supported a letter recommending that HHS adopts EHB drug coverage standards that would offer access to “all or substantially all” medications in six therapeutic classes affecting conditions such as cancer, kidney disease and epilepsy. Read the letter here.