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Health Benefit Exchanges Must Meet Key Requirements

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A health benefit exchange should be a competitive marketplace for Americans shopping for health insurance. From 2014 to 2016, only individuals and small groups are eligible to participate in an exchange. Beginning in 2017, larger groups may be permitted to participate.

The health plans offered in an exchange must meet standard requirements for affordability, essential health benefits and consumer protections. The Patient Protection and Affordable Care Act (PPACA) defines four coverage levels:

  • Bronze Plan: Covers 60 percent of the actuarial value of covered benefits.
  • Silver Plan: Covers 70 percent of the actuarial value of covered benefits.
  • Gold Plan: Covers 80 percent of the actuarial value of covered benefits.
  • Platinum Plan: Covers 90 percent of the actuarial value of covered benefits.

Exchanges also must include:

  • Adjusted community rating rules with rates only varying by age, tobacco use, geography and family status;
  • Essential benefit requirements;
  • Limits on individual cost-sharing;
  • Subsidies up to 400 percent of the federal poverty level; and
  • Penalties for individuals who don’t obtain coverage and for employers with more than 50 employees who don’t offer the minimum level of coverage.
    • In addition, exchanges must provide specific support services, such as:

  • Health plan rating system and rate review;
  • Standardized format and definitions for plan options and coverage;
  • Enrollment facilitation; and a
  • Website and toll-free hotline.
    • For more information about health benefit exchanges, please contact Patty Smith at 814/833-3200 or 800/815-2660.