Health insurance marketplace

Health insurance exchanges in the United States expand insurance coverage while allowing insurers to compete in cost-efficient ways and help them to comply with consumer protection laws. Exchanges are not themselves insurers, so they do not bear risk themselves, but they do determine which insurance companies participate in the exchange. An ideal exchange promotes insurance transparency and accountability, facilitates increased enrollment and delivery of subsidies, and helps spread risk to ensure that the costs associated with expensive medical treatments are shared more broadly across large groups of people, rather than spread across just a few beneficiaries. Health insurance exchanges use electronic data interchange (EDI) to transmit required information between the exchanges and carriers (trading partners), in particular the 834 transaction for enrollment information and the 820 transaction for premium payment.{{cite web |last=Scholl |first=Martin |url=http://www.hipaasuite.com/?option=com_easyblog&view=latest&Itemid=336 |title=Take advantage of the emerging market place of the Health Benefit Exchanges |date=October 16, 2014 |website=HIPAA Suite |url-status=dead |archive-date=November 24, 2014 |archive-url=https://web.archive.org/web/20141124044031/http://www.hipaasuite.com/?option=com_easyblog&view=latest&Itemid=336 }}{{better source needed |date=February 2017 |reason=Source is a blog post; text is incomplete. }}

File:ACA health insurance exchanges by state.svg |date=May 28, 2013 }}{{cite web|title=State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013 - Map|url=http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#map |publisher=Kaiser Family Foundation |date=May 28, 2013 }}{{update inline|date=February 2014}}

{{legend|#232|Creating state-operated exchanges}}

{{legend|#898|Establishing state-federal partnership exchanges}}

{{legend|#C8C8C8|Defaulting to federal exchange}}]]

Health exchanges first emerged in the private sector in the early 1980s, and they used computer networking to integrate claims management, eligibility verification, and inter-carrier payments. These became popular in some regions as a way for small and medium-sized businesses to pool their purchasing power into larger groups, reducing cost. An additional advantage was the ability of small businesses to offer a range of plans to employees, allowing them to compete with larger corporations. The largest such exchange prior to the ACA is CaliforniaChoice, established in 1996. By 2000, CaliforniaChoice's membership included 140,000 individuals from 9000 business groups.{{citation needed|date=March 2024}}

Obamacare maintained the concept of health insurance exchanges as a key component of health care. President Obama stated that it should be "a market where Americans can one-stop shop for a health care plan, compare benefits and prices, and choose the plan that's best for them, in the same way that Members of Congress and their families can. None of these plans should deny coverage on the basis of a preexisting condition, and all of these plans should include an affordable basic benefit package that includes prevention, and protection against catastrophic costs. I strongly believe that Americans should have the choice of a public health insurance option operating alongside private plans. This will give them a better range of choices, make the health care market more competitive, and keep insurance companies honest."{{cite web |title=President Obama Reiterates Support for Public Option and Health Insurance Exchange |url=http://my.barackobama.com/page/community/post/obamaforamerica/gGGGpK |date=June 3, 2009 |first=Christopher |last=Hass |publisher=Obama for America |archive-url=https://web.archive.org/web/20120820095555/https://my.barackobama.com/page/community/post/obamaforamerica/gGGGpK |archive-date=August 20, 2012 |access-date=February 7, 2014}} Although the House of Representatives had sought a single national exchange as well as a public option, the Patient Protection and Affordable Care Act (ACA) as passed used state-based exchanges, and the public option was ultimately dropped from the bill after it did not win filibuster-proof support in the Senate.{{cite news |url=http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-What-s-a-health-exchange |title=Health care reform bill 101: What's a health 'exchange'? |publisher=Christian Science Monitor |date=March 10, 2010 |first=Peter |last=Grier}} States may choose to join together to run multi-state exchanges, or they may opt out of running their own exchange, in which case the federal government will step in to create an exchange for use by their citizens.

ACA was signed into law on March 23, 2010. The law required that health insurance exchanges commence operation in every state on October 1, 2013.{{cite web|title=Welcome to the Marketplace|url=https://www.healthcare.gov/marketplace/individual/|publisher=Healthcare.gov}}{{cite web|title=What is the Health Insurance Marketplace?|url=https://www.healthcare.gov/what-is-the-health-insurance-marketplace/ |publisher=Healthcare.gov}} In the first year of operation, open enrollment on the exchanges ran from October 1, 2013, to March 31, 2014, and insurance plans purchased by December 15, 2013, began coverage on January 1, 2014.{{cite news|url=https://money.cnn.com/2013/04/23/news/economy/obamacare-subsidies/index.html?hpt=hp_t5|title=Millions eligible for Obamacare subsidies, but most don't know it|publisher=CNN |first=Tami |last=Luhby |date=April 23, 2013}}{{cite web|url=http://kff.org/health-reform/issue-brief/establishing-health-insurance-exchanges-an-overview-of/|title=Establishing Health Insurance Marketplaces: An Overview of State Efforts|date=May 2, 2013|publisher=Kaiser Family Foundation|access-date=February 8, 2014|archive-date=April 24, 2018|archive-url=https://web.archive.org/web/20180424055850/https://www.kff.org/health-reform/issue-brief/establishing-health-insurance-exchanges-an-overview-of/|url-status=dead}}{{cite web|url=https://www.healthcare.gov/how-can-i-get-ready-to-enroll-in-the-marketplace/|title=How can I get ready to enroll in the Marketplace? |archive-url=https://web.archive.org/web/20130626172723/https://www.healthcare.gov/how-can-i-get-ready-to-enroll-in-the-marketplace |archive-date=June 26, 2013 |publisher=Healthcare.gov}}{{cite news|last1=Morgan|first1=David|title=Obamacare push accelerates as government shutdown nears|url=https://www.reuters.com/article/us-usa-healthcare-idUSBRE98T14R20130930?irpc=932|publisher=Reuters|access-date=October 1, 2013|last2=Begley |first2=Sharon|author-link2=Sharon Begley |date=September 30, 2013|quote=Sebelius said on Monday that 'the key date really is the 15th of December,' the deadline for buying coverage that starts on January 1.}} For 2015 open enrollment began on November 15, 2014, and ended on February 15, 2015.{{cite web|title=Glossary: Open Enrollment Period |url=https://www.healthcare.gov/glossary/open-enrollment-period/ |publisher=Healthcare.gov|access-date=October 4, 2013}}{{cite news|last=Young|first=Jeffrey|title=Obamacare Benefits Enrollment Will Start Slowly, White House Predicts|url=http://www.huffingtonpost.com/2013/09/25/obamacare-benefits_n_3988946.html|work=The Huffington Post|access-date=October 2, 2013|date=September 25, 2013}}{{cite magazine|first=Jonathan |last=Cohn |author-link=Jonathan Cohn |url=https://newrepublic.com/article/114163/limited-enrollment-periods-obamacare-means-young-people-cant-wait |title=Burn Your Obamacare Card, Burn Yourself |magazine=The New Republic |date=August 5, 2013}}

On the date the Patient Protection and Affordable Care Act of 2010 was enacted,{{when|date=March 2014}} only a few health insurance exchanges across the country were up and running. Among them were the Massachusetts Health Connector, the New York HealthPass - a non-profit exchange, and the Utah Health Exchange. Advocates claim these exchanges make these "markets" more efficient, providing oversight and structure, arguing that previous health insurance markets in the United States are poorly-organized and deal with wide variations in coverages and requirements among different companies, employers, and policies.{{cite web |last1=Blumberg |first1=Linda J. |first2=Karen |last2=Pollitz |url=http://www.urban.org/url.cfm?ID=411877 |archive-url=https://archive.today/20130416030634/http://www.urban.org/url.cfm?ID=411877 |url-status=dead |archive-date=April 16, 2013 |title=Health Insurance Exchanges: Organizing Health Insurance Marketplaces to Promote Health Reform Goals |publisher=Urban Institute |date=April 1, 2009 }}

It was unknown how many people in total successfully enrolled in the first week. The federal marketplace website was scheduled for maintenance on the weekend.{{cite web |url=https://www.npr.org/templates/story/story.php?storyId=229472259 |title=Glitches Slow Health Exchange Sign-ups |publisher=NPR |first=Kathy |last=Lohr |date=October 5, 2013}}{{cite news|title=Rush of interest continues on insurance Web sites|url=https://www.washingtonpost.com/national/health-science/obamacare-site-goes-live-with-some-glitches/2013/10/01/380a4300-2a9d-11e3-8ade-a1f23cda135e_story.html|newspaper=The Washington Post|date=October 1, 2013 |first1=Amy |last1=Goldstein |first2=Lena H. |last2=Sun |first3=Sandhya |last3=Somashekhar}}

CGI Group came under media scrutiny as a developer behind several marketplace websites,{{cite web|url=http://www.slate.com/articles/business/bitwise/2013/10/what_went_wrong_with_healthcare_gov_the_front_end_and_back_end_never_talked.html |title=What really went wrong with healthcare.gov? |first=David |last=Auerbach |date=October 8, 2013 |access-date=February 7, 2014 |publisher=Slate}} after numerous issues{{cite news|last=Periroth|first=Nicole|title=Problems at Health Care Web Site Not From Online Attack, Experts Say|url=https://www.nytimes.com/news/affordable-care-act/2013/10/02/problems-at-health-care-web-site-not-from-online-attack-experts-say/|newspaper=New York Times|date=October 2, 2013}} surfaced with the federal health insurance marketplace, HealthCare.gov.

On October 1, 2013, the state-run marketplaces also opened to the public, and some of them reported first statistics. During the first week of enrollment:

• 28,699 people enrolled in the California health plan marketplace
• 17,300 people enrolled in the Kentucky health plan marketplace
• More than 40,000 people enrolled in the NY State of Health marketplace
• On October 8, 2013, The Seattle Times reported that more than 9,400 people had enrolled in the Washington health plan marketplace.{{cite news|last=Westneat|first=Danny|title=Obamacare is here, GOP, ready or not|url=http://seattletimes.com/html/localnews/2021994306_westneat09xml.html|newspaper=The Seattle Times|date=October 8, 2013}} However, a later report clarified that many included in that count were Medicaid enrollees. By October 21, 2013, only 4,500 Washington residents had enrolled in private insurance through the state marketplace.{{cite web |url=http://blogs.seattletimes.com/healthcarecheckup/2013/10/21/washington-healthplanfinder-more-than-35000-have-enrolled-in-3-weeks/ |title=Washington Healthplanfinder: more than 35,000 have enrolled in 3 weeks |first=Amy Snow |last=Landa |date=October 21, 2013 |publisher=The Seattle Times}}

On October 23, 2013, The Washington Post reported that Americans with no health insurance would have an additional six weeks before they would be penalized.{{cite news|title=Americans will have an extra six weeks to buy health coverage before facing penalty|url=https://www.washingtonpost.com/national/health-science/americans-will-have-an-extra-six-weeks-to-buy-health-coverage-before-facing-penalty/2013/10/23/db52dd1a-3c36-11e3-a94f-b58017bfee6c_story.html|newspaper=The Washington Post|date=October 23, 2013 |first1=Sandhya |last1=Somashekhar |first2=Amy |last2=Goldstein |first3=Juliet |last3=Eilperin}} That deadline was extended to March 31, and those who do not enroll by then may still avoid incurring penalties and getting locked out of the healthcare enrollment system this year. Exemptions and extensions apply to:{{cite news | url=http://www.thewire.com/national/2014/03/obamacare-enrollees-get-post-deadline-special-enrollment-period-extension/359598/Obamacare | title=Obamacare: Enrollees Get Post-Deadline 'Special Enrollment Period' Extension | author=SARA MORRISON | date=March 25, 2014 }}{{Dead link|date=July 2024 |bot=InternetArchiveBot |fix-attempted=yes }}{{cite news|url=http://www.foxnews.com/politics/2014/03/25/obama-administration-announces-health-care-extension/|work=Fox News|title=Obama Administration Announces Health Care Extension|date=March 25, 2014}}{{dead link|date=November 2024|bot=medic}}{{cbignore|bot=medic}}

• Those living in states that use federal exchange, who may avail themselves of a "special entrollment period" that allows individuals to avoid penalties and enroll in a health plan by checking a blue box by mid-April 2014, stating they tried to enroll before the deadline (doing so provides a yet-undetermined amount of time to actually sign up after that). The New York Post reports: "This method will rely on an honor system; the government will not try to determine whether the person is telling the truth". State-run exchanges have their own rules; several will be granting similar extensions.
• Members of the Pre-Existing Condition Insurance Program, who were given a one-month extension until the end of April 2014.
• Those who have successfully applied for exemption status based on criteria published by HealthCare.gov, who are not required to pay a tax penalty if they don't enroll in a health insurance plan.{{cite news|author=DAN RITTER|work=Wall Street Cheat Sheet|date=March 25, 2014|url=http://wallstcheatsheet.com/personal-finance/ill-take-the-tax-10-obamacare-exemptions-you-dont-want.html/?a=viewall|title=I'll Take the Tax: 10 Obamacare Exemptions You Don't Want|access-date=March 26, 2014|archive-date=March 27, 2014|archive-url=https://web.archive.org/web/20140327075849/http://wallstcheatsheet.com/personal-finance/ill-take-the-tax-10-obamacare-exemptions-you-dont-want.html/?a=viewall|url-status=dead}}{{cite web|website=HealthCare.gov|url=https://www.healthcare.gov/exemptions/|title=How do I qualify for an exemption from the fee for not having health coverage?|access-date=March 26, 2014}}

Implementation of the individual exchanges changed the practice of insuring individuals. The expansion of this market was a major focus of ACA.{{cite book |last=Goldstein |first=Amy |chapter=Priority One: Expanding Coverage |editor-last=The Staff of the Washington Post |title=Landmark: The Inside Story of America's New Health-Care Law and What It Means for Us All |location=New York |publisher=Public Affairs |year=2010 |pages=73–83 |isbn=9781410428998 |chapter-url=https://books.google.com/books?id=Ppivy3XtAY8C&pg=PA73}} Over 1.3 million people had selected plans for 2015 marketplace coverage in the first three weeks of the year's open enrollment period, including people who renewed their coverage and new customers.{{cite web |date=December 15, 2014 |title=Open Enrollment Outreach and Education Round-Up |website=HHS.gov/HealthCare |publisher=U.S. Department of Health & Human Services |url=https://www.hhs.gov/healthcare/facts/factsheets/2014/12/open-enrollment-outreach-education.html |url-status=dead |archive-date=January 4, 2015 |archive-url=https://web.archive.org/web/20150104214655/http://www.hhs.gov/healthcare/facts/factsheets/2014/12/open-enrollment-outreach-education.html }}

As of January 3, 2014, 2 million people had selected a health plan through the health insurance marketplaces.{{cite news |url=http://www.cnn.com/2013/12/31/politics/obamacare/ |title=More than 2 million enrolled under Obamacare |date=December 31, 2013 |first1=Jim |last1=Acosta |author-link1=Jim Acosta |first2=Tom |last2=Cohen |publisher=CNN}} By April 19, 2014, 8.0 million people had signed up through the health insurance marketplaces and an additional 4.8 million joined Medicaid. As of February, 2015, about 11.4 million people had signed up for or been automatically renewed for 2015 marketplace coverage.content Today, more than 1,400 local outreach events have been conducted in federally facilitated marketplace states across the country.

{{Main|Provisions of the Patient Protection and Affordable Care Act}}

• Insurers are prohibited from discriminating against or charging higher rates for any individual based on pre-existing medical conditions or gender.{{cite web|url=http://www.nh.gov/insurance/consumers/documents/naic_faq.pdf|title=I have been denied coverage because I have a pre-existing condition. What will this law do for me?|publisher=New Hampshire Insurance Department|work=Health Care Reform Frequently Asked Questions|access-date=June 28, 2012|page=2}}
• Insurers are prohibited from establishing annual spending caps of dollar amounts on essential health benefits.{{cite news | first1=Jeremy | last1=Binckes | first2=Nick |last2=Wing | title=The Top 18 Immediate Effects Of The Health Care Bill | date=March 22, 2010| url =http://www.huffingtonpost.com/2010/03/22/the-top-18-immediate-effe_n_508315.html#s75147 | work =The Huffington Post | access-date = March 22, 2010}}
• All private health insurance plans offered in the Marketplace must offer the following essential health benefits: ambulatory care, emergency services, hospitalization (such as surgery), maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitative and habilitative services (services to help people with injuries, disabilities, or chronic conditions to recover), laboratory services, preventive and wellness services, and pediatric services.{{cite web|url=https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/|title=What does Marketplace health insurance cover?|publisher=Healthcare.gov}}
• Under the individual mandate provision (sometimes called a "shared responsibility requirement" or "mandatory minimum coverage requirement"),{{cite web |title=Minimum Coverage Provision |url=http://www.apha.org/advocacy/Health+Reform/ACAbasics/MC_provision.htm |publisher=American Public Health Association |access-date=2013-10-02 |archive-url=https://web.archive.org/web/20140701171554/http://www.apha.org/advocacy/Health+Reform/ACAbasics/MC_provision.htm |archive-date=2014-07-01 |url-status=dead }} individuals who are not covered by an acceptable health insurance policy will be charged an annual tax penalty of $95, or up to 1% of income over the filing minimum,{{cite web |quote=Generally, in 2010, the filing threshold is $9,350 for a single person or a married person filing separately and is $18,700 for married filing jointly. |publisher=Joint Committee on Taxation |url=https://www.jct.gov/publications.html?func=startdown&id=3673 |title=Technical Explanation of The Revenue Provisions of the Reconciliation Act of 2010, as Amended, in Combination With the Patient Protection And Affordable Care Act |date=March 21, 2010}} whichever is greater; this will rise to a minimum of $695 ($2,085 for families),{{cite news|last=Doyle|first=Brion B.|title=Understanding the Impacts of the Patient Protection and Affordable Care Act|url=http://www.natlawreview.com/article/understanding-impacts-patient-protection-and-affordable-care-act|access-date=17 April 2013|newspaper=The National Law Review|date=March 5, 2013}} or 2.5% of income over the filing minimum, by 2016.{{cite news|url=http://www.boston.com/business/personalfinance/managingyourmoney/archives/2010/03/tax_implication.html|title=Tax implications of health care reform legislation|last=Downey |first=Jamie|date=March 24, 2010|newspaper=The Boston Globe|access-date=March 25, 2010}} The penalty is prorated, meaning that if a person or family has coverage for part of the year they won't be liable if they lack coverage for less than a three-month period during the year.{{cite news|url=https://money.cnn.com/2013/08/13/news/economy/obamacare-penalty/index.html?source=cnn_bin|title=Uninsured next year? Here's your Obamacare penalty|publisher=CNN |date=August 13, 2013 |last=Luhby |first=Tami}} Exemptions are permitted for religious reasons, for members of health care sharing ministries, or for those for whom the least expensive policy would exceed 8% of their income.{{cite news|url=https://www.washingtonpost.com/blogs/ezra-klein/post/individual-mandate-101-what-it-is-why-it-matters/2011/08/25/gIQAhPzCeS_blog.html|title=Individual mandate 101: What it is, why it matters |publisher=Wonkblog at the Washington Post|first1=Sarah |last1=Kliff |first2=Ezra |last2=Klein |author-link2=Ezra Klein |date=March 27, 2012|access-date=July 2, 2012}} Also exempted are U.S. citizens who qualify as residents of a foreign country under the IRS foreign earned income exclusion rule.{{cite web|url=https://www.law.cornell.edu/uscode/text/26/5000A |title=Requirement to maintain minimum essential coverage |publisher=Cornell University Law School Legal Information Institute |quote=Described in 26 USC § 5000A(f)(4)(A) |date=September 18, 2013 }} In 2010, the Commissioner speculated that insurance providers would supply a form confirming essential coverage to both individuals and the IRS; individuals would attach this form to their Federal tax return. Those who aren't covered will be assessed the penalty on their Federal tax return. In the wording of the law, a taxpayer who fails to pay the penalty "shall not be subject to any criminal prosecution or penalty" and cannot have liens or levies placed on their property, but the IRS will be able to withhold future tax refunds from them.{{cite news|url=https://money.cnn.com/2012/06/29/pf/taxes/health_insurance_mandate/index.htm|title=How health insurance mandate will work |publisher=CNN|first=Jeanne |last=Sahadi |author-link=Jeanne Sahadi |date=June 29, 2012|access-date=July 12, 2013}}

• In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.{{cite news|url=http://www.kaiserhealthnews.org/Stories/2010/March/22/consumers-guide-health-reform.aspx|first=Phil |last=Galewitz|title=Consumers Guide To Health Reform|date=March 26, 2010|newspaper=Kaiser Health News}}{{cite news|url=http://www.cnn.com/2010/HEALTH/03/25/health.care.law.basics/index.html|title=5 key things to remember about health care reform|publisher=CNN|date=March 25, 2010 | access-date=May 21, 2010 |first=Sabriya |last=Rice}} The law also provides for a 5% "income disregard", making the effective income eligibility limit 138% of the poverty line.{{cite web|title=Medicaid Expansion: 5. Is Medicaid eligibility expanding to 133 or 138 percent FPL, and what is MAGI?|url=http://www.apha.org/APHA/CMS_Templates/GeneralArticle.aspx?NRMODE=Published&NRNODEGUID={D5E1C04A-0438-4FD4-A423-CEFDA0D9878D}&NRORIGINALURL=%2fadvocacy%2fHealth%2bReform%2fACAbasics%2fmedicaid.htm#Medi5|publisher=American Public Health Association}} States may choose to increase the income eligibility limit beyond this minimum requirement. As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that this withdrawal of funding was unconstitutionally coercive and that individual states had the right to opt out of the Medicaid expansion without losing pre-existing Medicaid funding from the federal government. For states that do expand Medicaid, the law provides that the federal government will pay for 100% of the expansion for the first three years, then gradually reduce its subsidy to 90% by 2020.{{cite news|url=https://money.cnn.com/2013/07/01/news/economy/medicaid-expansion-states/index.html|title=States forgo billions by opting out of Medicaid expansion|publisher=CNN |date=July 1, 2013 |first=Tami |last=Luhby}}{{cite web|url=https://www.usnews.com/debate-club/is-medicaid-expansion-good-for-the-states|title=Is Medicaid Expansion Good for the States?|publisher=U.S. News & World Report}} {{As of|2013|04|25|df=US|post=,}} fifteen states—Alaska, Alabama, Georgia, Idaho, Indiana, Iowa, Louisiana, Mississippi, Nebraska, North Carolina, Oklahoma, South Carolina, Texas, Wisconsin, and Virginia—were not participating in the Medicaid expansion, with ten more—Kansas, Maine, Michigan, Montana, Missouri, Ohio, Pennsylvania, South Dakota, Utah, and Wyoming—leaning towards not participating.{{cite news |last=Kliff |first=Sarah |date=April 25, 2013 |url=https://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/25/the-outlook-for-medicaid-expansion-looks-bleak/ |title=The outlook for Medicaid expansion looks bleak |newspaper=Washingtonpost.com |access-date=July 17, 2013}}{{update inline|date=February 2014}}
• The Patient Protection and Affordable Care Act eliminates lifetime and annual limits from plans in the individual health benefits exchanges. This effectively eliminates the ceiling on financial risk for individuals in the individual exchanges.{{cite book |last=MacGillis |first=Alec |chapter=The Insurers: More Customers, More Restrictions |pages=93–98 |editor-last=The Staff of the Washington Post |title=Landmark: The Inside Story of America's New Health-Care Law and What It Means for Us All |location=New York |publisher=Public Affairs |year=2010 |url=https://books.google.com/books?id=Ppivy3XtAY8C |isbn=9781410428998}}

The subsidies for insurance premiums are given to individuals who buy a plan from an exchange and have a household income between 133% and 400% of the poverty line.{{cite web|title=Health Insurance Premium Credits Under PPACA (P.L. 111-148)|url=http://assets.opencrs.com/rpts/R41137_20100406.pdf|publisher=Congressional Research Service|first1=Chris L. |last1=Peterson |first2=Thomas |last2=Gabe|date=April 6, 2010}}{{cite news | first=Phil | last=Galewitz | title=Health reform and you: A new guide | date=March 22, 2010 | publisher=msnbc.com | url =http://today.msnbc.msn.com/id/34609984/ns/health-health_care/ | archive-url =https://web.archive.org/web/20100325033413/http://today.msnbc.msn.com/id/34609984/ns/health-health_care/ | url-status =dead | archive-date =March 25, 2010 | access-date =March 23, 2010 }}{{cite news|url=http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-Who-gets-subsidized-insurance|title=Health care reform bill 101: Who gets subsidized insurance?|work=The Christian Science Monitor |first=Peter |last=Grier |date=March 20, 2010}} Section 1401(36B) of PPACA explains that each subsidy will be provided as an advanceable, refundable tax credits:Patient Protection and Affordable Care Act/Title I/Subtitle E/Part I/Subpart A and gives a formula for its calculation:Patient Protection and Affordable Care Act: Title I: Subtitle E: Part I: Subpart A: Premium Calculation

{{blockquote|Except as provided in clause (ii), the applicable percentage with respect to any taxpayer for any taxable year is equal to 2.8 percent, increased by the number of percentage points (not greater than 7) which bears the same ratio to 7 percentage points as the taxpayer's household income for the taxable year in excess of 100 percent of the poverty line for a family of the size involved, bears to an amount equal to 200 percent of the poverty line for a family of the size involved. *(ii) SPECIAL RULE FOR TAXPAYERS UNDER 133 PERCENT OF POVERTY LINE- If a taxpayer's household income for the taxable year is in excess of 100 percent, but not more than 133 percent, of the poverty line for a family of the size involved, the taxpayer's applicable percentage shall be 2 percent.|Patient Protection and Affordable Care Act: Title I: Subtitle E: Part I: Subpart A: Premium Calculation}}

A refundable tax credit is a way to provide government benefits to individuals who may have no tax liability{{cite web|url=http://hungerreport.org/2010/report/chapters/two/taxes/refundable-tax-credits|title=Refundable Tax Credits |archive-url=https://web.archive.org/web/20120305190558/http://hungerreport.org/2010/report/chapters/two/taxes/refundable-tax-credits |archive-date=March 5, 2012 |publisher=Bread for the World Institute}} (such as the earned income tax credit). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage. The U.S. Department of Health and Human Services (HHS) and Internal Revenue Service (IRS) on May 23, 2012, issued joint final rules regarding implementation of the new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.{{cite journal|url=http://www.gpo.gov/fdsys/pkg/FR-2012-05-23/pdf/2012-12421.pdf|title=Health Insurance Premium Tax Credit |date=May 23, 2012 |volume=77 |issue=100 |pages=30377–30400 |journal=Federal Register |location=Washington, D.C. |publisher=Government Printing Office}}{{cite press release|url=http://www.treasury.gov/press-center/Documents/36BFactSheet.PDF|title=Treasury Lays the Foundation to Deliver Tax Credits to Help Make Health Insurance Affordable for Middle-Class Americans |date=August 12, 2011 |publisher=United States Department of the Treasury}} Premium caps have been delayed for a year on group plans, to give employers time to arrange new accounting systems, but the caps are still planned to take effect on schedule for insurance plans on the exchanges;{{cite news|first=Robert |last=Pear |url=https://www.nytimes.com/2013/08/13/us/a-limit-on-consumer-costs-is-delayed-in-health-care-law.html |title=A Limit on Consumer Costs Is Delayed in Health Care Law |work=The New York Times |date=August 12, 2013 }}{{cite web|first=Jonathan |last=Cohn |url=https://newrepublic.com/article/114297/obamacare-consumer-protection-delay-and-conservative-overreaction |title=The Latest Right-Wing Freakout Over Obamacare |publisher=The New Republic |date=August 13, 2013 }}{{cite web |first=Teagan |last=Goddard |url=http://wonkwire.rollcall.com/2013/08/13/just-another-obamacare-delay/ |title=Just Another Obamacare Delay |publisher=Roll Call |date=August 13, 2013 |access-date=October 2, 2013 |archive-url=https://web.archive.org/web/20130927160703/http://wonkwire.rollcall.com/2013/08/13/just-another-obamacare-delay/ |archive-date=September 27, 2013 |url-status=dead }}{{cite web|first=Jonathan |last=Chait |url=http://nymag.com/daily/intelligencer/2013/08/george-will-now-obama-is-worse-than-nixon.html |title=George Will: Now Obama Is Worse Than Nixon |author-link=Jonathan Chait |publisher=New York |date=August 15, 2013 }} the HHS and the Congressional Research Service calculated what the income-based premium caps for a "silver" healthcare plan for a family of four would be in 2014:

{{multiple image | align = left | header = Maximum Out-of-Pocket Premium Payments | image1 = PPACA Premium CRS.jpg | alt1 = PPACA Premium CRS | width1 = 500 | caption1 =Maximum Out-of-Pocket Premium Payments Under PPACA by Family Size and federal poverty level. (Source: CRS) | image2 = PPACA Premium Chart.jpg | width2 = 450 | alt2 = PPACA Premium Chart | caption2 =Maximum Out-of-Pocket Premium as Percentage of Family Income and federal poverty level (Source: CRS) |}} {{Clear}}

In the individual market, sometimes thought of as the "residual market" of insurance,{{clarify|reason="thought of"? "residual market"?|date=February 2014}} insurers have generally used a process called underwriting to ensure that each individual paid for his or her actuarial value or to deny coverage altogether.{{cite journal |first1=Mark V. |last1=Pauly |first2=Bradley |last2=Herring |title=Risk Pooling and Regulation: Policy and Reality in Today's Individual Health Insurance Market |journal=Health Affairs |date=May 2007 |volume=26 |issue=3 |pages=770–779 |doi=10.1377/hlthaff.26.3.770|pmid=17485756 }} The House Committee on Energy and Commerce found that, between 2007 and 2009, the four largest for-profit insurance companies refused insurance to 651,000 people for previous medical conditions, a number that increased significantly each year,{{cite web|first1=Henry A. |last1=Waxman |first2=Bart |author-link1=Henry Waxman |author-link2=Bart Stupak |last2=Stupak |publisher=United States House Committee on Energy and Commerce |title=Re: Coverage Denials for Pre-Existing Conditions in the Individual Health Insurance Market [Memorandum] |date=October 12, 2012 |url=http://democrats.energycommerce.house.gov/Press_111/20101012/Memo.Pre-existing.Condition.Denials.Individual.Market.2010.10.12.pdf |access-date=December 15, 2012}} with a 49% increase in that time period.{{cite web |url=http://www.commonwealthfund.org/Blog/2010/Oct/Affordable-Care-Act-Options-for-People-Denied-Coverage-for-Preexisting-Conditions.aspx |title=Affordable Care Act Options for People with Preexisting Conditions |first=Jean P. |last=Hall |date=October 19, 2010 |publisher=The Commonwealth Fund}} The same memorandum said that 212,800 claims had been refused payment due to pre-existing conditions and that insurance firms had business plans to limit money paid based on these pre-existing conditions. These persons who might not have received insurance under previous industry practices are guaranteed insurance coverage under the ACA. Hence, the insurance exchanges will shift a greater amount of financial risk to the insurers, but will help to share the cost of that risk among a larger pool of insured individuals. The ACA's prohibition on denying coverage for pre-existing conditions began on January 1, 2014. Previously, several state and federal programs, including most recently the ACA, provided funds for state-run high-risk pools for those with previously existing conditions.{{cite journal |url=http://www.modernhealthcare.com/article/20110228/MAGAZINE/302289962 |title=States try it again |last=Vesely |first=Rebecca |date=February 28, 2011 |journal=Modern Healthcare |volume=41 |issue=9 |page=17}}{{cite journal|last=Haeder |first=Simon |title=Making the Affordable Care Act Work: High-Risk Pools and Health Insurance Marketplaces|journal=The Forum|volume=11|issue=3|year=2013|doi=10.1515/for-2013-0056|s2cid=147178678 }} Several states have continued their high-risk pools even after the first marketplace enrollment period.

:Pricing Factors Allowed in the exchange under the ACA:{{cite web |url=http://housedocs.house.gov/energycommerce/ppacacon.pdf#page=46 |title=Compilation of Patient Protection and Affordable Care Act |date=June 9, 2010 |publisher=Office of the Legislative Counsel}}

::*Age: 3:1

::*Smoking status: 1.5:1

Pricing variation will be allowed by area (within a state) and family composition ("tier") as well.

Within the exchanges, insurance plans are offered in four tiers designated from lowest premium to highest premium: bronze, silver, gold, and platinum. The plans cover ranges from 60% to 90% of bills in increments of 10% for each plan. For those under 30 (and those with a hardship exemption), a fifth "catastrophic" tier is also available, with very high deductibles.{{cite web| url=http://www.healthcare.gov/how-do-i-choose-marketplace-insurance/| title= How do I choose Marketplace insurance?| publisher= HealthCare.gov| access-date=October 28, 2013| quote=There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.}}

Insurance companies select the doctors and hospitals that are "in-network".{{clarify|reason="in-network" needs link or definition|date=February 2014}}{{cite news|title=Premiums unveiled show wide range for health overhaul plans|url=http://seattletimes.com/html/nationworld/2021890192_obamacarepremiumsxml.html|newspaper=The Seattle Times|date=September 24, 2013|first1=Sandhya|last1=Somashekhar|first2=Sarah|last2=Kliff|url-status=dead|archive-url=https://web.archive.org/web/20141218184935/http://seattletimes.com/html/nationworld/2021890192_obamacarepremiumsxml.html|archive-date=December 18, 2014}}

Proponents of health care reform believe that allowing comparable plans to compete for consumer business in one convenient location will drive prices down. Having a centralized location increases consumer knowledge of the market and allows for greater conformation to perfect competition. Each of these plans will also cap liabilities for consumers with out-of-pocket expenses at $6,350 for individuals and $12,700 for families.

A study by Avalere Health says that healthcare insurance premiums of popular plans available under Obamacare for 2015 rose by 3-4% .{{cite web|url=http://www.marketwatch.com/story/obamacare-premiums-for-2015-include-some-big-changes-2014-11-18|title=Obamacare premiums for 2015 include some big changes|first=Anne|last=Tergesen|date=18 November 2014 }}

According to the US Department of Health & Human Service, as enrollment for the Health Insurance Marketplace began on November 15, about 11.4 million people have explored their options, learned about the financial assistance available, and signed up for or renewed a health plan that meets their needs and fits their budget. As of February, 2015, $268 was the average monthly tax credit for people who qualify for financial assistance in 37 states using HealthcCare.gov through January 30.{{cite web |date=February 13, 2015 |title=By the Numbers: Open Enrollment for Health Insurance |website=HHS.gov/HealthCare |publisher=U.S. Department of Health & Human Services |url=https://www.hhs.gov/healthcare/facts/factsheets/2015/02/open-enrollment-by-the-numbers.html |url-status=dead |archive-date=February 15, 2015 |archive-url=https://web.archive.org/web/20150215101950/http://www.hhs.gov/healthcare/facts/factsheets/2015/02/open-enrollment-by-the-numbers.html }}

The health insurance advocacy group America's Health Insurance Plans was willing to accept these constraints on pricing, capping, and enrollment because of the individual mandate: The individual mandate requires that all individuals purchase health insurance.{{cite news|url=https://www.forbes.com/sites/brucejapsen/2012/06/17/mandate-to-buy-coverage-health-insurance-industrys-idea-not-obamas/|title=Mandate To Buy Coverage: Health Insurance Industry's Idea, Not Obama's|first=Bruce |last=Japsen|date=June 17, 2012|access-date=February 7, 2014|work=Forbes}}{{cite web|url=http://www.healthcare.gov/glossary/i/individualresponsibility.html|access-date=3 June 2013|title=Individual Responsibility - Glossary |archive-url=https://web.archive.org/web/20130619173728/http://www.healthcare.gov/glossary/i/individualresponsibility.html |archive-date=June 19, 2013 |publisher=HealthCare.gov}} This requirement of the ACA allows insurers to spread the financial risk of newly insured people with pre-existing conditions among a larger pool of individuals.{{citation needed|date=March 2024}}

Additionally, a study done by Pauly and Herring estimates that individuals with pre-existing conditions in the 99th percentile of financial risk represented 3.95 times the average risk (mean). Figures from the House Committee on Energy and Commerce would indicate that approximately 1 million high-risk individuals will pursue insurance in the health benefits exchanges. Congress has estimated that 22 million people will be newly insured in the health benefits exchanges.{{cite news |url=https://www.washingtonpost.com/opinions/cbo-report-shows-the-new-health-care-law-can-still-do-what-it-intended/2014/02/07/14fd6bf4-8eb0-11e3-b46a-5a3d0d2130da_story.html |title=The CBO report does not show the new health-care law is failing |date=February 7, 2014 |newspaper=The Washington Post |author=Editorial Board}} Thus the high-risk individuals do not number in high enough quantities to increase the net risk per person from previous practice. It is thus theoretically profitable to accept the individual mandate in exchange for the requirements presented in the ACA.{{citation needed|date=March 2024}}

HIX (Health Insurance eXchange) is emerging as the de facto acronym across state and federal government stakeholders, and the private sector technology and service providers that are helping states build their exchanges.{{citation needed|date=February 2014}} The acronym HIX differentiates this topic from health information exchange, or HIE.{{cite journal |url=http://journal.ahima.org/2010/06/01/accrediting-hie/ |title=Accrediting HIEs |date=June 1, 2010 |first=Chris |last=Dimick |journal=Journal of AHIMA |access-date=February 8, 2014 |archive-date=October 19, 2017 |archive-url=https://web.archive.org/web/20171019185641/http://journal.ahima.org/2010/06/01/accrediting-hie/ |url-status=dead }}

The de facto acronym of HIXSee more information on the HIMSS Dictionary at [http://ebooks.himss.org/product/himss-dictionary-healthcare-information-technology-terms-acronyms-organizations26783 2nd Edition of the HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations] {{Webarchive|url=https://web.archive.org/web/20160803110402/http://ebooks.himss.org/product/himss-dictionary-healthcare-information-technology-terms-acronyms-organizations26783 |date=2016-08-03 }}. will be replaced with HIEx in the 3rd Edition of the HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations, {{as of|2013|03|alt=to be released in March 2013 |lc=yes|post=.}}{{citation needed|date=February 2014}}

File:Medicaid expansion map of US. Affordable Care Act.svg by state.{{cite web |title=Status of State Medicaid Expansion Decisions: Interactive Map |date=8 May 2024 |url=https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map |publisher=KFF. Map is updated as changes occur. Click on states for details.}}

{{legend|#2b83ba|Not adopted}}

{{legend|#89CC7F|Adopted}}

{{legend|#FECDAC|Implemented}}]]

; Exclusion of many lower-income individuals

: NPR reported that large numbers of low income people were excluded in states that did not offer Medicaid expansion to 133% of the poverty line.{{cite web |url=https://www.npr.org/blogs/health/2013/10/01/228196533/in-florida-insurer-and-nonprofits-work-on-enrollment |title=In Florida, Insurer And Nonprofits Work On Enrollment |date=October 1, 2013 |first=Greg |last=Allen |publisher=NPR}}{{cite web |url=http://kff.org/interactive/subsidy-calculator/ |title=Subsidy Calculator |date=28 October 2021 |publisher=Kaiser Family Foundation}}

; Data security

: Minnesota's healthcare exchange was reported to have accidentally e-mailed personal information of more than 2,400 insurance agents to an insurance broker, according to the Minnesota Star Tribune.{{cite news|url=https://www.cbsnews.com/news/obamacare-marketplaces-raise-data-security-concerns/ |title=Obamacare marketplaces raise data security concerns |date=October 2, 2013 |first=Stephanie |last=Condon |publisher=CBS}}

; Loss of group coverage for part-time employees

: According to NPR, some employers such as Trader Joe's and Home Depot have decided to terminate health insurance for their part-time workers.{{cite web |url=https://www.npr.org/blogs/health/2013/10/04/229103233/part-time-workers-search-new-exchanges-for-health-insurance |title=Part-Time Workers Search New Exchanges For Health Insurance |first=John |last=Ydstie |date=October 4, 2013 |publisher=NPR}}

; Scams

: Scams were expected because of confusion over enrollment.{{cite web |url=http://www.klewtv.com/news/consumer/Scammers-newest-ruse-Health-care-reform-225558582.html |title=Scammers newest ruse: Health care reform |first=Connie |last=Thompson |date=September 30, 2013 |publisher=KLEW-TV |access-date=October 5, 2013 |archive-date=October 13, 2013 |archive-url=https://web.archive.org/web/20131013104316/http://www.klewtv.com/news/consumer/Scammers-newest-ruse-Health-care-reform-225558582.html |url-status=dead }}{{cite web |url=http://www.cbs58.com/news/local-news/Protecting-yourself-from-healthcare-law-scams-226070941.html |title=Protecting yourself from healthcare law scams |first=Tiffany |last=Tarpley |date=October 1, 2013 |publisher=WDJT-TV |access-date=October 5, 2013 |archive-date=October 13, 2013 |archive-url=https://web.archive.org/web/20131013093137/http://www.cbs58.com/news/local-news/Protecting-yourself-from-healthcare-law-scams-226070941.html |url-status=dead }}

; Restricted and narrow networks

: Some exchanges have been criticized for offering health plans that necessitate too many out-of-network claims. On October 5, 2013, Seattle Children's hospital filed a lawsuit for "failure to ensure adequate network coverage" when only two insurers included Children's in their marketplace plan.{{cite news|title=Left off many networks, Seattle Children's sues|url=http://seattletimes.com/html/localnews/2021968776_acachildrenssuitxml.html|newspaper=The Seattle Times|date=October 4, 2013 |first=Amy Snow |last=Landa}}

: Concerns have also been raised about insurance carriers' efforts to limit the number of providers in their networks to reduce costs. A study of the California marketplace confirmed these concerns, but also showed that geographic access was similar and quality at times superior in marketplace-based plans.{{cite journal|last1=Haeder|first1=Simon|last2=Weimer|first2=David|last3=Mukamel|first3=Dana|title=California Hospital Networks Are Narrower In Marketplace Than In Commercial Plans, But Access And Quality Are Similar|journal=Health Affairs|volume=34|issue=5|year=2015|pages=741–748|doi=10.1377/hlthaff.2014.1406|pmid=25941274|url=https://cloudfront.escholarship.org/dist/prd/content/qt5zn289b9/qt5zn289b9.pdf?t=ov3j5a|doi-access=free}}

; "Cherry-picking"

: The private health insurance industry fears that restricted eligibility and a market size that is too small could result in higher premiums, encourage "cherry-picking" of customers by insurers, and force a clearance of the exchange. That is what some believe will happen in Texas and California in their failed exchanges.{{Cite news|url=https://www.nytimes.com/2009/10/06/opinion/06mcgarr.html|title=A Texas-Sized Health Care Failure |first=Cappy|last=McGarr|date=October 5, 2009|access-date=October 6, 2009|newspaper=The New York Times}} One of these factors, "cherry-picking" of customers, will not be possible in the state-run exchanges mandated by the ACA, because all insurance plans will be "guaranteed issue" in 2014. Furthermore, the law will bring millions of new enrollees into the marketplace by way of the individual mandate requirement for all citizens to purchase health insurance and increase market size.{{cite web|title=The Affordable Care Act: The Individual Mandate|url=http://ipp.missouri.edu/files/ipp/attachments/the_affordable_care_act_the_individual_mandate.pdf|publisher=University of Missouri|access-date=February 23, 2014|archive-date=March 1, 2014|archive-url=https://web.archive.org/web/20140301061226/http://ipp.missouri.edu/files/ipp/attachments/the_affordable_care_act_the_individual_mandate.pdf|url-status=dead}}

A State-based Marketplace (SBM) is a state-specific online marketplace where American citizens and legal residents can comparison shop, apply, and enroll in subsidized health insurance plans via a government agency. Similar to Healthcare.gov, but created and maintained by the individual state. Sometimes referred to as a State-based Exchange (SBE),{{Cite web|title=State-based Exchanges {{!}} CMS|url=https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/state-marketplaces|access-date=2021-05-24|website=www.cms.gov}} State-based marketplaces strive to limit consumer confusion by standardizing information on plan benefits and making it easier to compare insurance policy cost and quality.

States that have opted to implement a State-based Marketplace are required to offer numerous forms of aid to consumers searching for coverage, such as toll-free hotlines to help consumers with plan selection, assistance in determining eligibility for federal subsidies or Medicaid, and conducting outreach to educate consumers on available coverage options in their state.{{citation needed|date=March 2024}}

State-based Marketplaces have developed as technology matures and the market and individual state needs have changed. Numerous states have opted to implement their own SBM.

This includes:

• California – Covered California{{Cite web|title=Covered California™ {{!}} The Official Site of California's Health Insurance Marketplace|url=https://www.coveredca.com/|access-date=2021-05-25|website=www.coveredca.com|language=en}}
• Colorado – Connect for Health Colorado{{Cite web|title=Connect for Health Colorado|url=https://connectforhealthco.com/|access-date=2021-05-25|website=Connect for Health Colorado|language=en-US}}
• Connecticut – Access Health CT{{Cite web|title=Access Manager for Web Login|url=https://www.accesshealthct.com/|access-date=2021-05-25|website=www.accesshealthct.com}}
• District of Columbia – DC Health Link{{Cite web|title=DC Health Link {{!}} Welcome to DC's Health Insurance Marketplace|url=https://dchealthlink.com/|access-date=2021-05-25|website=dchealthlink.com}}
• Idaho – Your Health Idaho{{Cite web|title=Your Health Idaho » Idaho's Official Health Insurance Marketplace|url=https://www.yourhealthidaho.org/|access-date=2021-05-25|website=www.yourhealthidaho.org|language=en-US}}
• Kentucky - kynect{{Cite web|title=kynect Benefits|url=https://kynect.ky.gov/benefits/s/?language=en_US|access-date=2022-09-01|website=kynect.ky.gov}}
• Maryland – Maryland Health Connection{{Cite web|title=Home|url=https://www.marylandhealthconnection.gov/|access-date=2021-05-25|website=Maryland Health Connection}}
• Massachusetts – Health Connector{{Cite web|title=Learn|url=https://www.mahealthconnector.org/learn|access-date=2021-05-25|website=Massachusetts Health Connector|language=en-US}}
• Minnesota – MNsure{{Cite web|title=MNsure Home|url=https://www.mnsure.org/|access-date=2021-05-25|website=MNsure}}
• Nevada - Nevada Health Linkhttps://www.nevadahealthlink.com/ {{Bare URL inline|date=August 2024}}
• New Jersey – Get Covered NJ{{Cite web|title=GetCoveredNJ|url=https://www.nj.gov/getcoverednj/|access-date=2021-05-25|website=www.nj.gov|language=en}}
• New York – New York State of Health{{Cite web|title=NY State of Health, The Official Health Plan Marketplace|url=https://nystateofhealth.ny.gov/|access-date=2021-05-25|website=nystateofhealth.ny.gov}}
• Pennsylvania – Pennie(tm){{Cite web|title=Pennie|url=https://pennie.com/|access-date=2021-05-25|language=en-US}}
• Rhode Island – HealthSource RI{{Cite web|title=Frequently Asked Questions|url=https://healthsourceri.com/frequently-asked-questions/|access-date=2021-05-25|website=HealthSource RI|date=28 August 2015 |language=en-US}}
• Vermont – Vermont Health Connect{{Cite web|title=VHC Landing Page|url=https://portal.healthconnect.vermont.gov/VTHBELand/welcome.action|access-date=2021-05-25|website=portal.healthconnect.vermont.gov}}
• Washington – Washington Healthplanfinder{{Cite web|title=Home {{!}} Washington Healthplanfinder|url=https://www.wahealthplanfinder.org/|access-date=2021-05-25|website=www.wahealthplanfinder.org}}{{Cite web|last=GetInsured|title=Which States Have State-Based Marketplaces?|url=https://company.getinsured.com/which-states-have-state-based-marketplaces/|access-date=2021-05-25|website=GetInsured|language=en-US}}

{{main|Cover Oregon}}

In March 2015, Oregon officially abolished its state-run health insurance marketplace, "Cover Oregon", in favor of a federally-run exchange.{{cite news

|url=http://www.oregonlive.com/health/index.ssf/2014/04/cover_oregon_after_spending_24.html

|title=Cover Oregon: $248 million state exchange to be jettisoned in favor of federal system

|last=Manning

|first=Jeff

|date=April 25, 2014

|access-date=April 27, 2014

|newspaper=The Oregonian

}}

{{One source section|date=September 2017}}

A private health insurance exchange is an exchange run by a private sector company or nonprofit. Health plans and insurance carriers in a private exchange must meet certain criteria defined by the exchange management. Private exchanges combine technology and human advocacy, and include online eligibility verification and mechanisms for allowing employers who connect their employees or retirees with exchanges to offer subsidies. They are designed to help consumers find plans personalized to their specific health conditions, preferred doctor/hospital networks, and budget. These exchanges are sometimes called marketplaces or intermediaries, and work directly with insurance carriers, effectively acting as extensions of the carrier.{{citation needed|date=September 2017}} The largest and most successful{{peacock inline|date=September 2017}} private health care exchange is CaliforniaChoice, established by CHOICE Administrators in 1996.{{cite web |title=About Us |website=CaliforniaChoice |url=https://www.calchoice.com/AboutUs.aspx |access-date=September 13, 2017 }}

Private health exchanges predate the Affordable Care Act. One example of an early health care exchange is International Medical Exchange (IMX), a company venture financed in Louisville, Kentucky, by Standard Telephones and Cables, a large British technology company (now Nortel), to develop the exchange concept in the U.S. using on-line technology. The product was created in the mid-1980s. IMX developed an eligibility verification system, a claims management system, and a bank-based payments administration system that would manage payments between the patient, the employer, and the insurance carrier. Like proposed exchanges today, it focused on standards of care, utilization review by a third party, private insurer participation, and cost reduction for the health care system through product simplification. The focus was on creating local or regional exchanges that offered a series of standardized health care plans that reduced the complexity and cost of acquiring or understanding health care insurance, while simplifying claims administration. The system was modeled after the standardized stock exchange and banking industry back office processes. The major difference was that IMX health care exchanges would provide their products through a national network of existing commercial banks rather than setting up a duplicate payment and administration systems network as proposed today. The IMX product rights were acquired by Anthem (then Blue Cross and Blue Shield of Kentucky). The exchange product became the basis for inter-carrier claims settlement between commercial insurance carriers and Blue Cross organizations. The founders of IMX were from top management at Humana, and top management of First Tennessee National Corp (now First Horizon).

In overlapping markets, the co-existence of public and private exchange plans can lead to confusion when speaking of an "exchange plan." In California, Anthem Blue Cross offers HMO plans through both the state-run Covered California exchange and the private CaliforniaChoice exchange, but doctor networks are not identical. Physicians advertising acceptance of Anthem Blue Cross Exchange HMOs may misinform individuals enrolled in Anthem Blue Cross Exchange HMOs through the private exchange.

• Health care reform
• Health care reform in the United States
• Health system
• Health Advocate
• Health insurance
• Health Insurance Innovations
• Universal health coverage by country

{{reflist|30em}}

• [https://www.healthcare.gov HealthCare.gov]
• [https://www.cms.gov/marketplace/about/exchange-coverage-maps Insurer marketplace participation by county] (Yearly recent and historic maps)
• [https://fas.org/sgp/crs/misc/R43066.pdf Status of Federal Funding for State Implementation of Health Insurance Exchanges] Congressional Research Service (2014)
• [http://www.c-spanvideo.org/videoLibrary/ C-SPAN Video Library] {{Webarchive|url=https://web.archive.org/web/20161027131927/http://www.c-spanvideo.org/videoLibrary/ |date=2016-10-27 }}: [http://www.c-spanvideo.org/search/?keywords=Health+Insurance+Exchange Search Health Insurance Exchange]

: See "Clips" tab then "Clips Timeline" drop-down for abstracts of edited clips from the following videos:

:* [http://www.c-spanvideo.org/program/TheFederalH Health Care Law Exchanges] Apr 22, 2013, Jenny Gold, Kaiser Health News correspondent, Interview

:* [http://www.c-spanvideo.org/program/PoliticoD Report Video Issue Health Insurance Exchanges] Jul 25, 2013, Politico Pro Health Care Breakfast Briefing

:* [http://www.c-spanvideo.org/program/JulieR Update on the Health Care Law] Jul 1, 2013, [https://www.npr.org/people/2101102/julie-rovner Julie Rovner], National Public Radio health policy correspondent, Interview

• [https://fas.org/sgp/crs/misc/R44065.pdf Overview of Health Insurance Exchanges], Congressional Research Service, July 1, 2016

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Category:Healthcare reform in the United States

Category:CGI Group

Category:Health insurance

Category:Universal health care

Category:Health education

Category:Public health