Three Steps to a Successful Health Insurance Change


Chini Krishnan, co-founder and CEO of GetInsured

Since the enactment of the Affordable Care Act, we have seen how federal administrations come and go. However, over the course of changes and improvements in the law over time and across party lines, one thing has remained constant, namely, state-based exchanges or markets (SBM). they have provided and will continue to provide states with the autonomy and flexibility to address the problem. unique needs of the health insurance markets and consumers across the country in a way that cannot.

Jessica Altman, Pennsylvania insurance commissioner sums it up well: “When we talk about getting something back into state control, this is a real narrative that can attract both sides of the aisle. There’s nothing political about making health insurance more affordable.”

Due to the numerous variations in state populations, such as income, education, and health status, as well as the combination and geographic location of physicians, hospitals, and clinics, and the level of competence of insurers, there really is no single federal solution. when it comes to operating a health insurance exchange. A state must also take into account its agent / agent market penetration ratio, in addition to the ever-changing regulatory environment.

The flexibility and cost savings offered by state markets allow state governments to drive real and lasting changes in their healthcare markets. New Jersey and Pennsylvania, the two most recent states to leave the Federal Facility Market (FFM), also known as, saw a decline in premiums, an increase in health insurance enrollment and a large reduction of operating costs during its period. first enrollment period open only as SBM.

According to a recent study published in the Journal of Health Politics, Policy and Law, “almost generally, states with their own exchanges have achieved higher enrollment rates than their federal counterparts, along with lower premiums and better consumer education and protection. “.

Considering all this, we hope that the states will continue to make the transition from the FFM to their own SBM; Maine and New Mexico are in the process of making the transition and states like Virginia are preparing to begin the hiring process.

In a testimony earlier this year to the Tennessee Legislature Health Insurance Subcommittee Randy Pate, who recently served as director of the Center for Consumer Information and Insurance Oversight (CCIIO) at the Federal Centers for Medicare and Medicaid Services (CMS) , said: “I can tell you first hand. of the importance of states in regulating their own health insurance markets. States, more than the federal government, are in the best position to address unique issues. States are more sensitive to the specific needs of their communities and better able to protect the interests of consumers, and states are at the forefront of creativity and innovation to address the crisis facing the United States health care system. ”

Taking the step out of is no small task, so for states considering the transition, here are the first steps to rolling the ball:

1. Plan your market.

Under federal law, states operating their own SBMs have great latitude to design and implement exchanges within federal standards. For example, SBM states have full control over Qualified Health Plan (QHP) certification and in conducting outreach and marketing efforts. States can also decide how they want to determine Medicaid eligibility. These are just some of the many decisions a state will have to make. Thinking about how you want your exchange to look and work will help you set the plan for everything that comes next.

2. Determine what type of technology is best for your condition.

Better technology and lower costs make it easier for states to set up and operate their own SBMs than ever before, saving taxpayers and subscribers money. But choosing the right platform is critical to meeting your budget and design needs. States can choose from custom, open source platforms, accelerators, and SaaS, to name a few. It is important that all market stakeholders understand the risks and benefits of each type of solution.

Although they became popular in 2013, custom solutions have shown that, in most cases, they are too expensive and require time to be sustainable. States that have recently emigrated have managed to do so at a fraction of the cost of previous exchanges, with significantly lower operating costs. In my experience, software-as-a-service (SaaS) solutions have proven to be the most beneficial for states, as they provide policy flexibility, lower costs, shorter implementation times, and shared improvements.

3. Consider how you want SBM to work with Medicaid.

An important consideration about how your state market will work is how applicants who are likely to be eligible for Medicaid or the Child Health Insurance Plan (CHIP) are handled. Some SBM states are known as “Determination States”. In these states, the SBM makes the final Medicaid or CHIP modified gross income (MAGI) eligibility determination. In other states, known as “Assessment States,” the SBM conducts a preliminary assessment of Medicaid eligibility, with the final determination made by the state’s integrated eligibility determination system based on the rules of Medicaid Eligibility When taking control of a state’s health insurance market with an SBM, exchange ownership eligibility (a state of determination) is best practice. Regardless of which path the state chooses, this is an important structural decision that must be made when considering assembling an SBM.

While there are many issues to consider when making the transition, the above three considerations will help state governments lay a solid foundation for moving forward successfully with a health insurance-based exchange. in the state.

Ultimately, the state has the power to come up with a solution that really works for its residents. According to New Jersey Banking and Insurance Commissioner Marlene Caride, “The beauty of [a state-based exchange] is that we can adapt it to New Jersey residents and have the ability to help [them] when they need it “.

About Chini Krishnan

Chini Krishnan is co – founder and CEO of Make sure, the company that revolutionized public sector healthcare with SaaS-based technology. Today, GetInsured is the leading provider of health insurance enrollment technology for the state governments of California, Idaho, Minnesota, Pennsylvania, Nevada, New Jersey and Washington. GetInsured technology has allowed more than 15 million registrations so far.

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