A First Look at Health Plan Requirements in State Exchanges

With open enrollment less than nine months away, state exchanges are moving quickly to get ready to open their doors to consumers. One of the critical duties of an exchange is to develop a certification process for Qualified Health Plans (or “QHPs,” the term for plans approved for sale in exchanges). The first crop of states have released Requests for Proposal (RFPs), solicitations or other documents relating to QHP-certification requirements for their state or partnership exchange. These materials give us a peek at what plans might actually look like during the first year of operation.
The Affordable Care Act (ACA) requires QHPs to meet a set of criteria in order to participate in an exchange; however, states can decide to go beyond this set of criteria and place additional requirements on plan participants. Some states, like Maryland and Nevada, will take all comers and simply require plans to announce they will offer plans on the exchange. Other states, like California and Vermont, are soliciting bids—a form of “active purchasing”—from plans that wish to participate in the exchange, and the states will make their QHP selections later this year. For more on active purchasing, see our blog post here.
We’ve combed through documents from Oregon, Delaware, California, Vermont and Connecticut to find what’s unique about their certification process. Below we highlight, in four key areas, some examples of states’ plan standards that go beyond federal minimum requirements.
Plan Design
Qualified health plans are required to meet federal standards for covered services and cost-sharing. Plans have a designated “metal” tier based on their level of coverage—platinum, gold, silver or bronze—and carriers must offer at least a silver and gold plan in order to participate in the exchange.

• California’s solicitation requires carriers to submit all metal tiers along with a catastrophic-coverage plan for each rating region in which they are submitting a bid.
• Connecticut’s QHP solicitation prohibits tobacco rating and requires a gold, silver and bronze plan from each participating carrier.
• Delaware’s Request for Letters of Intent requires issuers to offer gold, silver and bronze plans.
• Oregon’s RFA requires carriers to offer gold, silver and bronze plans.
• Vermont’s RFP requires carriers to submit at all metal levels and a total of six standard plan designs developed by the exchange in order to be eligible to offer QHPs.

Network Adequacy
The ACA sets minimum provider network standards to ensure sufficient access to care.

• Connecticut requires that carriers must have contracts with at least 75 percent of essential community providers (providers that serve predominantly low income, medically underserved individuals) in any county in Connecticut and with at least 90 percent of Federally Qualified Health Centers (FQHCs) or “look-alike” health centers in the state.
• Delaware requires carriers to have a continuity of care plan as well as specific network-adequacy requirements to ensure access to health care. QHPs must meet requirements related to a physician/patient ratio and maximum driving time to a primary care provider (PCP).
• Vermont applies existing network adequacy standards for MCOs (Managed Care Organizations) to QHPs. These include maximum driving times to primary care and other providers (30-90 minutes) and maximum wait times for care.
• California requires carriers to list all contracts with essential community providers (ECPs) and they must include at least 15 percent of 340B entities per geographic service area and at least one ECP hospital per geographic service area. Carriers with networks that include county hospitals and FQHCs will be viewed more favorably.

Quality
The ACA requires quality measurement, a quality improvement strategy, and accreditation for plans offered through exchanges.

• Oregon offers carriers that receive quality accreditation prior to January 2014 the chance to have a special icon on the exchange website. The state also gives carriers an option to design two additional plans for each metal tier that demonstrate innovation through wellness programs, networks, or mechanisms other than premiums and benefits.
• California has laid out a number of guidelines related to quality that will guide their selection of QHPs, including aligning delivery systems and providers and payment reform. The RFP asks carriers to outline the mechanisms they intend to use to improve health care quality.
• Vermont requires QHPs to comply with state regulations related to quality, including creating a quality management program that monitors and evaluates care outcomes, a chronic care program, and annual quality improvement goals.
• Delaware will require issuers to participate in state quality-improvement workgroups designed to standardize QHP quality-improvement strategies and activities.

Certification Duration
Exchanges are also required to develop procedures for recertification of QHPs.

• California will enter into contracts with QHPs for up to three years and does not anticipate a full solicitation process in 2015 and 2016.
• Connecticut states that the exchange will certify QHPs for two years at a time.
• Oregon will also certify plans for two years at a time.
• Vermont will recertify plans on a tri-annual basis.

What unique standards is your state developing related to QHP certification? Tell us in the comments below.