States’ Approaches to Qualified Health Plan Certification
*Chart updated June 12, 2014
State health insurance exchanges have unique strategies for certifiying health plans for people to purchase through the exchange beginning on October 1, 2013. Some exchanges plan to selectively contract and negotiate prices with plans; others plan to add standards for plans beyond the federal requirements; and others are accepting all plans that meet the federal requirements.
This chart highlights information about state approaches to qualified health plan certification. The information comes from state and partnership exchange documents available on State Refor(u)m and on state websites. These documents provide key insights about state exchanges approach to certification in the first few years of exchange operations.
This chart highlights information about state approaches to qualified health plan certification. The information comes from state and partnership exchange documents available on State Refor(u)m and on state websites. These documents provide key insights about state exchanges approach to certification in the first few years of exchange operations.
| State | Exchange Authority to Actively Purchase* | Exchange Implementation of Active Purchasing | Expected QHP Certification Date and Length | Additional Network Adequacy Requirements | Rating Standards | Standard Plan Designs |
|---|
| State | Exchange Authority to Actively Purchase* | Exchange Implementation of Active Purchasing | Expected QHP Certification Date and Length | Additional Network Adequacy Requirements | Rating Standards | Standard Plan Designs |
|---|---|---|---|---|---|---|
| Does legislation or executive order allow the exchange to use active purchasing strategies, prohibit it, or is silent? | Is the exchange actually using active purchasing strategies when coverage starts in 2014? | Date when plans will receive certification and the length of the certification period. | Are there additional network adequacy requirements beyond what the ACA stipulates? | What rating factors can QHPs use: geographic, age, tobacco? | Has the exchange developed standard plan designs? | |
| Arkansas | N/A (partnership state) | N/A (partnership state) | July 31, 2013 One year [1] |
No additional requirements in the first year. | Tobacco rating 1.2:1. | N/A |
| California | Allowed | Yes – plans to consider overall value of plans and negotiate. | June 30, 2013 Up to three years |
Essential Community Provider (ECP) and 340B entities requirements. | Tobacco rating prohibited, age rating 3:1, geographic rating allowed. | Yes |
| Colorado | Prohibited | No | July 31, 2013 | Tobacco rating 1.15:1. | ||
| Connecticut | Allowed | Yes – additional certification criteria beyond the federal requirements. | July 15, 2013 Two years |
Essential Community Provider (ECP) and FQHC requirements. | Tobacco rating prohibited, 3:1 age rating, geographic rating allowed. | Yes |
| Delaware | N/A (partnership state) | N/A (partnership state) | July 31, 2013 One year |
Timeliness and Primary Care Provider (PCP) ratio requirements. | No geographic rating. | N/A |
| District of Columbia | Allowed | Yes- additional requirements but no contract negotiation. | August 15, 2013 | Carriers submit access plan with metrics on wait times, provider to patient ratios, and time and distance. [2] | Tobacco and geographic rating prohibited. Age rating 3:1. | Yes, in 2015. |
| Hawaii | Prohibited | |||||
| Idaho | Prohibited [3] | No | ||||
| Illinois | N/A (partnership state) | N/A (partnership state) | July 31, 2013 One year |
Carriers must submit a geographic map with providers marked to ensure that provider ratios, driving distances and referral standards are met. | Tobacco rating 1.5 to 1, 3:1 age rating, thirteen geographic rating areas. | N/A |
| Iowa | N/A (partnership state) | N/A (partnership states) | July 31, 2013 One year |
Carriers must submit information on provider/enrollee ratios, greatest travel distance, inadequate networks, service area, and 24/7 accessiblity. | Tobacco rating 1.5 to 1, 3:1 age rating, seven geographic rating areas. | N/A |
| Kentucky | Silent | No | Two years | Hospital, primary care and specialist requirements, driving distance and wait times. | ||
| Maryland | Allowed | No – not for at least 2 years. | July 1, 2013 | No additional requirements for 2014. May standardize requirements in 2015. | Tobacco rating 1.5 to 1, 3:1 age rating, geographic rating allowed. | No |
| Massachusetts | Allowed | Yes – standards above federal minimum and negotiates rates. | September 2013 | Yes | ||
| Michigan | N/A (partnership state) | N/A (partnership state) | July 31, 2013 One year |
No additional requirements. | Tobacco rating 1.5 to 1, 3:1 age rating, geographic rating allowed. | N/A |
| Minnesota | Allowed in 2015. | Not in 2014. | Additional driving distance/time requirements. | Tobacco rating 1.5 to 1, 3:1 age rating, geographic rating allowed. | ||
| New Hampshire | N/A (partnership state) | N/A (partnership state) | July 31, 2013 One year |
Additional driving distance/time and wait time requirements. | Tobacco rating 1.5 to 1, 3:1 age rating, no geographic rating. | N/A |
| New Mexico | Prohibited [4] | No | Additional driving time, wait time, specialist and primary care provider ratio requirements. | Tobacco rating 1.5:1, geographic rating allowed. | ||
| New York | Silent | Yes – standards above federal minimum. | July 15, 2013 | Network composition and driving time requirements. | No age or tobacco rating. Geographic rating allowed. | Yes |
| Nevada | Silent | No | August 1, 2013 | Proposed statewide requirements include maximum driving time/distances and provider ratios. | ||
| Oregon | Allowed | Yes – standards above federal minimum. | July 15, 2013 Two years |
No additional requirements. | Tobacco rating 1.5 to 1, 3:1 age rating, geographic rating allowed. | Yes |
| Rhode Island | Allowed | Yes – additional certification criteria beyond the federal minimums and plans to negotiate. | Primary care geographic distribution and office hours requirements. | |||
| Vermont | Allowed | Yes – additional certification criteria beyond the federal requirements and plans to negotiate. | July 15, 2013 | Driving time and waiting time requirements. | No tobacco, geographic rating or age rating. | Yes |
| Washington | Silent | No – standards same as federal minimum. | August 21, 2013 One year |
Provider sufficiency and choice requirements. | Tobacco rating 1.5 to 1, 3:1 age rating, geographic rating allowed. | No |
| West Virginia | N/A (partnership state) | N/A (partnership state) | July 31, 2013 One year |
Travel times and provider/enrollee ratio requirements. | Tobacco rating 1.5 to 1, 3:1 age rating, geographic rating allowed. | N/A |
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Notes:
[1] Deadline for state recommendations for certification to HHS and FFE certification duration
[2] The DC exchange recommends that in 2016, prospective certification for QHPs will be instituted and they will require carriers to meet ACA and DC standards in these access plans.
[3] Idaho legislation says that the exchange cannot prohibit a carrier from participating in the exchange as long as the carrier meets applicable law. Potentially, the state could pass a law that goes beyond the federal minimums, but this is unlikely at this point.
[4] Legislation states that the “exchange shall not purchase qualified health plans from insurance health issuers to offer for purchase through the exchange.” However, NM is adding additional certification criteria.
*We define active purchasing broadly here. It can mean any or all of the following strategies: 1) adding standards for plan certification above the federal requirements and then certifying all plans that meet these standards; 2) selective contracting with where the exchange limits the number of plans participating by using selective criteria; and 3) negotiating price with plans individually and deciding to exclude plans.
Produced by Rachel Dolan and Jade Christie-Maples
[2] The DC exchange recommends that in 2016, prospective certification for QHPs will be instituted and they will require carriers to meet ACA and DC standards in these access plans.
[3] Idaho legislation says that the exchange cannot prohibit a carrier from participating in the exchange as long as the carrier meets applicable law. Potentially, the state could pass a law that goes beyond the federal minimums, but this is unlikely at this point.
[4] Legislation states that the “exchange shall not purchase qualified health plans from insurance health issuers to offer for purchase through the exchange.” However, NM is adding additional certification criteria.
*We define active purchasing broadly here. It can mean any or all of the following strategies: 1) adding standards for plan certification above the federal requirements and then certifying all plans that meet these standards; 2) selective contracting with where the exchange limits the number of plans participating by using selective criteria; and 3) negotiating price with plans individually and deciding to exclude plans.
Produced by Rachel Dolan and Jade Christie-Maples
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– See more at: https://www.statereforum.org/state-QHP-certification#sthash.QJkzPVKq.dpuf
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