Request a Free ConsultationX
Name :

Daytime Phone :
Email Address :

Briefly describe the project :

On Time

You WILL receive your information within the timetable in our proposals.

On Budget

Our proposal fee is what you will pay…no surprises when you receive your final invoice.

An Exchange Guide for Health Care Insurance Companies

Types of Exchanges (HIX)

States may proactively choose a Federally-facilitated exchange, or choose to operate its exchange as a State Partnership, which allows the Department of Health and Human Services to administer and operate select Exchange activities. Each states' readiness to be operational will be assessed on January 1, 2012. If a state is deemed not ready, the office of the Secretary of the Department of Health and Human Services will step in to establish a Federally-facilitated Exchange. States with an "Exchange blueprint" that shows significant progress toward readiness, on that date, may be granted conditional approval.

Contracting Relationships

Various contracting relationships are allowed by Patient Protection and Affordable Care Act. In the "clearinghouse mode," states will include within their Exchanges all qualified health plans which meet federally-specified criteria, which include a prescribed essential benefits package. Alternatively, states can require the exchange to contract with only selected high-performance qualified health plans, possibly to meet agreed-upon criteria for consumer choice, value, or outcomes. Each state will be authorized exercise judgment of whether a health plan's participation is "in the interests of" consumers and employers. States may impose more rigorous plan certification requirements beyond Federal definitions, or may negotiate for different products or pricing. Federal grant funding is available for the establishment and operation of Exchanges until January 1, 2015; Exchanges are required to be self-sustaining after that date.

Small Business Health Options Programs

States will also be required to operate a Small Business Health Options Program - or SHOP - a mechanism by which small businesses with up to 100 employees will be able to provide their employees with a choice of qualified health plans that fit their needs and budgets. States can choose to include SHOPs within their main health exchange, or may carve them out separately.

Risk Corridors

A temporary "Risk Corridors" program will be operated by the Federal government from 2014 to 2016. Its purpose is to shield qualified health plans from uncertainty in rates as the Exchange ramps up, when insurers lack experience in predicting how to realistically set premiums. The programs will limit insurer losses and profits by providing payments to plan based on actual expenses in relation to a target amount. Issuers of qualified health plans offered through the exchange will be reimbursed a portion of medical costs that exceed 103% of the target. The program will also require reimbursement from issuers of qualified health plans when medical costs are less than 97% of the target.


A transitional reinsurance program, designed to stabilize premiums, will be in place for the first 3 years of State Exchange operation, from 2014 through 2016. All health insurance issuers, self-insured group health plans and third-party administrators will be required to contribute to a reinsurance fund of $25 billion. This fund will provide support to qualified health plans that cover individuals with high medical costs in the individual health insurance market.

Navigator Programs

Patient Protection and Affordable Care Act mandates that health insurance Exchanges award grants to public or private entities who will serve as "navigators." Navigator's roles will be to furnish the information that will help consumers choose among the health insurance options that best fit their circumstances and guide them through the enrollment process. Navigators must belong to a minimum of two of the following categories:

  • Community and consumer-focused nonprofits
  • Trade, industry, and professional associations
  • Commercial fishing industry, ranching and farming organizations
  • Chambers of Commerce
  • Unions
  • Resource partners of the Small Business Administration
  • Licensed agents and brokers
  • Other public or private entities that meet the requirements of this section, including by not limited to Indian tribes, tribal organizations, urban Indian organizations, and State or local human service agencies.

Our company specializes in providing strategic, demographic and market information designed to enhance our health care clients’ bottom lines. One informational service we provide is the number of households (or families) in your service area according to federal poverty levels. With this information, your company will know the market potential or exchanges and can therefore extrapolate financial and market projections.

Through our proprietary system, developed by our experts, we have this information available at the geographic level you need.