Health Insurance Marketplaces and CO-OPs
Health Insurance Marketplaces (formerly known as Exchanges) are a centerpiece of the Affordable Care Act (ACA), and became fully operational nationwide in January 2014. Marketplaces provide a menu of insurance options to qualified individuals who are without access to affordable insurance. Separate Marketplaces were also established for small employers with up to 100 employees. In states that opt out of creating their own Marketplace, the Department of Health and Human Services (HHS) takes responsibility for developing one.
While states have some flexibility, Marketplaces must meet the following minimum requirements:
- Consumer usability and enrollment requirements: Marketplaces must enroll individuals and small businesses in a user-friendly way.
- Plan certification requirements: A Marketplace must certify that plans offered meet the standards outlined in the ACA.
- Transparency: Marketplaces must publish specified financial information and pass annual audits by the HHS.
- Financial Stability: Marketplace administration must be self-financing by January 1, 2015, through premiums or other sources. In the interim, federal grants are available to support state implementation.
Along with the Marketplaces, ACA law mandates the creation of a new type of non-profit health insurer, called a Consumer Operated and Oriented Plan (CO-OP). CO-OPs are run by their customers and are meant to offer consumer-friendly, affordable health insurance options to individuals and small businesses. Under law, the CO-OP’s board of directors is elected by customer-members, and a majority of the directors must themselves be customers. CO-OPs must also use profits to lower premiums, improve benefits, or improve the quality of members’ health care.
The AAFP has strongly supported the development of Health Insurance Marketplaces and CO-OPs as a critical means of increasing access to care. We are tracking the implementation of the Marketplaces and the creation of CO-OPs on a state-by-state basis, and providing members with information as it becomes available.
Although the open enrollment deadline has passed, there are still state-specific options for coverage. Special enrollment eligibility(www.healthcare.gov) can be found at www.healthcare.gov.
Coalition Letter to NAIC on Prescription Drug Benefit Management Model Act - November 30, 2017(5 page PDF)
AAFP Letter Responding to the 2019 Marketplace Proposed Rule - November 21, 2017(3 page PDF)
AAFP Letter to CMS on ACA Regulatory Reduction to Empower Patients - July 12, 2017(2 page PDF)
AAFP Letter CMS on 2017 Marketplaces - January 11, 2016(5 page PDF)
AAFP Letter to HHS on Proposed 2017 Benefit and Payment Parameters - December 16, 2015(4 page PDF)
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