AAFP Releases Principles for Health Insurance Exchanges

States Should Develop Exchanges Aligned With Family Medicine Principles

April 27, 2011 05:00 pm News Staff

As states move forward with creating the individual state health insurance exchanges called for in the Patient Protection and Affordable Care Act, the AAFP has created a set of eight principles designed to help its constituent chapters address insurance exchange issues with state legislators and regulators.

The state health insurance exchanges essentially are marketplaces that will be set up so individuals and small businesses can compare and purchase private health insurance plans. HHS will establish initial guidance on the formation of the exchanges, but states have flexibility in how the exchanges operate, what benefits will be included, and how patients and physicians will interact with insurers and their products.

The flexibility in how the exchanges are structured provides an opportunity for family physicians to push for delivery system reforms that will enhance patient care, such as the patient-centered medical home, or PCMH, said Greg Martin, AAFP manager of state government relations, in a letter to AAFP chapters. "Whether or not state policymakers seek advice from (AAFP) chapters on various elements of exchanges, chapters could consider the value of engaging legislators and state regulators to make sure state rules not only protect primary care but also allow for a positive role for primary care."

Martin noted that the AAFP's Family Medicine Principles for State Health Insurance Exchanges document provides a starting point for chapters to discuss with policymakers how state health insurance exchanges can encourage and support primary care.

The document comprises eight principles:

  • Fair representation of stakeholders -- According to the AAFP, the governing body of an exchange should include at least one seat for consumers and one seat for primary care physicians, and these seats should be in equal proportion to the total number of seats allotted to insurers, specialty medicine, health systems and other stakeholders.
  • Enhanced access and payment for the PCMH -- Benefits in the exchanges should include enhanced access via e-visits, open scheduling and expanded hours. In addition, physicians should receive enhanced payments for care coordination and the PCMH.
  • Standardized contracting -- All plans should use the same standard physician contract, just as enrollee applications are standardized. States that create multistate exchanges or that enter into interstate compacts for purchasing insurance should harmonize contracting rules across all participating states, and "all products" clauses should be prohibited.
  • Primary care targets -- Exchanges should set targets for primary care spending by participating plans.
  • Require robust primary care-based essential benefits -- States should require health plans to offer primary care services beyond those required by the federal essential benefits regulation.
  • Presume eligibility -- Upon submitting an application, enrollees should receive provisional enrollment so they can receive essential preventive and primary care services.
  • Reward quality -- Quality measures should be aligned across plans in the exchanges and with the state's Medicaid, Children's Health Insurance Plan, and state and local employee health benefits plans. Such measures also should coordinate with Medicare, when possible.
  • Protect consumers and physicians -- If they are not incorporated into the administrative framework of the exchange, consumer assistance and information offices should work closely with a state's exchange. Patients and physician practices should be allowed to access the services of such programs for concerns about insurance products purchased both inside and outside the exchange.