The proposed rules provide details on the purpose, scope and operation of the exchanges. The rules cover these key areas:
- Basic functions of a HIX. The exchanges are state-based competitive marketplaces where individuals and small businesses will be able to apply for, comparison shop and purchase private or public health insurance. HIX will be responsible for business functions such as eligibility and enrollment systems, as well as financial and health plan management. Each exchange will be required to have a navigator or outreach and education program for individuals and small businesses.
- Standards for establishing a HIX. Each exchange will need HHS approval. States will submit their proposals for meeting HIX requirements, including a readiness assessment that demonstrates that the proposed exchange meets operational standards for exchanges such as setting up a call center and a website. HHS plans to develop a template for the exchange proposal.
- Offering insurance through a Small Business Health Options Program or SHOP. The proposed rule permits businesses with as many as 100 employees to be eligible to offer coverage through a SHOP, which will be operated by an exchange. Similar to individual coverage, the SHOP program will have a website where employees can shop for the best prices and benefits. Employers can select a level of coverage they will offer (bronze, silver, gold or platinum plans) and define their contribution toward their employees’ coverage.
- Certifying health plans for HIX participation. The proposed rules suggest the minimum standards to qualify a health plan, including the size of its network and service area. However a state may decide to set additional standards such as affordability and quality to meet the special needs of its population.
- Premium stability. To help protect HIX insurers and enrollees from market uncertainties as healthcare reform is implemented, HHS proposes to offset the claims for high-risk enrollees.