Update: Health Insurance Exchanges
Posted on November 22, 2010 | Comments (5)
One of the great challenges in buying health insurance has been a highly fragmented market. Individuals and group purchasers lack a reliable means for seeing their choices in one place and in a manner that allows them to compare what the plans cover, which providers are in various plans’ practice networks, how cost-sharing might differ, and how numerous competing plans might compare on key measures of quality performance. Nor has there been an active, consumer-oriented system for assuring that insurance plans that are offered in the individual and small group markets provide comparable coverage, cover the benefits that are considered essential to any health insurance plan, have accessible provider networks, and are accountable for specific measures of health care quality. State insurance departments play a different role in most states, overseeing health insurers’ solvency and marketing and business practices. But typically insurance departments do not, as part of their work, organize the health insurance market to make it accountable and user-friendly to individual and group consumers.
Health insurance exchanges are designed to help individuals and small employer groups be better positioned to purchase high quality health insurance by creating “organized markets” that simplify the job of selecting and enrolling in coverage and securing performance information about available products. Health insurance exchanges have been a key element of numerous health reform proposals; indeed, the concept of an exchange lies at the core of systems that turn on the competitive selection of health insurance products in the individual and group markets. Massachusetts’ Commonwealth Health Insurance Connector Authority, established as part of the state’s 2006 health reform legislation, is probably the best known example of a health insurance exchange. The Medicare Part D prescription drug benefit also utilizes an exchange concept as the means by which beneficiaries select their prescription drug plans. At the same time, there are several issues that can derail the development and functionality of exchanges, including adverse selection, a low number of participants, over-complexity, transparency and disclosure, and competition, among other things.
A health insurance exchange might carry out numerous functions: helping individual and group purchasers calculate and compare (e.g., individuals versus families; older versus younger individuals; small versus larger employer groups); providing information about the plans and negotiating prices; helping purchasers gain access to available subsidies; and assuring that premium payments to plans are adjusted to reflect the level of health risk among enrollees (a practice known as risk adjustment) in order to assure payment fairness depending on the specifics of their products. For example, health plans may differ on the level of pharmacy benefits covered or may offer provider networks that are broader or narrower. Health plans’ provider networks may also perform differently on key measures of health care quality. Depending on these variations, plans may attract sicker versus healthier populations.
Health insurance exchanges are designed to overcome a basic problem, namely the lack of a robust, organized market for the purchase of health insurance by individuals and small business. In the absence of an organized market, the price of coverage rises because of the additional costs incurred in marketing to and supporting thousands of small customers. In addition, the lack of an exchange means the absence of an organized group of individuals and small business purchasers across whom the cost of coverage can be spread.
Exchanges have the potential to serve large numbers of individual and group health purchasers across an entire region. As a result, they have the potential to make purchasing easier and more efficient than is the case in a highly fragmented market in which thousands of individual and small group consumers are attempting to navigate the health insurance marketplace with incomplete information. Comprehensive and transparent quality and pricing information across a full range of products can be made available in an organized and logical fashion.
In addition to the broad concerns about designing and operating exchanges noted above, numerous technical issues can arise in structuring a health insurance exchange:
- Should exchanges operate under federal authority, state authority, as a quasi-governmental authority, or as some combination of possible options?
- Should exchanges operate as government agencies or quasi-governmental entities (such as a federally- or state-chartered private corporation) or should they be private enterprises that contract to carry out defined functions?
- Who will be eligible to enroll in coverage through an exchange? Individuals only? Small group purchasers? Large group purchasers?
- Will all insurers that wish to do business with an exchange and play by its rules be allowed to sell their products (i.e., an “any willing plan” participation standard) or should an exchange be allowed to select plans based on price and quality (i.e., value)?
- Will exchanges be the only pathway to coverage, or will insurers be allowed to sell directly to individuals and groups outside of the exchange, using different pricing, product, and marketing standards?
- What functions will exchanges carry out? Will they be merely a shopping center where buyers meet sellers, or will exchanges act as active purchasers who negotiate with plans over price, performance, and quality in order to shape the health insurance market for buyers?
- What role, if any, will exchanges play in using their purchasing power to effectively shape the quality of health care itself for both the general population and populations at risk for disparities in health and health care?
Changes Made by the Health Reform Law
The Affordable Care Act establishes “American Health Benefit Exchanges” (serving individuals) and “SHOP” Exchanges (serving small employer groups), to be operated by states that elect to establish exchanges for individuals and employer groups through which they can buy “qualified health plans.” Exchanges are crucial under the law not only because of their ability to organize the market for individual and small group products but also because of their ability to support purchasing and exercise broad plan oversight. In order to receive subsidies, in the form of premium assistance credits, individuals must buy “qualified health plans,” and in order to have its product certified by the HHS Secretary as “qualified,” insurers must offer their plans (at least at the “silver” and “gold” levels) through an Exchange. (Insurers can offer qualified health plans outside of Exchanges but must charge the same premium rate regardless of whether the plan is offered through or outside the Exchange). Exchanges thus are conceived as the principal gateway to affordable insurance for low and moderate income individuals, since they must have the capacity not only to make plans available but also to facilitate enrollment on a subsidized basis.
The Act directs the Secretary of HHS to issue regulations related to the establishment and operation of Exchanges, as part of comprehensive regulations governing the insurance, reinsurance, and risk-adjustment aspects of the law. States also may elect not to establish Exchanges. If the Secretary determines by January 1, 2013 that a state has not taken the necessary steps to establish an Exchange and reform its insurance laws as required under the Act, then the Secretary must establish and operate an Exchange and implement related insurance reforms.
The law’s Exchange reforms underscore congressional intent that Exchanges be actively involved in shaping the marketplace for health care, not just health insurance, because of their obligation to collect and report on health plan quality performance measures. Thus, the goal is for exchanges to be marketplaces where consumers can not only learn about the coverage options that are available and compare price and value, but also can begin to understand how the quality of the care offered by qualified health plans might differ in key ways.
Specifically the law provides that:
- Not less than one year from the date of enactment (thus, by March 23, 2011), the Secretary is required to make awards to states for planning the establishment of an American Health Benefit Exchange. Planning grants will be renewable in states that are “making progress, as determined by the Secretary” in establishing the Exchange and in implementing the health insurance reforms applicable to insurance sold in the individual and group markets.
- States that elect to establish Exchanges must complete their operational planning by January 1, 2014. By January 1, 2015, participating states must “ensure” that their Exchanges are “self-sustaining” and must permit the Exchange to “charge assessments or user fees to participating health insurance issuers, or to otherwise generate funding” to support Exchange operations.
- Participating states must establish American Health Benefit Exchanges, whose purpose is to “facilitate the purchase of qualified health plans” by individuals. States also must establish Small Business Health Options Programs (known as SHOP Exchanges), whose purpose is to assist qualified small employers (under 100 employees or under 50 employees at state discretion through 2016) in “facilitating” the enrollment of their employees in “qualified health plans” offered in a state’s small group market. States may elect to merge their American Health Benefit and SHOP Exchanges into a single exchange, “but only if the exchange has adequate resources to assist such individuals and employers.”
- The Secretary must, “by regulation, establish criteria for the certification of health plans as qualified health plans” that may be sold in state Exchanges. The criteria “shall require” that in order to be certified, plans must:
- meet marketing requirements and not employ “marketing practices” or “benefit designs” that “have the effect of discouraging the enrollment in such plan by individuals with significant health needs”;
- ensure a “sufficient choice of providers (in a manner consistent with applicable network adequacy provisions under §2702(c) of the Public Health Service Act), and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers”;
- include within health insurance plan networks “essential community providers, where available, that serve predominantly low income, medically underserved individuals, such as health providers defined in §340(B) of the Public Health Service Act”;
- be accredited within their local markets by an entity recognized by the Secretary for their performance on a range of measures, including clinical quality, patient experience ratings, consumer access, utilization management, quality assurance, provider credentialing, complaints and appeals, network adequacy and access, and patient information program;
- “implement” a “quality improvement strategy” as defined in the Act;
- utilize a “uniform enrollment form” that is consistent with criteria developed and submitted to the Secretary by the National Association of Insurance Commissioners;
- provide to enrollees and prospective enrollees, and to each Exchange in which the plan is offered, information on quality measures for health plan performance identified as part of the National Strategy to Improve Health Quality; and
- comply with pediatric quality performance reporting requirements under §1139 of the Social Security Act.
- The Secretary must:
- develop an “enrollee satisfaction system” applicable to qualified health plans operating in Exchanges with more than 500 enrollees;
- continually update the federal Internet portal and assist states develop their own portals;
- make available for Exchanges “a model template for an internet portal that may be used to direct qualified individuals and qualified employers to qualified health plans”, to “assist such individuals and employers in determining whether they are eligible to participate in an Exchange or eligible for a premium tax credit or cost-sharing reduction, and to present standardized information (including quality ratings) . . . . and the uniform outline of coverage required under the Public Health Service Act to assist consumers in making easy health insurance choices.”
- The Secretary must require Exchanges to provide for an “initial open enrollment” period (as determined by the Secretary not later than July 1, 2012); annual open enrollment periods “for calendar years after the initial open enrollment period;” special enrollment periods of the type specified under the Internal Revenue Code and the Social Security Act; and special monthly enrollment periods for Indians.
- Exchanges may be either governmental entities or nonprofit agencies, whose principal obligation is to “make available qualified health plans to qualified individuals and qualified employers.”
- States may require qualified health plans operating in Exchanges to “offer benefits in addition to the essential health benefits” required of all exchange operating health plans under the Act. States that do require additional benefits “must assume the cost” and “make payments to an individual enrolled in a qualified health plan offered” in the state or “on behalf of an individual. . . . directly to the qualified health plan in which the individual is enrolled.”
- Exchanges must:
- implement procedures for the “certification, recertification, and decertification, consistent with guidelines developed by the Secretary of health plans as qualified health plans”
- to operate toll-free assistance hotlines;
- maintain an Internet website through which enrollees and prospective enrollees may obtain standardized comparative information on plans;
- “assign a rating to each qualified health plan offered” in accordance with criteria developed by the Secretary;
- use a standardized format for presenting health benefit plan options including the uniform outline of coverage required under the Public Health Service Act’s insurance requirements;
- inform individuals of Medicaid and CHIP eligibility requirements in their state “or any applicable state or local public program” and “if through screening of the application by the Exchange, the Exchange determines that such individuals are eligible for any such program, enroll such individuals in such program”;
- establish and “make available by electronic means” a calculator to determine the actual cost of coverage after the application of any premium tax credit” and “any cost sharing reduction”;
- grant a certification (and inform the Secretary of the Treasury), where applicable, attesting that “for purposes of the individual responsibility penalty” of the Act, “an individual is exempt from the individual requirement or from the penalty imposed” because “there is no affordable qualified health plan available through the Exchange, or the individual’s employer, or because the individual meets the Act’s other exemption requirements;
- identify employees who were determined to be eligible for the premium tax credit either because the employer did not provide minimum essential health coverage as defined under the act or because the coverage provided by the employer was determined to provide the “required minimum actuarial value;”
- identify and report to the Treasury Secretary individuals who have changed employers or who cease to receive coverage under a qualified health plan; and
- establish Navigator programs using experienced and knowledgeable individuals (who may not work for insurers or be paid by insurers for plan enrollments) to assist individuals and small employers participate in the Exchange.
- Exchanges are prohibited from using any funds “intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of Federal or State legislative and regulatory modifications.”
- Exchanges must consult with stakeholders such as “educated health care consumers who are enrollees in qualified health plans, individuals and entities with experience in facilitating enrollment in qualified health plans, representatives of small businesses and self-employed individuals, state Medicaid offices, and advocates for enrolling hard to reach populations.”
- Exchanges may certify a health plan to participate if the plan meets the qualified health plan certification requirements and “the Exchange determines that making available such health plan” through the Exchange “is in the interest of qualified individuals and qualified employers in the State or states in which the Exchange operates. At the same time:
- An Exchange may not exclude a health plan on the basis that such plan “is a fee-for-service plan or through the imposition of premium price controls, or on the basis that the plan provides treatments necessary to prevent patients’ deaths in circumstances the Exchange determines are inappropriate or too costly.”
- Exchanges must require health plans seeking certification as qualified health plans to “submit a justification for any premium increase prior to implementation of the increase. Exchanges must take this information (as well as information related to unjustified premium increases under PHSA §2794) “into consideration” in determining whether “to make such health plan available through the Exchange.”
- Exchanges must require health plans seeking certification to submit to the Exchange, the State insurance department, and the Secretary, and make available to the public, “accurate and timely disclosure” of certain information, in “plain language” including:
- “Claims payment policies and practices”;
- “Periodic financial disclosures”;
- “Data” on enrollment and disenrollment;
- “Data” on the number of claims that are denied;
- “Data” on “rating practices”;
- “Information” on cost-sharing and payments with respect to any “out-of-network coverage”;
- “Information” on enrollee and participant rights under Title I of the PPACA related to health insurance standards and practices.
- Exchanges must “require health plans seeking certification as qualified health plans to permit individuals to learn the amount of cost sharing (including deductibles, copayments, and coinsurance) under the individual’s plan or coverage” that the individual would be responsible for payment “in a timely manner upon the request of the individual.” Information must, at a minimum, be made available through the Internet.
- The Secretary of Labor must “harmonize” rules related to “accurate and timely disclosure” to participants by group health plans governed by ERISA with the disclosure rules developed by the HHS Secretary and applicable to plans that seek qualified health plan certification.
- Exchanges can operate in more than one state if each State in which the Exchange operates permits operation and if the Secretary approves the regional or interstate Exchange.
- States may operate subsidiary Exchanges if each such Exchange serves a geographically distinct area and the area is at least as large as the premium rating areas required under §2701(a) of the Public Health Service Act.
- States may contract with “eligible entities” to carry out 1 or more Exchange responsibilities. Eligible entities include corporations that are not health insurers or controlled by health insurers, state Medicaid agencies.
- The HHS Secretary must develop guidelines for quality payment strategies that “reward quality through market-based incentives.” Health plans operating in Exchanges will be expected to periodically report in accordance with the guidelines developed by the Secretary for quality payment strategies. A strategy is a “payment structure that provides increased reimbursement or other incentives for:”
- “improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including through the use of the medical home model, for treatment or services under the plan or coverage”;
- The “implementation of activities to prevent hospital readmission through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional”;
- The “implementation of activities to improve patient safety and reduce medical errors through the use of best clinical practices, evidence-based medicine, and health information technology under the plan or coverage”;
- The implementation of wellness and health promotion activities; and
- The implementation of “activities to reduce health and health care disparities, including through the use of language services, community outreach, and cultural competency training.”
- Mental health parity applies to Exchange plans.
- Allows qualified individuals to enroll in any qualified health plan available to the individual and for which the individual is eligible and permits employers to provide support for coverage of employees under a qualified health plan by selecting the level of coverage recognized under the Act with respect to qualified health plans.
- Nothing in Title I prohibits health insurers from offering “health plans” outside the exchange to “qualified individuals” or “qualified employers.” That is, employers and individuals remain free to buy health plans that do not meet “qualified health plan” criteria.
- Nothing in Title I prohibits a qualified individual or employer from enrolling in or selecting a “health plan” offered outside of the Exchange.
- Nothing in Title I “shall be construed to terminate, abridge, or limit the operation of any requirement under state law with respect to any policy or plan that is offered outside of an Exchange.”
- The only health plans that the federal government may make available to Members of Congress and congressional staff are “health plans that are created under this Act” or “offered through an Exchange established under this Act.”
- Qualified individuals are limited to state residents (in the case of individuals seeking to enroll in a qualified health plan in the individual market) who are either citizens or nationals or “aliens lawfully present” in the U.S. Incarcerated individuals, other than those who are incarcerated pending the disposition of charges, are barred from enrollment through exchanges.
- Qualified employers are “small” employers that elect to make all “full time” employees eligible for a qualified health plan offered through an exchange.
- Permits states, beginning in 2017, to “allow” issuers of health insurance products in the large employer group market (more than 100 full-time employees) to offer qualified health plans through exchanges. Clarifies that “nothing . . . shall be construed as requiring the issuer to offer such plans through an Exchange.”
Agency: The Department of Health and Human Services has primary responsibility for implementation of the Exchanges. Because exchanges will be available to ERISA-governed group health benefit plans in the small market (and potentially the large group market if a state so chooses), both the Departments of Labor and Treasury also will play significant roles.
Key Dates: States that desire to establish Exchanges (both American Health Benefit Exchanges and SHOP Exchanges) will be eligible for planning grants by March 2011. Therefore, the regulations that the Secretary is required to issue can be expected before that date. Throughout the development period, guidelines and additional policy documents can be expected because of the complexity of building the exchange markets, the milestones that the law requires in measuring state readiness by 2014, and the numerous requirements applicable to exchanges. In setting the milestones, a key date is January 1, 2013, when the Secretary of HHS must decide if state Exchanges will be ready for implementation on January 1, 2014.
Process: The law requires HHS to issue regulations implementing regulations and anticipates additional guidelines and other policy guidance.
Key Issues: The Exchange provisions of the law are detailed and comprehensive. At the same time, the provisions are broadly conceived and leave to the Secretaries of HHS, Labor, and Treasury responsibility for interpretation and implementation. Issues that are of key interest are those that will most significantly affect states’ decisions about participation, in light of the fact that states need not participate and can instead relegate the task of establishing and operating Exchanges to the federal government. This decision may be further influenced by the fact that federal supporting funds cease as of January 1, 2015, at which point Exchanges must have a self-sustaining strategy. Further coloring the picture is that fact that states must make progress simultaneously on three fronts: the adoption of individual and small group market reforms that comport with federal requirements; the establishment of rating and reinsurance reforms; and the implementation of Exchanges. (Insurance reforms apply to products sold both within and outside Exchanges, although individual subsidies are available only to qualified health plan products purchased through Exchanges).
- Financial and technical support: What level of financial and technical support will be available to states that elect to implement Exchanges?
- Benchmarks of progress: What standards will the Secretary set for states as they progress through the planning and insurance reform stages? Of particular importance will be the January 1, 2013 progress benchmarks.
- Exchange structure: What standards will be set for states that desire to merge the American Health Benefit and SHOP Exchanges? How will the Secretary use the regulatory process, and the fact that insurance sales can also take place outside Exchanges, to promote robust Exchanges that attract both individual and group purchasers?
- Qualified health plans: How will the qualified health plan criteria be interpreted and applied? What tools will be developed for promoting quality improvement strategies and performance reporting, and how will the Exchange quality improvement provisions be coordinated with the National Quality Improvement Strategy?
- Screening and enrolling Medicaid and CHIP beneficiaries: What standards will be developed for the coordination of Exchange enrollment with Medicaid and CHIP agencies in order to assure that Medicaid and CHIP-eligible individuals receive coverage through these programs?
- Regional and subsidiary Exchanges: How will the Secretary interpret the regional and subsidiary exchange requirements? What standards will states be required to meet before they can establish regional entities? How will the Secretary balance the need for flexibility with assuring risk pools of sufficient size to make the Exchanges powerful purchasers and to guard against adverse selection?
- Quality payment: How will the Secretary incentivize quality payment and how will this strategy be coordinated with the numerous other quality payment strategies throughout the law aimed at creating efficient quality and value?
- Navigation: How will the Secretary implement the navigation elements of exchanges and interpret standards related to assuring no conflicts of interest on the part of navigators? At the same time, how will the Secretary interpret the law to encourage Exchange navigation and purchasing and minimize the non-Exchange market?
- Coordination of financial information with the Treasury Department: How will the Secretaries of HHS and Treasury assure that the appropriate level of information is transmitted to the Internal Revenue Service?
- Eligible individuals and groups: How will the Secretary assure enforcement of the residency and citizenship and legal status requirements applicable to eligible individuals?
- Harmonization of disclosure rules with ERISA disclosure rules: How will the Secretary of Labor assure harmonization between Exchange and ERISA disclosure requirements?
- Discretion of exchange to exclude a plan: How will the Secretary of HHS coordinate the value purchasing authority of Exchanges with prohibitions against exclusion on the basis of premium controls and coverage standards that permit coverage of conditions and procedures that are deemed inappropriate or too costly?
- Permissible sources of self sustaining funding and prohibitions on expenditures: How will the Secretary interpret the self-sustaining provisions of the law in relation to permissible sources of funding and limitations on expenditures of funds?
- Regulations implementing the insurance regulatory provisions were made public in June, 2010.
- On August 3 2010, (75 Fed. Reg. 45584), OCIIO issued a Request for Comments (RFC) that sought comments from interested persons regarding various aspects of the legislation. The RFC discussed the basic elements of exchanges and solicited comments related to state exchange planning grants, implementation timeframes, state exchange operations, qualified health plans, quality, exchanges in non-electing states, enrollment and eligibility, outreach, employer participation, rating areas, consumer experience, risk adjustment and reinsurance, and risk corridors, and paperwork reduction-related matters. OCIIO indicated that the comments received (the comment period closed October 4, 2010) would be used in fashioning exchange regulations.
- On November 18, 2010, HHS issued guidance on exchanges that did not contain responses to the specific comments filed in response to the August 3 RFC. Instead the letter sought to clarify a range of matters, particularly the scope of state-operated exchange obligations under the law, in particular the obligation to accept applications and provide enrollment support to all individuals. At the same time the letter also reiterated states’ option to administer separate SHOP exchanges. The guidance set forth a series of “principles and priorities” that according to HHS will “inform federal funding and technical support” for the establishment of state exchanges:
- Assuring that state exchanges have “the authority necessary to meet all the exchange requirements of the Affordable Care Act” as well as clarification that HHS will “work with” states that elect not to establish an exchange
- The need for flexibility and efficiency to maximize the value of state exchanges
- Streamlined access and continuity of care, so that exchanges can serve as enrollment points for all health programs while “promoting seamless access for applicants eligible for other health programs beyond the Exchange coverage options”
- The obligation to consult with a “broad range of stakeholders”
- Transparent standardized reporting on a range of matters including “ price, quality, benefits, consumer choice and other factors that will help measure and evaluate performance”
- Efficient and non-discriminatory administration that prevents fraud and abuse.
Following a summary of the legal provisions applicable to the structure and operation of state exchanges, the November 18th guidance set forth an additional series of matters for states to “consider” in establishing and operating exchanges:
- The fact that states have a choice in the organizational form of state exchanges, which can be either public entities or nonprofit corporations
- The fact that exchanges can operate as either active purchasers or as open marketplaces
- The expectation that SHOP exchanges will be able to offer streamlined services to employers “including options for how employers can provide contributions toward employee coverage that meet standards for small business tax credits”
- The fact that 2011 regulations will address risk adjustment standards applicable to all health plans including demographic, diagnostic, and prescription drug data reporting requirements, as well as standards for reinsurance applicable to all plans in the individual market and risk corridors for qualified health plans in the individual and small group markets
- The fact that standardized performance reporting measures will be required
- The range of choices that states have under the law with respect to “whether to form regional exchanges or establish interstate coordination for certain functions, whether to use 50 employees as the cutoff for small group market plans until 2016 . . . , whether to require additional benefits in the Exchange beyond the essential health benefits, whether to establish a competitive bidding process for plans, whether to extend some or all Exchange-specific regulations to the outside insurance market (beyond what is required in the Affordable Care Act).”
The HHS letter also notes that the next round of exchange grants will be awarded in 2011 and that exchanges must be self-funded by January 1, 2015.
Authorized Funding Levels
Funding for Exchanges is not subject to an upper limit but is authorized only through December 31, 2014, after which state Exchanges are expected to be self-sustaining.
 Timothy Stoltzfus Jost, Health Insurance Exchanges in Health Care Reform: Legal and Policy Issues (Commonwealth Fund, 2009) http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Dec/Health-Insurance-Exchanges-in-Health-Care-Reform-Legal-and-Policy-Issues.aspx (Accessed July 1, 2010).
 John Kingsdale, Health Insurance Exchanges – Key Link in a Better-Value Chain, New Eng. Jour. Med. 362:2147-2150 (June 10, 2010).
 Jon Kingsdale and John Bertko, Insurance Exchanges Under Health Reform: Six Design Issues for the States, Health Affairs 29:6 (June, 2010) pp. 1158-1163.
 Timothy Stoltzfus Jost, Health Insurance Exchanges and the Affordable Care Act: Key Policy Issues (Commonwealth Fund, 2010) http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jul/1426_Jost_hlt_insurance_exchanges_ACA.pdf (Accessed July 15, 2010).
 Richard C. Frank and Richard Zeckhauser, Health Insurance Exchanges – Making the Markets Work, New Eng. Jour. Med. 361:1135-1137 (2009).
 §1401, adding §36B to the Internal Revenue Code.
 Section 2702(C) of the Act establishes network adequacy standards to assure that plans that operate using provider networks limit their enrollment to individuals who live, work, or reside within their service areas. Plans may close enrollment to additional members if they can demonstrate that they are applying their capacity measures uniformly and in fact do not have the capacity to serve additional enrollees.
 Section 340(B) of the PHSA provides access to discounted drugs for certain health care providers that serve low income populations, such as federally qualified health centers, urban Indian health clinics, tribal clinics, family planning clinics receiving funding under Title X of the Public Health Service Act, and other providers.
 §3011, adding §399HH to the Public Health Service Act.
 §1311 (c)(5)(A).
 §2716 of the PHSA.
 For example, changes in family or work status.
 §1311(d)(2)(A). Exchanges must permit issuers and plans that offer only limited scope dental benefits that meet Internal Revenue Code requirements to be offered in the exchange if the plan “provides pediatric dental benefits meeting the requirements of PPACA §1302(b)(1)(J), relating to pediatric services standards applicable to essential benefits. All qualified health plans offered in exchanges must cover essential benefits.
 Described in detail in §1311(i).
 Described in detail in §1311(i).
 The term “plain language” means “language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices of plain language writing. The Secretaries of HHS and Labor are required to “jointly develop and issue guidance on best practices of plain language writing.” §1311 (e)(3)(B).
 Title I of the Act enumerates the new federal standards applicable to health insurance in the individual and group market and group health benefit plans.
 §1311(f)(2). Under PHSA §2701, states must establish premium rating areas that must be reviewed by the Secretary.
 Section 1302(d) recognizes levels of coverage for qualified health plans that offer essential health benefits, with the levels corresponding to their actuarial value (bronze, silver, gold and platinum).
 §1312 (d)(1)(A).
 §1312(f)(1) and (3).