Functions of the Health Care Exchanges for 2014

For employers to understand the big picture, our earlier posts described the government subsidies, individual mandates and employer mandates. Today, we discuss the role of the new exchanges, beginning in 2014, for employees who don’t have employer-sponsored coverage or unaffordable employer-sponsored coverage. The basic concept of the exchange is to facilitate the interaction between insurance companies and consumers using a common platform for comparison of qualified health plans.

The roles and responsibilities of the exchanges go far beyond that basic concept though, including consumer assistance, eligibility assistance, enrollment assistance and other responsibilities. Below is a detailed list of the exchanges’ duties.

Qualified Health Plan Administration

  • Certify, recertify, and decertify qualified health plans that can participate in the exchange
  • As part of the certification process, the exchange must review the premium changes of qualified health plans
  • Rate qualified health plans based on their quality and price
  • Establish a Small Business Health Options Program (SHOP) either separate or combined with the individual exchanges

Consumer Assistance

  • Maintain a toll-free telephone help line to respond to requests for assistance
  • Maintain a website for comparison of qualified health plans
  • Provide comparison information on qualified health plans in a standardized format, including the summary of benefit coverage
  • Identify “Navigators” for consumer education

Eligibility Assistance

  • Review eligibility in Medicaid, Children’s Health Insurance Program (CHIP), and applicable state or local public programs
  • Certify individuals as exempt from the individual mandate
  • Certify individuals as exempt from the penalty for failure to maintain minimum essential coverage
  • Create, and make available, an electronic calculator for government subsidies
  • Certify individuals who are eligible for government subsidies
  • Certify an individual’s change of employers
  • Certify the end of coverage by a qualified health plan
  • Provide employers with a list of employees who have been certified as eligible for government subsidies who end qualified health plan coverage

Enrollment Assistance

  • For individuals eligible for Medicaid, CHIP or applicable state or local public programs, enroll the individuals
  • Provide initial, annual and special enrollment periods for the qualified health plans


  • Consult with relevant stakeholders about the responsibilities listed above
  • Maintain financial integrity required by health care reform

Today’s post was contributed by Maureen Maly and Megan Hladilek.

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