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For some Americans, selecting a health insurance plan will soon feel a bit like shopping. As part of healthcare reform, each state is required to have a Health Insurance Exchange (HIE or HIX) in operation by Jan. 1, 2014.

Given the complexity of the topic, we’ve created the attached infographic that visually represents the process Americans will experience when participating. If you’re planning to write about HIXs in the near future – we hope you’ll consider using this graphic to help explain the process to your readers.

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  • Q:  How will states develop a HIX? A: States can either build their own HIX structure or buy a platform from the federal government.
  • Q:  Who can participate in a HIX? A: Only individuals without other coverage, individuals from whom coverage is unaffordable or inadequate, or small employers can participate in the exchange in 2014. Large employers can join the exchange in 2017.
  • Q:  How many people are expected to participate? A: The Exchanges are expected to cover as many as 29 million people by 2019, including five million with employment-based coverage.

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21 Responses

  1. HIEs [Bye-Bye]?

    It’s clear that Health Information Exchanges across the country are in trouble.

    For example, CareSpark closed its doors; the CEO of Cal eConnect just resigned, and the Minnesota Health Information Exchange ceased operations.

    Dr. David Edward Marcinko MBA
    http://www.BusinessofMedicalPractice.com

    Like

  2. Proposed Rule on State Exchanges Released

    Dr. Marcinko – On July 11, 2011, CMS issued the proposed rule for state Affordable Insurance Exchanges design and implementation, as mandated by the Patient Protection and Affordable Care Act. The proposed rule lays the groundwork for compromise between insurer lobbies, states, consumer groups, and their varying interests.

    http://www.healthcapital.com/hcc/newsletter/08_11/exchanges.pdf

    Mike

    Like

  3. Dentistry at a fair price

    For years, I have been the sole voice on the internet demanding transparency from dental benefits companies like Delta Dental, BCBSTX and Brighter.com. As a matter of fact, anyone can quickly tell that I am the only dentist in the nation holding discount dentistry brokers accountable for the advertised level of quality they sell to clueless clients. I’m pleased to say that finally, it looks like a slow-moving giant is on the way to help in the honorable fight for honesty. But it will take a while. In the meantime, how about you?

    According to “Health exchanges – Coalition seeks dental input at state level,” yesterday’s ADA News article by Craig Palmer, transparency in benefits will occur once the nation’s Health Information Exchanges go online in 2014… depending of course on whether the consumer-friendly Organized Dentistry Coalition gets a seat at the table and if Obamacare survives emersion in common sense without waterwings.

    http://www.ada.org/news/6283.aspx

    Palmer writes: “The health insurance exchanges scheduled to open for business in 2014 should maximize competition among dental plans and assure transparency in benefits information, a coalition of national dental organizations will tell the Obama administration, which is writing rules for employers, insurers and the states.”

    Even if eventually dental patients’ interests are appropriately represented at the table by the consumer-friendly ODC, it’s still going to take a lot of grass-roots pressure to put a stop to dentalcare stakeholders’ deceptions that permeate the dental benefits industry.

    For example, because of politicians’ unquestioning respect of Wall Street sweetheart Brighter.com CEO Jake Winebaum, he has become one of many harmful, powerful influences in Washington. Otherwise, how can the FTC not notice the stink of a healthcare scam: Winebaum promises his clients intricate handwork by “top-rated dentists” at a 60% discount when the industry averages 65% in overhead expenses before top-rated dentists get paid a cent. Even Medicaid, a de-facto charitable dentistry broker, pays dentists better – giving the poor in the US a much better chance at popular dentists in the community than Brighter.com.

    Anyone with grade-school math skills should recognize the odor that results from discount dentistry with no quality control. Yeah. I’d say the dental benefits industry could stand some transparency. Don’t you?

    I like the suggestions the Coalition offered for exchanges, including:

    – State or federal officials who develop the exchange or exchanges in each state must seek input from state dental societies in the early development of the exchanges to help assure consumer-friendly web sites for dental patients.

    – Access to dental health care for special needs individuals with disabilities should be specifically addressed in the exchange design and implementation.

    – And my favorite: Individuals serving as consumer navigators in the exchanges should have a full understanding of the dental coverage options because the dental delivery system is very different from the medical system. [Public acknowledgement of dental patients’ interests would be truly unprecedented in the federal government].

    Doc, please contact your state lawmakers and support transparency in dental benefits. All it takes is one look at a Brighter.com ad, and you’ll agree that this time it’s important. http://www.brighter.com/

    If we continue to silently allow stakeholders to misrepresent our dental patients’ needs then we are to blame for allowing predictable harm. Consumers deserve to know that dentistry done quickly may be cheap, but it is generally of lower quality care than dentistry at a fair price for everyone.

    D. Kellus Pruitt DDS

    Like

  4. Orion and Microsoft Announce Joint eHealth Initiative

    Orion Health has signed a Memorandum of Understanding with Microsoft Corporation to co-market their health information exchange (HIE) and data aggregation and analysis products to the public and private HIE and integrated delivery network (IDN) markets.

    http://www.healthcare-informatics.com/ME2/dirmod.asp?type=news&mod=News&mid=9A02E3B96F2A415ABC72CB5F516B4C10&tier=3&nid=EE988FBC272F4445B742021EC2ED6607

    Charles

    Like

  5. CMS releases Medicaid expansion final rule

    Charles – In 2014, the systems for Medicaid, CHIP and health insurance exchanges will coordinate to deliver coverage, improve quality and lower costs.

    http://www.govhealthit.com/news/cms-releases-medicaid-expansion-final-rule?topic=30,31

    Any thoughts?

    Norman

    Like

  6. HHS Releases Final Rule on State Insurance Exchanges

    On March 12th, 2012, HHS released its final rule concerning state Health Insurance Exchanges, a critical component of the Patient Protection and Affordable Care Act.

    http://www.healthcapital.com/hcc/newsletter/4_12/exchange.pdf

    Although, the rule provides states with flexibility in the design of their exchange, some critics believe the final rule have expressed concern with the amount of uncertainty that still surrounds the operations of exchanges.

    Source: Robert James Cimasi MHA AVA CMP™
    [Health Capital Consultants, LLC]
    via Ann Miller RN MHA

    Like

  7. As Predicted by some Naysayers … HIEs failing at true interoperability

    Until EHR vendors incorporate shared standards, HIEs will remain in stunted development, where most only exchange very simple data sets, according to a new report from Chilimark Research.

    http://www.govhealthit.com/news/report-hies-failing-true-interoperability?topic=08,12,

    Dr. David Edward Marcinko MBA
    [Editor-in-Chief]

    Like

  8. On HIEs

    Federal Employees Health Program Experiences Lack Of Competition In Some Areas, Raising Cost Concerns For Exchange Plans

    http://content.healthaffairs.org/content/31/6/1321.abstract?etoc

    Dr. Cunningham

    Like

  9. Brawling over health care moves to rules on exchanges

    A New York Times article:

    http://www.msnbc.msn.com/id/48108219/ns/us_news-the_new_york_times/

    Provision involves subsidies for millions of low and middle-income people.

    Hope Rachel Hetico RN MHA

    Like

  10. HIEs – A Major Disconnect

    I recently came upon some unsettling information about the current state of HIEs (Health Information Exchanges).

    In this essay, Evan Steele writes about the problems that HIEs face and the challenges most commonly being attributed to funding, business sustainability and insufficient EHR penetration.

    http://blog.srssoft.com/2012/07/hies-a-major-disconnect/?jmid=51220&j=275904646&utm_source=JangoMail&utm_medium=Email&utm_campaign=HIEs%3A+A+Major+Disconnect+%28275904646%29&utm_content=marcinkoadvisors%40msn%2Ecom

    But, what I discovered in conversations with a major HIE reveals an even bigger shortcoming.

    Ann Miller RN MHA
    [Executive-Director]

    Like

  11. Obamacare Is Still Vulnerable

    President Obama won re-election, and his administration has asked state officials to decide by Friday November 16th, whether their state will create one of Obamacare’s health-insurance “exchanges.”

    http://thehealthcareblog.com/blog/2012/11/10/obamacare-is-still-vulnerable/

    States also have to decide whether to implement the law’s massive expansion of Medicaid. The correct answer to both questions remains a resounding no.

    Victor

    Like

  12. Health Insurance Exchanges; by state

    1.California – 4
    2. Illinois – 4
    3. New York – 4
    4. Missouri – 3
    5. Pennsylvania – 3
    6. Massachusetts – 2
    7. Michigan – 2
    8. Minnesota – 2
    9. Arizona – 1
    10. New Jersey – 1
    11. Washington – 1

    Source: HealthQuest Publisher’s Health Insurance Exchange Directory 2013 Version 2

    Like

  13. 6 things to know about deductibles in the Health Insurance Marketplace

    1. Having health insurance can lower your costs even when you have to pay out of pocket to meet your deductible.

    2. A health insurance deductible is different from other types of deductibles

    3. All Marketplace plans cover preventive care

    4. In 2014, there’s a $6,350 maximum for individual out-of-pocket costs for in-network services

    5. Over 70% of Marketplace plans have deductibles under $3,000

    6. Silver plans can save you more

    Source: Healthcare.gov

    Like

  14. Where Four State Health Exchanges Went Wrong

    Oregon, Minnesota, Maryland and Massachusetts are still struggling to get back on track after a disastrous launch that makes HealthCare.gov look successful by comparison.

    http://www.propublica.org/article/epic-fail-where-four-state-health-exchanges-went-wrong?utm_source=et&utm_medium=email&utm_campaign=dailynewsletter

    So, is this an Epic Fail?

    Lyle

    Like

  15. HIEs

    Retail health insurance marketplaces, known as exchanges, are dramatically changing both the employer benefits environment and the health insurance business.

    For example, PwC’s Health Research Institute found that employers faced with rising costs and regulatory demands are moving away from the benefit business, pushing individual consumers to take on new responsibility for their own health insurance. This will fuel significant growth of health exchanges over the next decade in the new health economy.

    Exchanges may be most attractive to employers looking to shift healthcare decision-making to their employees. Employers with fewer than 50 full-time employees will have the option of sending workers to the public exchanges without penalty, while for some companies, private exchanges may offer more affordable insurance than they could obtain on their own.

    In fact, according to PwC’s 2014 Touchstone survey of 1,200 employers, 32 percent of employers are considering moving their active employees to a private exchange in the next three years. In addition to alleviating administrative burden, the move to a private exchange presents additional benefits that would otherwise require too much time and money for many employers to implement on their own, such as integrated wellness programs, online benefit sites and consumer decision support.

    Dr. David Edward Marcinko MBA
    [Certified Physician in Healthcare Quality]

    Like

  16. 41% of Employers Consider Private HIX for Benefits Delivery by 2018

    According to the second annual study by the Private Exchange Evaluation Collaborative (PEEC):

    • 6.4% of employers already implemented private exchanges for 2015.
    • 67% say they are not considering public exchanges for part-time employees.
    • 85% said “tools that aid in plan selection” were “very important,” on the shopping experience.

    Source: Private Exchange Evaluation Collaborative
    (PEEC)
    http://www.amazon.com/Hospitals-Healthcare-Organizations-Management-Operational/dp/1439879907/ref=sr_1_4?s=books&ie=UTF8&qid=1334193619&sr=1-4

    Like

  17. Health Insurance Marketplaces … there they GO!

    When state health insurance marketplaces were created under the Affordable Care Act (ACA), the Obama administration was worried there wouldn’t be enough competition to keep premiums low. So it loaned $2.4 billion to establish 23 nonprofit health insurers known as consumer operated and oriented plans, or co-ops.

    Although the co-ops struggled in their first two years, most were still expected to offer plans for 2016 when the marketplaces open for enrollment on November, First, 2015.

    http://www.msn.com/en-us/money/personalfinance/obamacare-marketplaces-shutting-down-amid-cash-crunch/ar-BBmz1WH?li=AA4Zjn&ocid=U348DHP

    But now, Maybe NOT!

    Freddie

    Like

  18. There are several important lessons to be learned from the recent CO-OP failures, but the most important remains the one that keeps fading from memory:

    It Ain’t Called Risk for Nothin’*

    Unlike the early HMOs that formed with the protections and financial support provided under the HMO Act of 1973, CO-Ops entered a pretty mature market in which existing competitors were anything but contented and complacent, and in which there were no relatively easy ways to reduce costs substantially, to say nothing more about Congress suddenly de-funding programs meant to provide support to CO-Ops.

    Non-CO-OP provider-owned and venture capital-backed new plans face a similar but not identical set of challenges. Too many to list, much less discuss in this response, so I’ll limit them to three and a half: three affect both types of start-ups, and a cultural challenge facing provider-owned start-ups.

    1. Undercapitalization. Health insurance is heavily leveraged, meaning the effects of profits and losses are magnified beyond those of a simple investment. A plan must have far more than the minimally required assets to operate safely, and it doesn’t take a lot of financial losses for a small plan to deplete their reserves to the level where the state declares them impaired; think Bill Paxton in the movie Alien, shouting “Game over man! Game over!” On the other side, the ACA places strict limits on how much profit an insurer can make or keep through the MLR limits, and prohibits an insurer from trying to subsidize losses in future premiums beyond such things as the cost of capital and the like.

    2. Rapid Growth. All business must grow to thrive or even survive. But growth can be too rapid; think dandelions or cancer. Rapid growth in a small company quickly overwhelms everything: IT systems, accounting and IBNR calculations (a geeky thing to say, but critical nevertheless), member and provider services, provider payment. Everything.

    3. Adverse Selection. This is a bigger challenge for provider-owned start-up health insurers, but both types share it. New insurers under the ACA generally must access the market through the public health exchanges, which have proven to be the adverse risk magnets they were predicted to be. Congress made this particular magnet a super-magnet by defunding money that was to be used to reduce its impact in the first years of exchange operations. See Challenge #1.

    3.5. Think Members, not Patients. Provider-owned start-up plans think of people as patients, not members, because they are in the business of caring for patients. But it undercuts the obvious need that any plan needs more members than patients in order to fund its medical costs. Focusing, even subconsciously on patients and “frequent fliers” is a way to ensure that Challenge #3 becomes half again as large as it is to begin with, and it’s back to Challenge #1.

    * Any new entrants into the business of accepting and managing the risk for health care costs should be required by federal law to have this statement tattooed across their foreheads in reverse letters so they have to read it every time they look in a mirror. OK, that would be fun to see but probably not practical.

    Peter R. Kongstvedt MD
    [via Ann Miller RN MHA]

    Like

  19. Some lessons from the travails of Health CO-OPs

    1. It is easier to be successful in strategically contiguous markets than it is to be successful as a start-up. A few examples of strategically contiguous markets include services to the exchange market if a health plan already offers to the individual market, offering to individual markets if one already offers to Medicaid, forming an insurance subsidiary if your organization is already successful as a hospital system and introducing one’s current suite of products in a new geographic area.

    2. While exchanges should lower barriers to entry, they are only partly successful in doing so. In any case, lowered barriers to entry are insufficient for success.

    3. While product differentiation can be helpful, incumbent competitors are also aware of this and respond in kind. If an incumbent already has a reputation of being acceptable in the market, the new entrant faces the cost to overcome it.

    4. If the differentiation you establish is not sufficiently substantial, then the competitive battle will be fought on the basis of price. Because profit margins are so thin in health insurance, price leadership likely requires cost leadership over the long term.

    5. Be shrewd with administrative costs. While they are small relative to health care costs, they are more manageable. Unlike health care costs, they are susceptible to process improvements and are subject to make-or-buy decisions by the health plan management.

    Douglas B. Sherlock CFA
    [Senior Health Care Analyst]
    Sherlock Company

    Like

  20. Four Reasons Why Private Exchanges Will Grow

    1. Savings – Employer clients saw an average increase of 1.5 percent, compared with the 4.6 percent increase reported by companies responding to the survey
    2. Defined Contribution – Some employers are moving away from the defined-benefit approach to health coverage for their workers
    3. CadillacTax – The controversial 40 percent tax on high-cost plans, which could affect a third of large employers, goes into effect in 2018
    4. Choice – Employers benefit if their workers become savvy shoppers and engaged consumers of health care services, and giving them more choices for coverage is a good starting point

    Source: Hospitals and Health Networks

    Like

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