State Exchanges and Essential Health Benefits

When the Affordable Care Act is fully implemented in 2014, individuals and small businesses will have access to affordable coverage through a new competitive private health insurance market – State-based Health Insurance Exchanges.

Health Insurance Exchanges will provide individuals and small businesses with a “one-stop shop” to find and compare affordable, quality health insurance options.  With these Exchanges, Americans will no longer be on their own in trying to find comprehensive, affordable health coverage.  Exchanges will bring new transparency to the market so that consumers will be able to compare plans based on price and quality.

2017 CMS Final Letter to Issuers in the Federally-Facilitated Marketplaces
The Centers for Medicare and Medicaid Services (CMS) has released its final 2017 “Letter to Issuers” that provides instruction and guidance for qualified health plans in the federally-facilitated marketplaces established by the Affordable Care Act. The information in this letter also provides information on CMS’ review of state-based marketplace requirements. Provisions included in the letter applicable to managed care pharmacy include review of discriminatory benefit design; formulary coverage and use of clinical guidelines for coverage; formulary tiering of medications for certain conditions; cost sharing provisions; and, quality issues.  

2016 Final Letter to Issuers in the Federally-facilitated Marketplaces
1 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Consumer Information & Insurance Oversight 200 Independence Avenue SW Washington, DC 20201 Date: February 20, 2015 From: Center for Consumer Information and Insurance Oversight (CCIIO), Centers for Medicare & Medicaid Services.

AMCP Summary of 2016-17 Proposed Rule on Marketplace Plans (Dec. 2014)
On November 21, 2014, the Centers for Medicare and Medicaid Services (CMS) released a proposal for changes, updates, and additions to 2016-17 requirements for qualified health plans (QHPs) that participate in the federally-facilitated marketplaces.

AMCP Summary of the Proposed Rules for State Insurance Exchanges
This document provides a summary of the Department of Health and Human Services (HHS) proposed rule (CMS-9989-P) to implement state insurance exchanges and qualified health plans. Sections directly related to managed care pharmacy are highlighted in yellow.

AMCP Summary of the Proposed Rules Related to Reinsurance, Risk Corridors, and Risk Adjustments
This document provides a summary of the Department of Health and Human Services (HHS) proposed rule (CMS-9975-P) to implement standards for reinsurance, risk corridors, and risk adjustment. Sections directly related to managed care pharmacy are highlighted in yellow.

CMS Illustrative List of Potential Benchmark Plans for Health Insurance Exchanges
1 Essential Health Benefits: Illustrative List of the Largest Three Small Group Products by State Summary This document provides illustrative information to complement the bulletin on essential health benefits (EHB) under the Affordable Care Act released on December 16, 2011. Specifically, it provides a list of the pro

Final Marketplace Rule
CMS’ Final Rule on 2015 Health Insurance Marketplace Requirements Requires Plans to Provide Expedited Medication Exceptions Process May 19, 2014 On Friday, May 16 the Centers for Medicare and Medicaid Services (CMS) released its final rule for health insurance marketplace plan requirements for 2015. The final rule prim

Kaiser Family Foundation: State Action Towards Creating Health Insurance Exchanges 

Kaiser Family Foundation: State Health Exchange Profiles  

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