Health Insurance Exchanges Update

One of the more popular sessions at the Academy of Managed Care Pharmacy 24th Annual Meeting on April 26 featured Paul Frostin, PhD, Director, Health Research and Education Program, Employee Benefit Research Institute. Frostin’s presentation, “Essential Benefits and Exchanges Update for Managed Care Pharmacy,” identified highlights of the of the Exchanges final ruling and talked about how these changes would impact managed care pharmacy.

In particular, Frostin mentioned that the final rule would allow states to go beyond minimum standards. States would also be able to charge fees to carriers to cover cost of operating exchanges. As far as transparency, exchange carriers would need to provide enrollees with an enrollment package and include information on hot to access the provider directory and drug formulary.

Notable Dates

Assuming that the Supreme Court proclaims these exchanges constitutional, states that have failed to establish an exchange in the shortened timeline will have few legislative options remaining. If a state fails to establish an exchange, a federally facilitated exchange will be implemented. Following the initial setup, here are the timelines going forward:

Jan 2013 – Department of Health and Human Services (HHS) will certify exchanges as fully or conditionally operational
Oct 2013 – Open enrollment begins
Jan 2014 – Exchanges should be fully operational
Jan 2015 – Exchanges must be financially self-sustaining

But before a final rule can be made, there may need to be some clarification from HHS, such as comments on interim rules related to definitions of pharmacy benefit management, generic drugs, rebates, discounts, etc. Frostin also mentioned that, when definitional issues come into question, definitions will be aligned with the Medicare program to the extent possible. Essential health benefits per the Affordable Care Act include the following:

Ambulatory patient services
Emergency services
Hospitalization
Maternity/newborn care
Mental health and substance abuse service
Prescription drugs
Rehabilitative and habilitative services
Laboratory services
Preventive and wellness services
Pediatric services

For more information about this presentation, please visit www.amcp.org.

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