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INS-053: Principles for a Health Insurance Exchange

 
Principles for a Health Insurance Exchange: The Wisconsin Medical Society (Society) supports the following principles related to private and public health insurance exchanges.

Private and Public Exchanges
Health Literacy

  • Plans should have minimum number of providers who are available to meet the needs of patients with limited English proficiency, diverse cultural and ethnic backgrounds, physical and mental disabilities, and children and adults with complex medical conditions.
  • Exchange sites should operate at a health literacy level that is appropriate and low enough so that they can be understood by those with lower health literacy levels.

 
Transparency

  • The Wisconsin exchange, a federally facilitated exchange, and/or private exchanges should be user-friendly for consumers, employers, providers and insurers. It should present choices and product information in a clear, efficient and accurate manner.
  • Exchanges should maintain the highest levels of website security and privacy to protect patient health care information.
  • Consumers should have clear information regarding the design of their plan’s provider network, including provider networks and formularies that are tiered, information about cost-sharing responsibilities associated with each tier and appeals processes.
  • Provider directories must be accurate, up-to-date and easily accessible. Insurers should have to share provider networks with the Office of Commissioner of Insurance and make them available to both members and the general public. Updates to online directories should be made in a timely fashion. Regulators should monitor the accuracy of provider directories on an ongoing basis and especially at open enrollment.

 
Affordability of Insurance Products and Premium Assistance

  • Exchanges should offer multiple levels of actuarial value, such as catastrophic, bronze, silver, gold and platinum coverage.
  • Tax credits and cost-sharing subsidies shall be available to help low-income people purchase health insurance whether the exchange is state-based, a state-federal partnership or a federal exchange, on the public exchange.
  • Exchanges should create more accessible ways for members to pay for their insurance including by in-person and with cash.

 
Exchange Contracting

  • Insurers should clearly communicate with physicians and providers if they are in-network or out-of-network for plans offered by the insurer, how many providers are in the network and what services they will be contracted to provide, and what the criteria is for tier designation or for inclusion in a (nonexclusive) narrow network.
  • In order to maintain patients’ continuity of care and to ensure that physicians are compensated for the services they have rendered to patients insured by a health plan, insurers should be required to notify physicians of patients’ grace period status in real time.

 
Public Exchanges Only
Public Exchange Design and Enrollment

  • The Society prefers a state-based health insurance marketplace exchange, but if the state is unable to set up its own exchange in a way that meets the needs of its residents, the Society supports a federal or state/federal partnership exchange.
  • The State of Wisconsin, exchange entity and federal government should properly invest funds for enrollment strategies to increase public exchange enrollment.

 
Governance and Administration of Public Exchanges

  • A public state-based exchange in Wisconsin should be governed by a quasi-public entity or authority that is accountable to but also independent of state government. Such a structure should incorporate the expertise of Wisconsin’s health care community, provide transparency and accountability to citizens, and maintain freedom from undue political influence. Meetings of the governing entity should be open to the public.
  • The governing entity of the public exchange should recognize its potential as a portal to health information, and use it to promote value, wellness and population health for the State of Wisconsin.
  • At least one practicing physician should serve on the board of the exchange governing entity.
  • The public exchange should help administer and coordinate health care subsidies and mandates, and communicate with other government programs to determine eligibility. It should ensure insurance portability and continuity of coverage amid consumers’ changing incomes, Medicaid and other program eligibility, and significant life events.

 
Influence of Public Exchange on Insurance Market

  • The governing entity of the public exchange must proactively work to avoid adverse selection, by (1) using its negotiating power to influence the coverage offered by plans participating in the exchange; (2) managing the number of plans allowed to participate on the exchange; (3) requiring that insurance products sold outside the exchange meet the same minimum standards as those sold on the exchange; and (4) using careful risk adjustment mechanisms.
  • The governing entity of the public exchange should promote robust competition and encourage innovation among insurers and products while assuring a commitment to value and coordinated care. The Commissioner of Insurance should have the power to limit unjustified rate increases for products offered on the public exchange. (HOD, 0416)