Health Insurance Exchange Contracts

Opportunities to participate in Health Insurance Exchanges may in your mail.

Health Insurance Exchanges (or Marketplaces) will begin Open Enrollment in October for effective dates in 2014. There will be two exchanges: Individual and Small group Health Options Program (SHOP) for employers with 50 or fewer employees. In Ohio, the federal government is the ultimate governing authority however, the Ohio Department of Insurance (ODI) maintains a Plan Management role, meaning they will continue to regulate this market. Issuers who wanted to sell products had to file with ODI by May 31. In a June 6 press release, ODI announced 14 issuers have submitted 214 product plans for review. Later, a partial list was released:


*CO-OP = Consumer Oriented and Operated Plan. 24 CO-OPs were established via federal ACA grants as new players in the health insurance markets. InHealth Mutual intends to use the Ohio PPO Connect network which is a partnership of HealthSpan, Quality Care Partners, Ohio Health Choice, & Ohio State University Health Plan. Your participation in any one of these individual networks dictates your participation in Ohio PPO Connect.

Other sources list Humana and Time/Assurant as applicants. In addition, we believe the managed Medicaid payers (Buckeye, CareSource, Molina, Paramount, and United HealthCare) are likely applying to sell products on the Individual Exchange. This would allow those companies to more easily retain individuals who change eligibility from Medicaid to private insurance and vice versa.

All of these products must contain Ohio’s Essential Health Benefits (EHBs) which includes adult and child annual exams, plus a child materials benefit at a minimum, as part of the medical benefit plan. Because of this, issuers are sensitive to the adequacy of the primary eye care network. You may have already received noticed from some of these organizations asking you to consider participating in their “exchange” or “marketplace” products. They do not have to do this to place products on the exchange, but if they want different terms (rates, covered services, etc.), you will likely receive a contract or amendment to your current agreement. As usual, you must prudently review these terms to make the best business decision for your practice, including the base contract in you are sent an amendment. Some issuers are taking a passive approach to amending contacts by saying “failure to timely object constitutes your acceptance” so read these communications carefully.

This is an unproven market, so it is nearly impossible to project the risks/rewards of participation. However, this is the new market for individual and small group health insurance. A Milliman analysis fro Ohio projected the individual market may more than double from 350,000 to 735,000, due mostly to the individual mandate, and an additional 170,000 covered via SHOP. While there will continue to be products available outside the exchanges, premium subsidies for those with annual incomes between 100-400% of the federal poverty level are only available inside the individual exchange and small business must purchase via the SHIP to receive potential tax credits.

For more detailed information on Health Insurance Exchanges or Marketplaces see the resources from the Health Policy Institute of Ohio at

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