Making Sense of Qualified Health Plans and the Washington Health Benefit Exchange


The Washington State Health Care Authority (HCA), Health Benefit Exchange (HBE) has been hosting a number of meetings to discuss what’s to come with the establishment of a state run health insurance exchange.

An important issue the Exchange must decide on is the process and criteria by which it will certify Qualified Health Plans (QHP). The timetable for that QHP decision making process is illustrated below:

The Affordable Care Act (ACA) defines a QHP as “a health plan that is certified by the Exchange, provides the essential benefits package, and complies with other requirements established by HHS and the Exchange.” More specifically, for a plan to be certified it must:

  1. 1.  Meet certain marketing requirements
  2. 2.  Meet certain network adequacy requirements
  3. 3.  Include in their networks essential community providers that serve low-income, underserved communities
  4. 4.  Be accredited by an entity that HHS recognizes for accreditation of health plans

In a draft accreditation proposal from May 28, 2012, HBE states it “will recognize Health Plan Accreditation on these two product lines: Commercial and Medicaid.” Further, the HBE will recognize an issuer as accredited by applying these accreditation statuses held by an issuer:

NCQA: excellent, commendable, accredited, provisional, or interim.
HBE will not recognize these NCQA statuses: denied, appealed by issuer, in process, revoked, scheduled, suspended, or expired.

URAC: Full, conditional, or corrective action.
HBE will not recognize this URAC status: denial.

Initially, the HBE has proposed that unaccredited issuers will still have the option to become certified as an unaccredited issuer.  This would require that this issuer:

Must be scheduled to achieve Exchange accreditation in the plan types (HMO, MCO, OS, PPO) the issuer will use to offer QHPs.

Must achieve accreditation before the beginning of the third certification process after the issuer began offering QHPs. For example, if an unaccredited issuer began offering QHPs in 2014, then it would need to become accredited by the beginning of the 2016 certification process.

This is a lot to digest, and information will continue to be presented with coming meetings scheduled in the weeks ahead. We’ll continue to keep you posted and provide break-downs of the info as it arrives. As always, stay tuned.

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