Plan Management: Issues for State, Partnership and Federally Facilitated Health Insurance Exchanges

Summary: This report is the first to review how state and federal regulators currently perform plan management activities and assess how those activities are likely to change as a result of the ACA. Such activities include confirming a plan’s “good standing,” assessing network adequacy, reviewing rates and benefits, regulating marketing practices, improving quality, and conducting ongoing compliance monitoring. The report concludes that certifying and managing health plans in the exchange will require far greater collaboration across state agencies and with the federal government.

The authors found that the ACA’s requirements for plan management in some cases expand on what states currently do to regulate insurance, but in other cases call for a paradigm shift in how state regulators approach their role. The report notes that effective plan management becomes even more complicated in states where the federal government is operating the exchange, although the federal agency responsible (the Centers for Medicare and Medicaid Services, or CMS) already has considerable experience managing private health plans through Medicare Advantage.

The report is a product of a NASI project funded by the Robert Wood Johnson Foundation to provide technical assistance to states developing health insurance exchanges. Related products include a toolkit offering legislative language for policymakers implementing Exchanges and issue briefs on Exchange governance, active purchasing, federally facilitated Exchanges and coordination with Medicaid.