MEDICAL ECONOMICS
Ready, set …? Feds prepare for insurance exchange in Texas
BY AMY LYNN SORREL The federal government says it will be ready to launch a health insurance exchange in Texas come Oct 1. That’s the date individuals can begin buying and enroll- ing in plans offered through an Orbitz-style, online market- place exclusively for health coverage. But a number of unknowns still linger, particularly for phy- sicians who may hear from health plans eager to build net- works for insurance products they wish to sell in the exchange. Because Gov. Rick Perry chose not
to authorize a state-based marketplace, Texas defaulted to a federally run pro- gram. Although state insurance regu- lators will play a part, the Centers for Medicare & Medicaid Services (CMS) already took the reins in getting it off the ground. However, a number of moving parts remain in play, from ap- proving qualified health plans for sale in the exchange, to setting up eligibil- ity and enrollment systems and coor- dinating connections with the state Medicaid program. A June report by the Government Accountability Office (GAO) says that “much progress has been made, but much remains to be accomplished within a relatively short
patients will remain uninsured. In states like Texas, which have chosen not to expand their Medicaid programs, some people will not qualify for financial assistance in the exchange or for Medicaid coverage.
And whether deciding to participate in an exchange net- work or figuring out patients’ share of insurance costs, “physi- cians are still going to have to decide how or whether to deal with health plans” and carefully evaluate those contracts and relationships, says TMA Medical Eco- nomics Specialist Donna Kinney.
“Pricing will be higher than it is today.”
amount of time,” with some activities “behind schedule” (www
.gao.gov/products/GAO-13-601).
Still, once up and running, officials expect the exchange to
help make a dent in the state’s high uninsured rate. Roughly 6 million Texans — a quarter of the population — are uninsured. The Texas Health and Human Services Commission (HHSC) estimates 40 percent of those people are eligible for exchange subsidies authorized by the Patient Protection and Affordable Care Act (PPACA). For physicians, that could mean more patients walk in the door with health coverage. But the exchange still holds a lot of questions for doctors, TMA officials say. For starters, it remains to be seen which insurers will partic-
ipate and how networks and payment rates will be structured. Some things, on the other hand, will stay the same: Some
Feds in charge Because PPACA requires most individ- uals to have health insurance by 2014, the law required states to set up so- called health insurance exchanges — now referred to as marketplaces — as another avenue for purchasing cover- age. The marketplaces are scheduled to begin open enrollment periods for individual and small employer cover- age in October, for coverage beginning Jan. 1, 2014. In Texas and other states choosing not to expand Medicaid, people with incomes between 100 percent and 400
percent of the federal poverty level (FPL) are eligible for tax credits or discounts through the exchange to help subsidize their premiums and other cost-sharing such as copays and de- ductibles. Those with incomes below 100 percent FPL do not qualify for that assistance, nor would they qualify for Medicaid unless they qualify as disabled.
In states that adopted Medicaid expansion, patients with in- comes up to 133 percent of FPL would receive Medicaid cover- age; those with incomes between 133 percent and 400 percent FPL can get financial help in the exchanges. Small businesses, which may include physician practices,
also are eligible for tax credits to help provide health coverage to their workers. The health reform law gave states the option of running their own exchanges within federal guidelines, an offer Gov-
August 2013 TEXAS MEDICINE 49
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