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“If a plan is offered inside or outside the exchange in Texas, it’s still going to be regulated by the state.”


along the way for creating a streamlined application and setting up the technol- ogy for the enrollment process and ex- changing information with states, among other tasks.


Officials also said they regularly com- municate with states about the status of so-called qualified health plans approved for sale in the insurance marketplace. Carriers had until early May to submit their applications, and CCIIO expects to finalize a list of qualified health plans for federally run exchanges in September. TMA is tracking the issue and in late


May asked the Texas Department of Insurance (TDI) to find out how many and which plans were eligible for the exchange.


ernor Perry has refused despite earlier legislative efforts to adopt a Texas model. House Bill 636, introduced dur- ing the 2011 legislative session, would have allowed Texas to create and run its own marketplace. That, bill author and physician Rep. John Zerwas, MD (R- Simonton), said at the time, is a better alternative to federal control, given that health insurance reform is such a big piece of the federal health reform leg- islation. TMA supported the bill, along with the Texas Association of Business, the Texas Association of Health Plans, and the Texas Hospital Association. TMA also advocated that a state-run exchange tailored to the Texas market would be a better avenue for Texas patients and small employers, including physician practices, to obtain affordable health insurance in a transparent manner and with less federal interference. (See “Get- ting Connected,” April 2011 Texas Medi- cine, pages 37–40.) In fact, the federal government will operate insurance marketplaces in half of the states. States have the option to take over beginning in 2015. But Texas has no plans to do that, according to the governor’s office. “To this point, we have not seen any flexibility from the [federal government] on anything having to do with health care reform, and these exchanges are no different,” spokeswoman Lucy Nashed said.


50 TEXAS MEDICINE August 2013


Tick tock Unlike state-run exchanges, the federal government will handle everything from running and marketing the website, edu- cating consumers, and setting up a fed- eral call center to determining eligibility for subsidies and approving which plans can participate.


U.S. Health and Human Services Sec-


retary Kathleen Sebelius told the House Ways and Means Committee in April that the exchanges will be ready in time for open enrollment on Oct. 1, and officials have maintained that confidence despite the recent GAO report. Secretary Sebelius also asked Con-


gress for another $1.5 billion to run the exchanges in 2014, on top of the $1 bil- lion allocated under PPACA for imple- mentation in 2013.


CMS, which oversees the exchanges


through the Center for Consumer Infor- mation and Insurance Oversight (CCIIO), did not respond to Texas Medicine’s inter- view requests.


During a May webinar hosted by the


National Institute for Healthcare Man- agement Foundation, CMS representa- tives acknowledged lingering concerns surrounding the government’s opera- tional readiness, and the exchanges’ ability to foster competition and provide affordable coverage to the uninsured. But they said the process has pro-


gressed from policymaking to an op- erational mode, hitting their deadlines


State plays a role


Even though the federal government largely runs the show, Texas state agen- cies still play a role when it comes to linking the exchange to Medicaid and regulating insurers. Federal law requires that the state Medicaid program and the Children’s Health Insurance Program (CHIP) estab- lish mechanisms for connecting with the


Qualified health plans must meet fed- eral standards for providing a package of essential health benefits (EHBs) in 10 categories of care:


1. Ambulatory services, 2. Emergency care, 3. Hospitalization, 4. Maternity and newborn care, 5. Mental and behavioral health treat- ment,


6. Prescription drugs, 7. Rehabilitation, 8. Laboratory services, 9. Preventive and wellness services and chronic disease management, and


10. Pediatric care.


Texas defaulted to the Blue Cross and Blue Shield BestChoice PPO as a bench- mark for what constitutes an EHBs pack- age.


Carriers also must certify they have adequate networks, and federal officials say they are carefully monitoring insur- ers’ service areas to make sure patients have sufficient access to care and choice.


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