exchange and coordinating eligibility. It also requires a single, streamlined appli- cation for coverage, whether that ends up being through Medicaid, CHIP, or the exchange.
Those changes translated to technical adjustments at the state level so appli- cations can easily flow between the ex- change and HHSC to get patients to the right place for coverage, says Stephanie Goodman, the agency’s spokesperson. States also had to adjust their method- ologies for calculating patients’ income to a single federal standard so eligibility for the various programs is determined consistently and no one falls through the cracks.
“Those are big system changes hap- pening now,” Ms. Goodman said. Some have the potential to create ef-
ficiencies. But given what she described as aggressive timelines to adapt, prob- lems may lurk.
“On the Medicaid side, our goal is to determine whether someone is Medic- aid eligible as quickly as possible,” Ms. Goodman said. Yet it remains unclear just how HHSC will receive information from the exchange to do that. And even though CMS unveiled a shortened, more streamlined application intended to sim- plify the process, “the way it looks now, it could mean we don’t have enough information.” Physicians, however, have access to
the same system to verify Medicaid eli- gibility, she adds. As for insurance regulation, state of- ficials say there are additional federal components health plans must comply with for approval to participate in the exchange. “But the creation of these exchanges
doesn’t change the fact that states still regulate insurance,” said Katrina Daniel, TDI associate commissioner of life, ac- cident, and health insurance. “If a plan is offered inside or outside the exchange in Texas, it’s still going to be regulated by the state. Where state regulations ap- ply, if there is a violation, we will be the entity to enforce that.”
That means even after federal ap-
proval of a qualified health plan, TDI staff reviews all policies sold in Texas to make sure they comply with state
insurance laws and continues to hold carriers accountable to complying with state rules related to network adequacy, premium charges or “rate review,” and prompt payment, among others. Federal regulations also include mini- mum standards for network adequacy
and rate review, for example. Given what TMA officials describe as Texas’ problematic history with a general net- work adequacy standard, the associa- tion in 2012 asked HHS to set more spe- cific network adequacy standards that, among other things, require insurers to
The exchange and the uninsured
A portion of the roughly 6 million uninsured Texans (24 percent of the state’s population) are expected to gain access to health insurance coverage through the newly established exchange marketplace. Here is a look at how the subsidies under the Patient Protection and Affordable Care Act and other provi- sions of the federal health reform law could impact the state’s uninsured rate. These numbers are based on 2013 data from the Texas Health and Human Services Commission.*
Estimated No. Percent of Uninsured Eligible for exchange
subsidies Income too high
for subsidies Currently Medicaid eligible
2,432,000 608,000 790,000
but not enrolled Adults eligible for Medicaid 1,398,000
expansion† Undocumented immigrants
Total uninsured in Texas 851,000 6,080,000
*Figures may not add up due to rounding. †Texas is not participating in Medicaid expansion. Some adults in this expansion-eligible population may be eligible for exchange subsidies.
August 2013 TEXAS MEDICINE 51 40 10 13 23 14
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