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[Excerpt] A health insurance exchange is a structured marketplace for the sale and purchase of health insurance. “Customers” can include individuals and businesses. The insurance companies (“issuers”) that choose to sell their products through an exchange may be required to comply with consumer protections, such as offering insurance to every qualified applicant. Exchanges, however, are not issuers; rather, exchanges contract with issuers who will make insurance products available for purchase through exchanges. Essentially, exchanges are designed to bring together buyers and sellers of insurance, with the goal of increasing access to coverage.

This rather broad definition allows for a great deal of latitude, and therefore variance, in the number and scope of responsibilities covered in a particular exchange. For example, the role of an exchange may be more or less administrative: facilitating the sale and purchase of health insurance. An administrative-only exchange may function similar to websites that allow individuals to find airline travel options and purchase tickets (e.g., Kayak). Such an approach does not necessarily change or establish standards for the products being sold (whether they are health plans or airline tickets), or limit the types of buyers and sellers participating in the exchange, beyond what already exists in the private market. An example of a minimalist health insurance exchange is the Utah Health Exchange. Essentially, Utah’s exchange is an Internet portal that is “designed to connect consumers to the information they need to make informed health care choices, and in the case of health insurance, to execute that choice electronically.”

At the other end of the spectrum, an exchange may have multiple functions beyond the role of insurance marketplace. For instance, an exchange may be responsible for implementing regulatory standards, such as requiring standardization of all products offered through it or imposing requirements on exchange participants. An exchange may be responsible for determining eligibility for exchange plans and government-provided subsidies. An example of a more regulatory-oriented exchange is the Health Connector (“Connector”) in Massachusetts. Similar to Utah’s exchange, the Connector provides an online tool to allow consumers and others to find commercial health insurance options available to them. In addition, the Connector also manages a publicly subsidized coverage program for low-income state residents, and offers certificates to exempt individuals from the state’s individual mandate, among other duties.

An exchange may occupy a physical location and/or be virtual (i.e., performing its functions on the Internet). It may be governed by a public agency, a private entity, or a hybrid organization. The insurance options offered through an exchange may also vary across insurance markets and plan types. Nonetheless, while the authority and responsibilities of an exchange may vary, its fundamental purpose is to provide a venue where insurance companies may sell their insurance products and purchasers can compare and choose from multiple options available to them. Thus an exchange allows for “one-stop shopping” with respect to health insurance.

The exchange concept was included in the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended), as a means to increase access to health insurance. While ACA places many restrictions on the design and function of exchanges, the law also leaves many operational decisions to the states. Such flexibility will likely lead to variation in exchange models across the states. For example, a state may decide to operate an exchange by itself, establish an exchange in partnership with the federal government, or leave this work entirely to the federal government. States had to declare whether they will have a state exchange by December 14, 2012. By February 15, 2013, states must declare whether they will operate an exchange in partnership with the federal government. The initial open enrollment period for all exchanges will begin on October 1, 2013, and all exchanges are to be operational and offering coverage on January 1, 2014.

This report looks at the requirements for exchanges established in ACA and provides information on the requirements and choices available to states for the establishment, functions, financial responsibilities, and coverage of the ACA exchanges. It also includes a brief discussion of the interactions between exchanges and other provisions in the law.


Suggested Citation
Fernandez, B. & Mach, A. L. (2013). Health insurance exchanges under the Patient Protection and Affordable Care Act (ACA). Washington, DC: Congressional Research Service.