Pursuant to the Patient Protection and Affordable Care Act ("ACA"), health insurance exchanges must be established in all states by January 1, 2014. These exchanges may be operated by the state, the federal government, or a partnership of both. The exchanges will allow individuals and small businesses to buy health care coverage from a variety of carriers in one place and will provide access to subsidies for eligible individuals. Because each state exchange is being developed separately from the others, the state exchanges are at varying degrees of readiness. It is unclear whether all the exchanges will be fully operational by the deadline.

State and federal health insurance exchanges are eventually expected to add approximately 30 million currently uninsured persons to the health insurance market.

As the new health insurance exchanges are implemented, health care providers and managed care organizations must stay up to date on the related federal and state law developments to understand how the exchanges will affect them.

Qualified Health Plans


  • "Health insurance issuer"
  • "Qualified Health Plan"
  • "Product"
  • "Essential health benefits"
  • "Platinum," "gold," "silver," and "bronze" categories of Qualified Health Plans

The exchanges are authorized to establish criteria and determine what plans (known as "Qualified Health Plans") can be offered, as well as to develop and enforce certain rules and regulations. Epstein Becker Green attorneys have experience:

  • advising plans that want to become Qualified Health Plan issuers in an exchange regarding exchange requirements and the applicability of federal and state laws;
  • assisting plans in applying to exchanges to become approved as Qualified Health Plans, including preparing required documents, such as compliance plans and products that comply with state and exchange obligations; and
  • interacting with regulatory authorities, such as the exchange, with respect to compliance and other issues.

Provider Participation Agreements

Providers are sometimes being asked to execute new agreements or amendments with respect to exchange products, and some providers are being excluded from these products. Our attorneys have experience preparing and reviewing managed care participation agreements with hospitals, physicians, and other providers of health care services to determine whether the agreements will apply to the new health insurance exchange products, when they are implemented.

Private Health Insurance Exchanges

A growing number of private health insurance exchanges are emerging as a result of the ACA. These alternative exchange offerings are driven by a movement toward defined-contribution plans where employers set the amount that they contribute to the cost of coverage. These private exchanges—which are primarily targeted to serve companies with more than 100 employees who will not be able to participate in state, federal, or small business exchanges under the ACA—in some cases, may compete with the government exchange. Our attorneys have experience providing advice and regulatory counseling on establishing private health insurance exchanges run by private sector companies or nonprofits.

Representative Matters

  • Counseled a health insurance issuer regarding participation in the largest private health insurance exchange in the country
  • Provided counseling and advice to a new health plan that sought to obtain licensure and approval as a Qualified Health Plan
  • Counseled and advised entities regarding the establishment of a private health insurance exchange
  • Provided regulatory advice and counseling to providers on proposed contract revisions related to products to be offered on state-based health insurance exchanges
  • Provided regulatory advice and counseling to one of the largest not-for-profit managed health care companies on a corporate private exchange
  • Provided counseling and advice to a health plan that sought to expand its Medicaid license to offer commercial products on an exchange and obtain approval to become a Qualified Health Plan issuer on the exchange

For more information on our health insurance exchanges experience, please contact one of our professionals.