BALTIMORE – As the Nov. 16 deadline draws near for states to determine whether and how they will run their own health insurance exchange, Maryland has no doubt about where it stands.
The state moved quickly to set up its Maryland Health Benefit Exchange so that will be ready when open enrollment starts in October 2013, as required under the Affordable Care Act.
Physicians have been involved in creating the exchange and will have an ongoing say in how it operates, according to Gene M. Ransom, CEO of MedChi, the Maryland State Medical Society.
MedChi has been watching closely the exchange’s development in part because the society wants to ensure that protections currently in place – such as those restricting how prior authorization is used by insurers – will not be overturned or altered as part of the new insurance framework, Mr. Ransom said in an interview.
In addition, many Maryland physicians are very likely to purchase employee health coverage through the state exchange, Mr. Ransom said, noting that as small businesses, the rates available through the exchange might be more attractive than those currently available on the open market.
Doctors also may end up helping to fund the exchange’s ongoing operations, although how – and how much they will be asked to pony up – is not entirely clear yet, according to Rebecca Pearce, executive director of the Maryland Health Benefit Exchange.
While the Maryland exchange is fully funded via federal grants through 2014, it is required by law to become self-sustaining after that.
A task force is formulating funding recommendations for the state legislature. Based on past work, possible funding mechanisms include a transaction-based fee on providers; a fee attached to licensure; or a special assessment on insurers or hospitals, Ms. Pearce said.
The notion of physicians being asked to help fund the exchange does not sit well with MedChi, said Mr. Ransom, who added that such an idea has not been mentioned publicly during exchange board meetings or exchange committee meetings. Nor has it been broached privately with any MedChi lobbyists or staff, he added.
If such a fee were levied, "We would be adamantly opposed," Mr. Ransom said.
Health insurance exchanges, a major feature of the Affordable Care Act, are supposed to create an open marketplace for individuals and small groups to buy health insurance coverage and help to bring them some of the economies of scale enjoyed by large groups.
The marketplaces have been likened to an Orbitz or Travelocity for health insurance. Under the ACA, a state can either run its own exchange, have the federal government run it, partner with the federal government, or opt out.
As of early November, 16 states said they would go solo, 3 wanted partnerships, 16 were studying options, 8 were silent, and 8 said they would not create an exchange, according to the Kaiser Family Foundation.
Five states -- Connecticut, Maryland, Nevada, Rhode Island, and Vermont – as well as Washington, D.C., have received advanced (level 2) funding from Health and Human Services department.
Maryland has been certain of its plans since the passage of the ACA. In September 2011, Gov. Martin O’Malley (D) appointed Ms. Pearce. The Maryland Health Benefit Exchange has received $157 million through four planning and establishment grants from the HHS.
The exchange is lead by a board of trustees chaired by Dr. Joshua M. Sharfstein, state secretary of health and mental hygiene. Dr. Georges C. Benjamin, executive director of the American Public Health Association, also is on the board.
Physicians – many of them active MedChi members, according to Mr. Ransom – as well as advocates, insurance carriers, consumers, business leaders, and community leaders, also serve on the five committees the exchange has established. Those committees address navigators, continuity of care, plan management, finances, and implementation.
The exchange has also set up a website for the Maryland Health Connection, through which consumers will find and select insurance.
About 14% (730,000) of Maryland’s population is uninsured, but only 40% of them are thought to be eligible for the exchange coverage, Ms. Pearce said in an interview. In the first year, an estimated 145,000-180,000 will enroll for coverage through the Connection, she said. By 2020, some 250,000 will likely be purchasing coverage through the exchange.
As required by the ACA, the Maryland exchange will use navigators to reach special populations, such as non-English speakers, or the disabled. Navigators will offer in-person assistance to walk people through their choices and the enrollment process.
Navigators also are tasked with helping individuals and small employers apply for tax credits as well as linking individuals to other programs for which they might be eligible for, such as Medicaid or the Children’s Health Insurance Program. Navigators may not have conflicts of interest, although independent insurance agents and brokers may serve as navigators.