November 12, 2013




All Blue Cross and Blue Shield of Kansas Contracting Providers


Connie Winkley – Education/Communication Coordinator
Institutional Provider Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association


Health Insurance Marketplaces (a.k.a. Exchanges)

Health Insurance Marketplaces created by the Patient Protection and Affordable Care Act of 2010 are in operation and provide Blue Cross and Blue Shield of Kansas another avenue to continue as the insurer Kansans trust with their health.

As of October 1, consumers have been able to purchase health insurance at Coverage purchased on Health Insurance Marketplaces will become effective January 1, 2014.  Valuable information for providers on the Exchange and the products BCBSKS is offering can be found by clicking the following link: Exchange, BlueCard and Kansas Provider Networks

A list of terms relevant to the Exchange and their definition includes the following:

Affordable Care Act
The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
Essential Community Providers
Health care providers that serve predominately low-income, high-risk, special needs and medically-underserved individuals.  The Department of Health and Human Services (HHS) proposes to define essential community providers as including only those groups suggested in the ACA, namely those named in section 340B(a)(4) of the Public Health Service Act and in section 197(c)(1)(D)(i)(IV) of the Social Security Act.
For purposes of this document, the term Marketplace/Exchange refers to the public exchange as established pursuant to the Affordable Care Act (ACA):  A new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Affordable Insurance Marketplaces will offer a choice of health plans that meet certain benefits and cost standards.
The ACA allows for each state the opportunity to establish a State-based Marketplace.  Recognizing that not all States may elect to establish a State-based Marketplace, the ACA directs the Secretary of HHS to establish and operate a Federally-facilitated Marketplace in any State that does not do so, or will not have an operable Marketplace for the 2014 coverage year, as determined in 2013.
Small Business Health Options Program (SHOP)
Allows employers to choose the level of coverage and offer choices among health insurance plans. State-run Marketplaces are scheduled to become available by January 2014, with the federal government stepping in to run Marketplaces for states that are not ready. For 2014 and 2015, states can decide whether to include businesses with 100 or fewer or 50 or fewer employees in their Marketplace. In 2016, all businesses with 100 or fewer employees must be able to purchase insurance through these Exchanges. The Marketplaces have the option of including employees with more than 100 employees beginning in 2017.
Qualified Health Plan (QHP)
Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.

The United States Department of Health and Human Services (HHS) published the following rules regarding provisions of the Patient Protection and Affordable Care Act providing the framework to assist states in setting up Health Insurance Marketplaces:

March 27, 2012: Final and Interim Rule: Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers – Published March 27, 2012:
Affordable Care Act-establishment-of-exchanges-and-qualified-health-plans#p-3"> Care Act-establishment-of-exchanges-and-qualified-health-plans#p-3

August 17, 2011: Patient Protection and Affordable Care Act; Exchange Functions in the Individual Market: Eligibility Determinations; Exchange Standards for Employers – Published August 17, 2011:
Affordable Care Act-exchange-functions-in-the-individual-market-eligibility"> Care Act-exchange-functions-in-the-individual-market-eligibility

The Patient Protection and Affordable Care Act (PPACA):

Health and Human Services Department

If you have any questions regarding the Health Insurance Marketplaces, please contact Blue Cross and Blue Shield of Kansas at (800) 318-2596.