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8 components of a health care exchange

1. Qualified health plans (QHP) 1. Qualified health plans (QHP)

The exchange will certify, re-certify and de-certify qualified health plans. A QHP is a plan that meets certain criteria including, but not limited to, providing essential benefits and complying with certain deductible and out-of-pocket restrictions.

2. Metal levels of QHP 2. Metal levels of QHP

Various so-called metal tiers of QHPs will be offered through the exchange. Health insurance plans in the exchange have to meet distinct levels of coverage — each metal tier corresponds to an actuarial value.


  • • Bronze plan: Required to have an actuarial value of 60 percent. Covered individuals would be expected to pay 40 percent through deductibles, co-pays and other cost-sharing features.

  • • Silver plan: Required to have an actuarial value of 70 percent. Covered individuals would be expected to pay 30 percent through deductibles, co-pays and other cost-sharing features.

  • • Gold plan: Required to have an actuarial value of 80 percent. Covered individuals would be expected to pay 20 percent through deductibles, co-pays and other cost-sharing features.

  • • Platinum plan: Required to have an actuarial value of 90 percent. Covered individuals would be expected to pay 10 percent through deductibles, co-pays and other cost-sharing features.

3. Quality and price rating 3. Quality and price rating

The exchange will assign a quality and price rating to each QHP. That will give consumers an apples-to-apples comparison when it comes time to choose a plan.

4. Standardized consumer information 4. Standardized consumer information

Employees will also be provided standardized consumer information about the QHP.

5. Electronic calculator 5. Electronic calculator

The calculator will include the ability to show any discount available after government assistance.

6. Consumer assistance 6. Consumer assistance

Consumer assistance is also available through a toll free number or a website showing comparative data among plans offered, as well as certain financial information related to the plans. Consumers will be assisted with eligibility, enrollment, program specifications, and general education, with a goal of informing the public about the availability of the exchange.

7. Consumers enrolled in eligible programs 7. Consumers enrolled in eligible programs

The exchange will determine eligibility for, and assist the consumer in enrolling in, available programs such as government-provided premium assistance or Medicaid.

8. Exemptions from individual mandate 8. Exemptions from individual mandate

Finally, the exchange will determine exemptions from the individual mandate.


  • • A member of a religious sect that is recognized as conscientiously opposed to accepting any insurance benefits

  • • A member of a recognized health care sharing ministry

  • • A member of a federally recognized Indian tribe

  • • An individual whose household income falls below the minimum threshold for filing a tax return

  • • An individual who experiences a short gap in coverage of less than three consecutive months during the year

  • • An individual who incurs a hardship, as certified by an exchange, which makes him/her unable to obtain coverage

  • • An individual who cannot afford coverage because the premium cost exceeds 8% of his/her household income

  • • An individual who is incarcerated

  • • An individual who is not a U.S. citizen or a U. S. national, nor an alien lawfully present in the U.S.

As an employer, there’s a lot you need to know in order to decide whether or not to offer health care through a health insurance exchange. But before you make a decision,
Karen McLeese, J.D., vice president of employee benefit regulatory affairs for CBIZ Benefits & Insurance Services, details the general functions of all exchanges, including state-based, federal, or state/federal partnerships. Here are the eight primary features of exchanges. [Images: Shutterstock]

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