Health Reform WK-EDGE Blueprint applications outline necessary steps for establishing state exchanges
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Tuesday, June 25, 2019

Blueprint applications outline necessary steps for establishing state exchanges

By Kayla R. Bryant, J.D.

CMS is prepared to offer considerable support to states as they plan and build exchanges, regardless of federal platform use.

States wishing to operate a state-based exchange (SBE) or a state-based exchange on the federal platform (SBE-FP) for coverage years starting on or after January 1, 2019, must submit a declaration of intent letter and a complete blueprint application. A state in the process of establishing its exchange may receive conditional approval upon submitting its blueprint, and will receive CMS support in executing its exchange functions (CCIIO Fact Sheet, June 17, 2019).

Exchange models. The three types of exchanges, which include federally-facilitated exchanges (FFE), involve various levels of state involvement. SBEs require states to perform all exchange functions, relying on HHS only for exemptions processing, risk adjustment, and employer appeals relating to advance premium tax credits (APTC) and cost-sharing reductions (CSR). SBE-FP exchanges require states to perform plan management, consumer assistance, and small business health options (SHOP) functions. HHS takes care of eligibility and enrollment for the individual market, as well as eligibility support. States choosing FFEs relinquish all exchange functions to HHS, but can elect whether the FFE performs Medicaid and Children’s Health Insurance Program (CHIP) assessments.

Application content. A state must submit a letter of intent signed by the governor declaring its exchange model. CMS will assist states with preparing the blueprint application, and will grant conditional approval for an SBE or SBE-FP that does meet all requirements at the time of blueprint application—provided that the state attests to meeting applicable requirements, provides projected completion dates for meeting additional requirements and shows significant progress toward these goals, and anticipates being operational for the next open enrollment period. States must submit SBE blueprints at least 15 months prior to the first open enrollment, and SBE-FP blueprints at least 3 months before open enrollment.

Application review and approval. CMS will readily monitor progress and provide guidance on the information technology (IT) system build. CMS may require submission of testing results or additional documentation to establish a state’s progress, as well as formal testing involving CMS’ Federal Data Services Hub. SBEs must provide extensive customer support via call centers, a web site, navigators, and accessibility features for those with disabilities or limited English proficiency. They must coordinate with affordability programs and SHOP, certify qualified health programs (QHP), continuously monitor QHPs for compliance, and maintain security and privacy. SBE-FPs must operate a toll-free hotline for customer assistance, conduct outreach activities, and certify QHPs.

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