This morning the US Department of Health and Human Services released the guidelines for states’ to use for setting up their insurance exchanges. HHS’ press release notes,

“Today, the U.S. Department of Health and Human Services (HHS) proposed a framework to assist states in building Affordable Insurance Exchanges, state-based competitive marketplaces where individuals and small businesses will be able to purchase affordable private health insurance and have the same insurance choices as members of Congress… Today’s announcement is designed to help support and guide states in their efforts to implement Exchanges.”

This should come as great news to states seeking guidance in setting up their exchange, but there are a number of regulations left out. In fact, within the proposed rule text HHS says,

“Subjects included in the Affordable Care Act to be addressed in separate rulemaking include but are not limited to: (1) standards for individual eligibility for participation in the Exchange, advance payments of the premium tax credit, cost-sharing reductions, and related CMS-9989-P 12 health programs and appeals of eligibility determinations; (2) standards outlining the Exchange process for issuing certificates of exemption from the individual responsibility requirement and payment under section 1411(a)(4); (3) defining essential health benefits, actuarial value and other benefit design standards; and (4) standards for Exchanges and QHP issuers related to quality.”

In other words, states still do not have guidance on who is eligible, what they are eligible for, the design or cost of the plans offered, or any quality standards. These remaining regulations may be a short list, but they constitute the majority of the substance of exchanges. If a state does not know who is eligible and what they will cost then they have little guidance to understand exactly how an exchange will impact their state. And if a state does not know how an exchange will impact them they cannot adequately prepare for their implementation. Because these guidelines leave out such substantial topics they provide little real guidance to states and stakeholders.

-Spencer Harris