The Affordable Care Act (ACA), defines QHP as an insurance plan certified by the Health Insurance Marketplace which provides Essential Health Benefits (EHBs), follows established limits on cost-sharing, and meets other requirements outlined in the application process.
QHPs offer the core set of benefits, including preventive services, mental health, and substance abuse services, emergency services, prescription drugs and, hospitalization. Some plans include benefits beyond the core set.
QHPs are categorized and labeled by a standard coverage level to help consumers compare plans. The four standard coverage levels which are also known as metallic tiers are:
- Bronze: Tthe plan must cover 60% of expected costs for the average individual
- Silver: The plan must cover 70% of expected costs for the average individual
- Gold: The plan must cover 80% of expected costs for the average individual
- Platinum: The plan must cover 90% of expected costs for the average individual
There are also catastrophic plans. Catastrophic plans have high deductibles and offer less coverage than the metal level plans. Premium tax credits could not be used with these plans. Consumers must be under 30 or meet other criteria to be eligible to purchase a catastrophic plan.
SHOP and the effect of Payer QHP on SHOP
Small Business Health Option Program (SHOP) is a health insurance exchange place that assists people to buy health insurance plans. SHOP QHPs would not be required to follow guidance from previous years if the 2019 payment notice proposed rule is finalized. Depending on the outcome of the proposed rule, the CMS would offer guidance as required.
The CMS has stated that issuers applying for certification of plans as QHPs, offered through federally facilitated SHOPs, should review the 2019 payment notice proposed rule and the final rule when it is promulgated.
What Makes a Plan a Qualified Health Plan?
For a plan to be availed on the marketplace it must be certified as a Qualified Health Plan, for which it must meet certain requirements including:
- Providing at least ten essential benefits, such as preventive services, drugs, lab services, pediatric services etc.
- Follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts and provide minimum actuarial value).
- Meets all other minimum standards outlined by the Affordable Care Act.