Overview of Final Exchange Regulations

This brief summarizes key provisions in the Patient Protection and Affordable Care Act (ACA), which codifies Medicaid eligibility and enrollment. The final rule integrates the "Establishment of Exchanges and Qualified Health Plans" and the "Exchange Functions in the Individual Market: Eligibility Determinations; Exchange Standards for Employers” (CMS-9989-F). The brief’s two sections offer (1) a high level overview of important highlights, focusing on key areas that have changed or expanded upon previous guidance, and (2) a section-by-section summary of the regulation.

The final rule represents the most significant guidance to date on the operation of Health Insurance Exchanges (Exchanges), setting forth minimum Exchange standards, including:

  • Eligibility and enrollment into qualified health plans (QHPs) and Insurance Affordability Programs (IAPs);
  • Minimum requirements for issuers to offer QHPs through the Exchange; and
  • Standards for employers to participate in the Small Business Health Options Program (SHOP).

The regulation seeks to balance giving states maximum flexibility to manage Exchange operation in a way that meets local market needs and reflects state values, while simultaneously ensuring compliance with the letter and spirit of the ACA.

This brief is provided by the State Health Reform Assistance Network, a program of the Robert Wood Johnson Foundation, managed by the Woodrow Wilson School of Public and International Affairs at Princeton University, which provides in-depth technical support to states to maximize coverage gains as they implement key provisions of ACA.