Creates state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage. Exchanges will have a single form for applying for health programs, including coverage through the Exchanges and Medicaid and CHIP programs.

Implementation: January 1, 2014

Implementation update: On July 15, 2011, HHS issued two proposed rules on the health insurance exchanges. The first rule detailed the specifics of how states may set up their exchanges, while the second rule focused on the standards related to risk adjustment, risk corridors and reinsurance provisions. HHS released the final rule on exchanges on March 27, 2012, and the final rule on risk adjustment, risk corridors, and reinsurance on March 23, 2012. HHS also issued a proposed rule on the SHOP exchange on March 11, 2013. On October 30, 2013, HHS issued a final rule outlining financial integrity and oversight standards pertaining to risk adjustment, risk corridors and reinsurance in the Exchanges.

On May 16, 2012, HHS issued guidance for Federally-facilitated Exchanges (FFE), which will be run by HHS in states that have not established an exchange or have selected to run a Partnership exchange. Also on August 14, 2012, HHS issued a Blueprint that states must submit to HHS by November 16, 2012 if they wish to operate a state-based exchange or a Partnership exchange. On November 15, HHS extended the deadline for submitting a blueprint for a state-based exchange to December 14, 2012. It also extended the deadline for submitting a state-federal partnership exchange blueprint to February 15, 2013. Enrollment in exchanges will begin on October 1, 2013. HHS issued FAQs on exchanges, market reforms, and Medicaid on December 10, 2012. The Department also released additional guidance on the partnership exchanges on January 3, 2013. On May 10, 2013, HHS announced new flexibility to allow states to run the SHOP-only exchange. States choosing this option would run the SHOP exchange while the federal government would run the individual exchange. On November 27, 2013, HHS announced that it would delay online enrollment for the SHOP exchanges by one year.

On March 11, 2014, HHS issued a final rule establishing payment and oversight parameters for 2014 related to the risk adjustment, reinsurance, and risk corridors program and fees for the Federally-facilitated Exchanges. On March 21, 2014, HHS issued a proposed rule addressing product, quality reporting, and non-discrimination standards for marketplaces and the insurance market in 2015 and beyond.

The ACA requires every exchange to operate a Navigator program to provide enrollment assistance to consumers. The final exchange rule, issued on March 27, 2012, specified the Navigator program standards. HHS further clarified the standards for Navigators and Non-Navigator Assistance programs in a proposed rule issued on April 5, 2013. The final rule also finalizes the requirement that exchanges must have a certified application counselor program. On May 1, 2013, HHS issued guidance on the role of agents, brokers, and web-brokers who will also be providing enrollment assistance to consumers.

Learn more: Where are states in establishing and implementing their health insurance exchanges? Track state actions with the Exchange Monitor.