Marketplace Success Stories

By Kevin Counihan, Health Insurance Marketplace CEO 

Three years in, the Health Insurance Marketplace is a competitive, growing and dynamic platform – a transparent market where issuers compete on price and quality, and people across the country are finding health plans that meet their needs, and their budgets.

Increasingly, the Marketplace is also serving as a laboratory for innovations and strategies that are helping us build a better health care system. Before the Affordable Care Act, individual market insurers competed in large part by finding and only covering the healthiest, cheapest consumers. Today, everyone can buy coverage, regardless of health status, and issuer competition centers on quality and cost-effectiveness. As a result, issuers in states across the country are finding innovative ways new ways to provide quality, cost-effective health care.

This week, as we’ve previewed, we’re inviting issuers to HHS to share their stories and their strategies for success on the Marketplace. We’re calling this conference “Marketplace Year 3: Issuer Insights & Innovation.”

The presenters at the forum include issuers from all regions of the country and range from major commercial insurers to Blues plans to integrated health systems to regional carriers to new plans to longstanding Medicaid plans. They’ll describe innovations around paying for high-quality care, working with doctors and clinicians to encourage coordinated care, and using data analytics to find patients, engage them in improving their health, and provide the services that meet their needs.

Here are some examples.

Value-Based Payment Design

Aetna set a goal to have 75 percent of its spending go through value-based contracts by 2020. Already today, they have more than 800 value-based contracts in 36 states like Texas, California, Virginia, Ohio, and many more. Under their national value-based care network, providers are transforming their practices and improving the patients’ experience. For example, they are identifying at-risk patients earlier, engaging patients in care decisions, coordinating care more effectively, and providing new hospital case managers to explain discharge instructions and new medications to patients. Not only are the value-based contracts improving quality, they’re paying off in reduced costs. Aetna is seeing medical costs come in 8 percent below what would otherwise be expected in areas with these contracts.

Blue Cross Blue Shield of Massachusetts has a payment model called an Alternative Quality Contract. It pays doctors and clinicians based on the quality, efficiency and effectiveness of their care. And it works. A study from the New England Journal of Medicine found that this program saved money; at the same time, it gave patients better care than similar patients in other states.

Coordinated Care

University of Pittsburgh Medical Center (UPMC) Health Plan in Pennsylvania realized that early collaboration between providers and care coordination teams leads to measurable success. These coordination teams are made up of nurses, social workers and community health workers who can visit while the patient is in the hospital, coordinate their care as they leave the hospital, and depending on the individual’s needs, check up on them at home. They’re trusted connections between patients and providers.

Intermountain Healthcare in Utah has placed behavioral health specialists within primary care offices. While it costs more up front, they’re finding that it reduces inpatient behavioral health admissions enough to lower overall costs in the long run while improving patients’ lives. They’re calling this effort a “Total Accountable Care Organization”, or TACO. It’s a health care system that cares for the physical health and behavioral health of its members, while tailoring its long-term supports and social service offerings for people with significant health needs.

Using Data Analytics to Improve Patient Care

Blue Cross Blue Shield in Florida closely analyzed its prospective Marketplace customers. From its analysis, they learned that their new market wouldn’t look the same as their pre-ACA individual market, and that there would be more variety in health issues across communities. Based on their research, they created plans for the different needs of unique communities. They used “place of delivery” care models to bring together nurses, analysts, pharmacists, social workers, and other experts into inter-disciplinary teams that focused on improving care for high-risk populations in particular communities.

Horizon Blue Cross Blue Shield in New Jersey used its consumer analytics to identify the uninsured markets in their area, and launch a targeted marketing strategy to reach those uninsured residents. With ad placements outdoors, on public transit, and through social media, as well as mail, digital and email outreach, it reached communities that other insurers hadn’t. For example, it saw opportunity in the large number of Latino residents who were uninsured. With a Spanish language marketing campaign, it helped grow its Latino membership from 8,000 to 30,000 members. And it stepped up its efforts to retain those new consumers.


These are just a few of the new ideas and innovative strategies that are being used – they’re what makes me so confident in the future of the Marketplace. And as this market continues to grow and mature, we’ll see even more stories of success as issuers in every state find new ways to provide reliable, quality, person-centered coverage for Americans and their families for years and decades to come.

In these last days of Open Enrollment, immigrant families need to know affordable coverage options are available

In these last days of Open Enrollment, immigrant families need to know affordable coverage options are available

Affordable coverage options are available in the Health Insurance Marketplace for eligible immigrant families. In fact, most people shopping for coverage on the Marketplace can find a plan with monthly premiums of $75 or less. But, act soon:  January 31, 2016 is the final deadline for you to sign up at or for 2016 coverage.  Don’t miss out on getting coverage for 2016 and risk owing a fee of $695 or more.

If you work with immigrant communities, we need your help to make sure people who are eligible for coverage understand that they should not be worried about applying for coverage if they have a family with mixed immigration status.

Here are 10 things immigrant families need to know about Marketplace coverage:

  1. To buy private health insurance through the Marketplace, you must be a U.S. citizen, a U.S. national, or be lawfully present in the United States. In addition, immigrants with certain other statuses are also eligible.  See a list of immigration statuses that qualify for Marketplace coverage.
  2. If you recently gained U.S. citizenship or had a change in your immigration status that makes you newly eligible to enroll in coverage through the Marketplace, you may qualify for a Special Enrollment Period. See if you can enroll in a Marketplace health plan outside Open Enrollment.
  3. Financial help is available. If you’re a lawfully present immigrant and meet other eligibility criteria, you can buy private health insurance through the Marketplace, and may be eligible for lower costs on monthly premiums and lower out-of-pocket costs based on your income. More than 8out of 10 people who have enrolled in a health insurance plan through the Marketplace have qualified for financial help. In fact, most people can find monthly premiums for $75 or less, after financial assistance. In general, individuals and families whose household income for the year is between 100 percent and 400 percent of the federal poverty line for their family size may be eligible for the premium tax credit or financial assistance to pay for your premium.  You can find the levels here based on the household size. If you make less than 100 percent of the federal poverty line, which is $11,770 for an individual or $24,250 for a family of 4 (higher in Alaska and Hawaii) and you aren’t eligible for Medicaid because of your immigration status, you may still qualify for lower costs on Marketplace coverage.
  4. If you’re a “qualified non-citizen” and meet your state’s income and other eligibility rules, you may be eligible for Medicaid or Children’s Health Insurance Program (CHIP) coverage. See a list of “qualified non-citizen” statuses and other important details.
  5. If you’re a “qualified non-citizen,” you may have a 5-year waiting period to get full Medicaid or CHIP coverage. This means you must wait 5 years after receiving “qualified” immigration status and meet all other eligibility rules in the state before being eligible for full Medicaid or CHIP. See a list of exceptions to the 5-year waiting period and other important details.
  6. Many immigrant families are of “mixed status,” with members having different immigration and citizenship statuses. Mixed status families can apply for financial assistance for private insurance for their dependent family members who are eligible for coverage through the Marketplace, or for Medicaid and CHIP coverage. Family members who aren’t applying for health coverage for themselves won’t be asked if they have eligible immigration status.
  7. Federal and State Marketplaces, as well as state Medicaid and CHIP agencies, can’t require you to provide information about the citizenship or immigration status of any family or household members who aren’t applying for coverage for themselves.
  8. States can’t deny you benefits because a family or household member who isn’t applying has not provided his or her citizenship or immigration status.
  9. Information that you provide to the Marketplace won’t be used for immigration enforcement purposes.
  10. If you’re not eligible for Marketplace coverage or you can’t afford a health plan, you can get low-cost health care at a nearby community health center. Community health centers provide primary health care services to all residents in the health center’s service area. Find more information here.
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