Core Functions of State Health Exchange

Core Functions of State Health Exchange

Deciphering Affordable Care Act (ACA) or ObamaCare, the core function of State Health Exchanges or Federal run Health Benefit Exchanges will include but not limited to:

  • Adjudication of appeals of eligibility determinations
  • Administration of premium tax credits and cost-sharing reductions
  • Applications and notices
  • Call center operations
  • Certification, recertification, and decertification of qualified health plans
  • Eligibility determination for Exchange participation on APTC and cost sharing reductions
  • Enrollment process
  • Exchange website
  • Individual responsibility determinations
  • Information reporting to IRS and enrollees
  • Medicaid/CHIP eligibility will be determined through an eligibility service
  • Navigator program
  • Notification and appeals of employer eligibility
  • Outreach and education
  • Premium tax credit and cost-sharing reduction calculator
  • Quality rating system
  • Risk adjustment and transitional reinsurance
  • Seamless eligibility and enrollment process with Medicaid/CHIP and other State health subsidy programs
  • SHOP Exchange-specific functions

To summarize ACA, the services of the Health Benefit Exchange (HBE) are only 5 fold:

  1. Certify and select qualified health plans
  2. Coordinate health care eligibility related to various plans/programs
  3. Establish a ‘Navigator’ program
  4. Establish a website and call center for customer service
  5. Select how to aggregate premiums

If you are a health plan and racing to get approved as QHP or State Health Exchange and need help around Technology and / or Services, you are welcome to connect with Manish Jaiswal @ 646.644.3049



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425 Washington Blvd., Jersey City,
New Jersey 07302, USA

Phone: +1 201.258.4704 / 201.258.4704
Fax: +1 201.604.3480