Exchange Basics
Exchange Market
Exchange Financials
Regulatory Changes
HLS Exchange Leadership Quotes
100
This law, passed in 2010, established the Individual Exchange.
What is the Affordable Care Act (ACA)?
The ACA was signed into law by President Obama in 2010.
Official nationwide exchange operation and enrollment began in late-2013 for the 2014 plan year.
100
These are the Exchange metal tiers. (bonus: name their target actuarial values (AV))
What are...
- Bronze (60%)
- Silver (70%)
- Gold (80%)
- Platinum (90%)
- Catastrophic (<60%)
100
These are the two primary forms of financial assistance offered through the Exchange.
What are 1) Advanced Premium Tax Credit Subsidy (APTC) and 2) Cost Sharing Reduction Subsidy (CSR)?
100
This Law in 2022 extended expanded APTC subsidies on Individual Exchanges through 2025 to protect consumers.
What is the Inflation Reduction Act (IRA)?
The IRA extended the enhanced Advance Premium Tax Credit (APTC) subsidies from the American Rescue Plan (ARPA) through 2025, significantly increasing financial help for marketplace health insurance by expanding eligibility to those over 400% of the Federal Poverty Level (FPL) and making subsidies larger for everyone, preventing premium hikes.
100
"I wish my AI Brain allowed me to interact better with normal people."
Who is Shyam Vichare?
200
These are the three primary goals of the ACA as described in the Law. (name at least one)
What is...
(1) Make affordable health insurance available to more people (e.g., providing subsidies and premium tax credits for eligible households)
(2) Expand the Medicaid program to coverall adults with income below 138% of the FPL (note: not all states have expanded their Medicaid program)
(3) Support innovative medical care delivery methods designed to lower the costs of health care generally
200
This is the approximate total number of enrolled Individual Exchange lives at the beginning of 2025. (range)
What is ~24.3 million?
200
This is the type of ACA plan that must be selected to be eligible for CSRs
What is a Silver plan?
200
This federal subsidy, crucial for reducing premiums in the Individual Exchange, ended after December 31, 2025.
What are enhance Advance Premium Tax Credits (APTCs)?
200
"Can we freakin' get going? I want this meeting ran like a Spaceship Launch."
Who is Martin Graf?
300
These are the organization(s) that regulate/oversee the Exchange
What is both the federal and state government?
The Exchange business is regulated at both the federal and state level. Regulatory activities and division of responsibilities between State and Federal authorities vary by Exchange type (SBE or FAE). Although CMS and the States provide guardrails and guidance around product design and operating model, insurers ultimately makes business decisions in this market.
300
These are factors contributing to the increase in Exchange enrollment from 2020 to 2024? (multiple correct responses)
What are...
- Expanded ACA coverage and subsidies in 2021 and 2022
- Medicaid re-determination: 2-3 M new enrollees, and >1 M during 2023 SEP)
- Economic impact of COVID 19: unemployment, drop in employer coverage, expanded SEP
- ICHRA: Estimated to be ~1M in 2025, nearly doubling each year since 2020; Centene, Oscar looking to ‘market make’
- What else?
300
These are the eligibility requirements for APTC (4 correct responses)
What are...
1. Have a household income from 100%-400% of the Federal Poverty Level (FPL); or if the benchmark plan (2nd lowest cost Silver plan) premium is >8.5% of household income above 400% FPL
2. Do not have access to affordable coverage through an employer (including a family member’s employer)
3. Are not eligible for Medicare, Medicaid, or CHIP
4. Meet citizenship/legal residency and tax filing requirements
300
This federal law enacted on July 4, 2025 implements major tax and spending policy changes, including the exclusion of extended APTCs beyond 2025.
What is OBBBA (One Big Beautiful Bill Act)?
300
"You do realize you have a multi-billion dollar Individual Exchange business on your hands? Do you know what that means? It means you matter!"
Who is Travis Kistler?
400
These are the key difference between Medicaid and the Exchange. (multiple correct responses)
What is...
- Other differences?
400
OW often uses the term "VUCA" to describe the Exchange, which stands for this.
What is "Volatile, Uncertain, Complex, and Ambiguous"?
400
This is the term for the program that transfers funds from plans with lower-than-average risk populations to those with higher-than-average risk populations.
BONUS Q: What is the actual % that higher risk-pool payers are reimbursed by lower risk-pool payers? (i.e., for every $1 of additional claim amount relative to the average, how much is that payer reimbursed?)
What is risk adjustment? (Bonus: ~60%)
400
As a result of OBBBA, KFF estimates that the average net premium payment for current subsidized enrollees will increase by this percentage. (Range)
What is 114%?
400
"Marketplace Leaders need to act as BLAME RECEPTACLES. In the words of Colonel Jessup: You WANT me up on that wall!"
Who is Terry Burke?
500
This is the number of categories of Essential Health Benefits (EHB) covered under the ACA.
What is 10?
EHBs include ambulatory patient services, emergency services, hospitalization, maternity/newborn care, mental health and SUD services, prescription drugs, rehabilitative services, lab services, preventative/wellness services, and pediatric services.
500
This is the percentage of ACA enrollees in 2024 that were new consumers (range).
What is 24%?
(45% were active re-enrollees and 31% were automatic re-enrollees)
How many of them are real...?
500
This is the only state that has applied to run its own risk adjustment program.
What is Massachusetts?
500
This employer-funded benefit - that was proposed in the budget reconciliation bill but ultimately not passed – would make the individual plan types more accessible and could drive marketplace enrollment.
What is ICHRA (Individual Coverage Health Reimbursement Arrangement)?
500
"I refuse to DoorDash lunch to the office for the third straight day. Can we just be normal people for once? I'm going out to get a salad."
Who is Laurie Bankhead?