Running a federal exchange — especially such a large one — will come with major administrative costs, and HHS will charge insurers a fee to cover those costs. The fee will be pegged to the number of customers each insurer has in the federal exchange.
In 2014, insurers will have to pay HHS 3.5 percent of the premiums for each plan they sell through the federal exchange, according to Friday's regulations.
It's hard to know yet how that translates into dollars, because a handful of states still haven't decided whether they plan to set up their own exchanges or punt to the federal government. States that operate their exchanges will likely also charge a user fee for participating insurers.
HHS said it might change the amount of its user fee in later years, as more people enroll coverage through the exchanges. It will also monitor states' fees.
The size of the fee is just one calculation in a difficult balancing act for exchanges. The new marketplaces — designed to function as a sort of Expedia for health insurance — have to be useful enough to attract patients but also lenient enough that insurers will want to participate.
Exchanges that don't attract enough insurance companies could end up saddling those carriers with unhealthy and expensive patients, driving up their costs even more and making them even less appealing to customers.
“It is important to keep in mind that any new fees to pay for the administration of exchanges will add to the cost of coverage, and that is why the focus needs to be on reducing administrative costs, streamlining operations, and avoiding regulatory duplication that will add complexity and increase costs," America's Health Insurance Plans (AHIP) said in a statement on the new rules.
Friday's regulations also provide more details about how the government will redistribute money to help insurers with especially sick customers stay afloat. Three related programs will help insurers transition to a dramatically changed insurance market.
"These are important programs that will help stabilize the market and mitigate some cost increases for consumers as the new insurance reforms take effect," AHIP said Friday.
The healthcare law provides fees — some funded by the government and some collected from insurers — to help offset the costs of taking on an influx of potentially unhealthy patients. The process, known as "risk adjustment," is designed to ensure that one insurance company doesn't end up with a disproportionately unhealthy risk pool.
The program "is intended to provide increased payments to health insurance issuers that attract higher-risk populations, such as those with chronic conditions, and reduce the incentives for issuers to avoid higher-risk enrollees," the new proposed rule states.