Consumers are supposed to be able to use a new system of health insurance purchase tax credits to buy coverage through the exchanges.

All policies sold through the exchange are supposed to meet minimum quality standards and offer designated levels of "actuarial value."

But a state can choose to be home to one exchange or several, to join a multi-state exchange program, or to have the federal government provide exchange services for its residents.

Officials at the U.S. Department of Health and Human Services (HHS) proposed in July that states also should be able to have a great deal in flexibility in other exchange design and governance matters.

AHIP appreciates HHS officials' efforts to provide flexibility, Durham and Gallaher write.

"We note that the rule's goal, as stated in the introduction, is to 'enhance competition in the health insurance market, improve choice of affordable health insurance,' and note our strong support for choices for consumers and competition in the insurance market that provides a full range of options for consumers," the AHIP representatives write.

The Centers for Medicare & Medicaid Services (CMS), the HHS arm running the program, could help improve the exchange construction process by publishing final rules and guidance as quickly as possible, and by publishing any technical specifications that have already been given to government contracts, the AHIP reps say.

HHS also should require states that decide not to create exchanges to be open about their decisions to work with the federal government or multi-state exchanges.

Some consumer groups and other interest groups have opposed insurer participation in many aspects of exchange administration and implementation of related programs.

At AHIP, "given the scope of the task of designing and implementing exchanges, we strongly support the decision to include insurers and insurance experts on governance boards," the AHIP reps say. "Our members have a great deal of experience and operational know-how to offer exchanges and will be valuable contributors to the governance process. If a state chooses to establish an exchange in an executive branch department, we suggest that the state be required to create an advisory committee that brings in stakeholder expertise and input, including feedback by insurers and insurance experts"