Payers' Role in Health Insurance Exchanges Unclear

States then will be responsible for either the plan management or consumer assistance, or both. Schwartz says she's hearing that states are interested in taking ownership of the consumer assistance piece because states want "people on the ground" to help members enroll.

"We've seen a lot of states are estimating that more than half the people coming in the door are going to need time with individuals by phone or in-person to figure out what plan to enroll in. A website alone will not help them," says Schwartz.

States may also opt for managing the consumer assistance portion of the partnership because the assisters, as they're called, are subsidized with federal money.

For the states that have defaulted to the federal government's way of running an exchange, details are still murky. "We do not yet know exactly what else the feds are going to put in place, and we don't know if it's going to be easy for states or hard," says Schwartz.

One big question is in which states will health plans participate? Commercial payers already in the group and individual markets are in the best position to get set up to participate in exchanges.

Aetna announced at its last investors conference that it planned on participating in more than a dozen exchanges. No other health plan has made such a statement,though some industry watchers expect more plans to come on board after the first of the year. Schwartz predicts it could take even longer.

"If the feds really wanted to make it easy for plans, they'll allow plans to fill out a form and check off all the different federally operated state exchanges they want to participate in, and then they'll [health plans] have to figure out if they're meeting the commercial insurance rules in all those states. By spring, we'll know a lot more," says Schwartz.