State Actions to Implement the Health Benefit

State Actions to Address Health Insurance Exchanges

Richard Cauchi, Health Program 11/26/2014

Gearing up for 2015 | View New Insurers and Premiums

Beginning Oct. 1, 2013, Health Insurance Exchanges, also called Marketplaces, opened to the public in all 50 states and D.C., offering health insurance coverage that began January 2014.  For state policymakers, activity and decisions began more than three years earlier. The implementation and state responses continue in the late fall of 2014. 

The Affordable Care Act of 2010 (ACA) gave states the option to establish one or more state or regional exchanges, partner with the federal government to run the exchange, or to decline or opt out which means the establishment of a Federally-Facilitated Marketplace.  In the months and years since the law was signed, every state governments’ legislative and executive branches considered the options and made choices, about how their state’s exchange would be run, whether, and how much federal start-up funds to request and accept, and determine who would regulate the new insurance products offered to residents.

This report provides both a snapshot and a detailed look at:

  1. 2015 Health Plans for Sale: The plans and latest information about enrollment and renewals for 2015.
  2. State Roles in Exchanges: The decisions made by states and the federal decisions affecting states, from 2010 to 2014.
  3. 2014 Implementation: The start-up steps and enrollment results in year one (2014).


Plans and Actions for 2015

On Nov. 15, 2014 health marketplaces or exchanges began a three-month open-enrollment period for the 2015 health insurance plan year.  Exchanges will provide new lists of insurance plan choices and premiums by state, and new consumer information that applies to both federal facilitated marketplaces and state-based exchanges. The reports below the map provide specifics as state decisions and federal guidance are released.  

  • Open enrollment for the 2015 coverage year began Saturday, Nov. 15, 2014 using or state-run websites in all 50 states, open for business and consumer sign-ups.
    • 2015 Health plan premium information for individuals and families.  This new web feature, launched by CMS Nov. 14, 2014, provides an unprecedented "all in one place" list of every health plan offered through, including 36 pricing scenarios such as "Adult individual age 21, 27, 30, 40, 50, and 60" and more than 100,000 lines of resulting monthly premiums before any subsidy reductions are applied. The material is invaluable to in-state researchers and policymakers, but not intended for use by enrollees. There is separate dental plan data with 39,000 listings.
    • opened in advance Nov. 10, 2014 with a new "see-plans" feature, for viewing 2015 prices, subsidies and choices. Users enter a zip code to see their community, or compare with a neighboring state or region.
  • Consumer reenrollment for 2015 explained for those who first obtained coverage for 2014 -- See HHS/CMS public enrollment announcement below, released Oct. 17, 2014.
  • Insurers offering health policies on exchanges for 2015, by state - this data is included in the NCSL state report below for those states with published plans. An NCSL Blog post of Oct. 29 summarizes advance reports, and includes a new 50-state map of insurer changes.  
  • -NEW- State Marketplace Approaches to Financing and Sustainability for 2015.   The Affordable Care Act provided significant start-up funds—over $4 billion has been awarded thus far—to help states set up their health insurance marketplaces. However, after January 1, 2015, there will be no more federal establishment funds awarded and state-based marketplaces, must be financially self-sustaining. Marketplaces may use a variety of approaches to fund their operations, including user fees, state appropriations, or redirecting existing revenue sources. Read the full Report, posted by The Commonwealth Fund, Nov. 7, 2014.
  • Supreme Court Accepts Obamacare Case.  The U.S. Supreme Court's docket leaped from boring to big with the grant of just one case: King v. Burwell. The issue in this case is whether tax credits for low and middle income health insurance purchasers are available under the Affordable Care Act (ACA) if insurance is purchased on a federal exchange rather than a state exchange. Only 16 states and the District of Columbia have fully established exchanges, with partnerships and variations in several other states. NCSL Blog post, 11/13/2014 by Lisa Soronen, executive director of the State and Local Legal Center.

  • 2014 Marketplace Enrollment by the Numbers - According to reports updated in August, HHS revised the ongoing enrollment to 7.3 million, to reflect changes in coverage to private employers or Medicaid, and eligibility reevaluations and denials. Reports and 50-state results are listed and linked below the map.  Also see state news and other state summaries and news below the map. NCSL 50-state snapshot table (below)
  • First year health coverage began Jan. 1, 2014, and usually extends through Dec. 31, 2014. Those who enrolled in health coverage through Marketplaces or Exchanges now receive health services and treatment, with coverage starting the first of each month for those with "qualifying events" such as leaving a job, having a baby, moving to a new state, etc. Health insurance coverage now includes pre-existing conditions, no-charge preventive visits and subsidized premiums for those with annual incomes less than 400 percent of federal poverty level (up to $95,400 for a family of four for 2015 plans; an increase from the 2014 maximum of $94,000). 

New 50-State Table of State and Federal Actions to Implement Exchanges or Marketplaces
View, print or download your state(s) in PDF Format  (Updated Nov. 26, 2014; total = 59 pages) Includes all information in the map.


Use this interactive map to view individual state snapshot information. Hover on state for quick facts; Click on state for details on legislation and 2014-15 implementation.

State-Run Exchange

State/Federal Partnership

Cyan box

State-run authority;

interim Federal role 

Purple box State-Run SHOP;
Federally-run Marketplace
for Individuals
Purple box

Federally Facilitated Marketplace (Exchange)


Overview of State Actions, 2010 to December 2014

States that created or wanted to create and run their own exchange had to submit blueprints and receive approval from the U.S. Department of Health and Human Services. By the December 2012 federal deadline, 18 states and the District of Columbia had submitted blueprints.  18 states and D.C. later received approval from HHS for their exchange.

  • As of late 2014, 14 states and the District of Columbia had enacted legislation to establish or authorize state-based health insurance exchanges. A few others were initiated by governors' executive orders. Massachusetts (2006) and Utah (2009) passed exchange laws prior to the enactment of the Affordable Care Act in March 2010. With Exchanges in operation, 14 states and D.C now fully operate their own state-run enrollment websites, while 36 others rely on the federal, including seven federal-state "partnership" exchanges. Michigan applied for and was conditionally approved as a partnership, but is operating as a federal marketplace.
  • Utah was first to request and be approved to run the SHOP exchange while the federal government runs the individual exchange. The Utah structure is now part of the HHS exchange final rules as another option to states.
  • Mississippi's elected insurance commissioner applied for a state exchange in 2012, but did not receive HHS approval. On Oct. 1, 2013, however, Mississippi received conditional federal approval to run an online SHOP marketplace where businesses with 50 or fewer employees can buy health insurance, launched January 2014.
  • Idaho requested that the federally facilitated exchange provide initial assistance to their exchange operation and enrollment for 2014 while they continue building a fully state run exchange. The Idaho state-run website is now live for 2015, serving individuals and small employers (SHOP).
  • New Mexico obtained approval to have the federally facilitated exchange provide operation of the individual exchange for plan years 2014 and 2015. New Mexico has a state-run SHOP exchange for 2014 and 2015, with their state-run individual marketplace now scheduled to launch November 2015. [Description updated 11/2014]
  • Seven states (Arkansas, Delaware, Illinois, Iowa, Michigan, New Hampshire and West Virginia) selected the state-federal partnership option, in which the state runs the consumer assistance and/or plan management function of the exchange. All such states were required to submit a blueprint and received HHS approval of partnership exchanges.  In 2015, plan management is being dropped by CMS/CCIIO as a formal option for state-partnership marketplaces. 
  • Arkansas's health exchange board voted to delay until 2017 the launch of its own state-run exchange for individual coverage. It plans to operate a state-run SHOP exchange for plan year 2016.
  • Illinois, in early 2014, indicated its intention to fully run its own exchange. It is approved by CMS as a state-federal partner marketplace for 2014 and continues that status for plan year 2015.
  • Oregon voted April 26, 2014 to abandon its state-run website for plan year 2015 and convert to the federal Nevada also is using in 2015.  Both states retain their HHS approved status as a state-run marketplace.
  • 2014 State Legislation to Establish a State-Run Exchange - NCSL analysis report, updated October 10, 2014.

The other states have defaulted to the federally facilitated exchange (marketplace). Every state in this federally facilitated category and the partnership category have the option of eventually running a fully state-based exchange.

2015 Responses and Implementation: Read More on Recent Developments

ACA Updates Icon

  • NCSL 50-state snapshot table (below)
  • Continuous and Special Enrollment Open: Medicaid and SHOP (small business) applicants usually do not have a enrollment deadline and may be able to sign up 12 months of the year. There also are several standard exceptions and "life events" that allow individuals to make Marketplace health insurance purchases between April 1 and November 15.
  • Employers with under 100 workers given until 2016 to offer coverage. On Feb. 10, 2014, the Treasury Department extended by one year the requirement that employers with between 50-99 workers meet the mandate to offer health insurance, a category that includes about seven percent of the private employee workforce. The new rules also will require 70 percent of workers to be covered in that first year. Read the Treasury fact sheet here [2 pp.] and final rule here [227 pp.].  
    How the federal policies affect employers:
    • Small Businesses with fewer than 50 employees: (about 96% of all employers): Under the Affordable Care Act, companies that have fewer than 50 employees are not required to provide coverage or fill out any forms in 2015, or in any year, under the Affordable Care Act.
    • Employers with 50 to 99 employees (about 2% of employers): Companies with 50-99 employees that do not yet provide specified-quality, affordable health insurance to their full-time workers will report on their workers and coverage in 2015, but have until 2016 before any employer responsibility payments could apply.
    • Larger employers with 100 or more employees (about 2% of employers): The overwhelming majority of companies with 100 or more employees already offer quality coverage.  The revised rules phase in the percentage of full-time workers that employers need to offer coverage to, starting with 70 percent in 2015 to 95 percent in 2016 and beyond. Employers in this category that do not meet these standards will make an employer responsibility payment for 2015.
  • -NEW- Explanation of eligibility for premium subsidies or Medicaid enrollment based on income - posted by HHS Nov. 4, 2014

Table of premium subsidies for 2014-2015

  • Explanation of Renewal Options, 2014 to 2015 (released Oct. 16, 2014)
    CMS description to help Marketplace enrollees stay covered 

    • "Consumers should come back to, reach out to the call center, or visit with an in-person assister to make sure they choose the plan that best meets their needs starting November 15, 2014.

      "The Centers for Medicare & Medicaid Services (CMS) is committed to making it as easy as possible for current Health Insurance Marketplace enrollees to renew their coverage for 2015. It is encouraging consumers to come back at the start of Open Enrollment on November 15, update their 2015 application, and compare their options to make sure they enroll in the plan that best meets their budget and health needs for next year. In mid-October consumers will begin to receive notices from the Federally-facilitated Marketplace in the mail and in their accounts, explaining how they can renew their coverage during Open Enrollment.

      CMS is working to make sure consumers have the assistance and information they need, this communication is just the beginning of an effort to help consumers stay covered. Importantly, to help simplify the re-enrollment process, when consumers return to starting on November 15 and initiate their 2015 application, 90 percent of their online application will already be filled out or pre-populated.  In-person assistance will be available to help review an applicant’s options and find a plan that best suits their needs. Also, we are staffing up an additional 1,000 call center representatives this year over last year that will be available to answer questions and walk consumers through the coverage process.

      If consumers do not return to the Marketplace to update their application, they generally will be auto-enrolled in the same plan - with the same amount of advance payment of the premium tax credit and same cost-sharing reductions – as the 2014 plan year. They can change plans during open enrollment through February 15, with coverage in their new plan starting on the first day of the next or second month depending on when they enroll.

      To help consumers better understand the renewal process, CMS is releasing today the 5 Steps to Staying Covered – to make it as simple as possible for them to choose the plan that best fits their needs and budget.  The consumer tested 5-step process includes:

  1. ​​​​Review: Plans change, people change – review your coverage and look for a letter from your plan about how your benefits and costs may change next year,
  2. Update: Starting November 15, log in and update your 2015 application - make sure your household income and other information is up-to-date for next year,
  3. Compare: Compare your current plan with other plans that are available in your area,
  4. Choose: Select the health plan that best fits your budget and health needs, and
  5. Enroll: The marketplace opens on November 15, make sure to review, update, compare and choose by December 15 to have any changes take effect on January 1.  Contact your plan after you’ve enrolled and make sure you pay your first month’s premium.
    Days left to enroll in Exchange health insurance to get Jan.1 coverage
    Federal Marketplace notices and professional training materials are available hereConsumers can learn more about the "5 Steps to Staying Covered here"
  • State-by-State Information Contacts for ACA Enrollment - An NCSL Resource for Legislatures (updated for new enrollment by consumers or small employers)
  •  Online SHOP Exchanges for small businesses delayed until 2015.  On Nov. 27, 2013 the Obama Administration announced another delay for SHOP the small businesses option to buy group insurance online for employees through the marketplaces run by the federal government in 36 states. This feature is now set to be in place one year later, in November 2014 for coverage in 2015.  Small employers can still use paper applications to buy through a federal marketplace for 2014, likely using an insurance broker. The 14 state-run exchanges can continue to use online tools to sign up small employers through SHOP. Small businesses with up to 25 employees can be eligible for premium subsidies, but only if the purchase is made through an exchange, and not the commercial market outside of the exchanges or marketplaces. The new HHS guidance for SHOP as of late November states: "You enroll in SHOP coverage directly through an agent, broker, or insurance company. Work with an agent, broker or insurance company to help you apply for SHOP eligibility and find and compare available SHOP plans. You can also use the HHS premium estimation tool on to browse and compare plans and pricing information."  More.

[Disclaimer: NCSL provides links to third-party sources for information only and is not responsible for opinions or links contained on such websites.]

By the Numbers: 2014 Enrollment Results in Detail

The enrollment process for the first year of ACA Marketplaces and Exchanges was the subject of intense scrutiny and commentary.  One result is an unprecedented quantity of reports, charts, maps and media coverage.  This state-specific material remains useful as the nation begins the new tally of 2015 enrollment.

  • About 3.8 million people enrolled in Health Insurance Marketplace plans in the final reporting period, which began March 2 and concluded on April 19. In August 2014, HHS revised the ongoing enrollment to 7.3 million, to reflect changes in coverage to private employers or Medicaid, and eligibility reevaluations and denials.
  • Medicaid and CHIP:  An HHS report released Aug. 8, 2014, calculated "more than 7.2 million additional people enrolled in Medicaid and the Children’s Health Insurance Program" compared to pre-October 2013.
    • 5 million people are enrolled in plans that meet ACA standards outside the Marketplace, according to a CBO estimate. When insurers set premiums for next year, they are required to look at everyone who enrolled in plans that meet ACA standards, both on and off the Marketplace.
    • 3 million young adults gained coverage based on the Affordable Care Act by being able to stay on their parents' health plan, with enrollment that began in October 2010.
    • State enrollment figures in detailMarketplace Enrollment Report. (released May 1, 2014, 45 pages PDF)  For State by States Tables (22 pages, PDF).  Medicaid through Exchanges: Enrollment Report. released May 1, 2014.  Detailed numbers are available, by states, individual insurers and local rating districts in Word, and Excel formats.  The comprehensive dataset, HIX Compare, contains: Premium information for all 7,027 Silver plans being sold through the ACA health insurance exchanges;  Benefit design and cost sharing requirements for all 1,208 unique Silver exchange plans.Posted by the Robert Wood Johnson Foundation. 

More Key Exchange and Health Reform Resources

  • American Health Benefit Exchange (Federal Overview)
    Includes information on essential health benefits packages, model legislation from NAIC, federal requirements for exchanges and guidance from HHS.
  • Premium Affordability, Competition, and Choice in the Health Insurance Marketplace, 2014 (PDF-26 Pages), U.S. HHS/ASPE Research Brief, published June 2014.
    This brief provides an overview of health insurance plan premiums available in the 2014 Marketplace and the important role of the advanced premium tax credit (“tax credit”) in helping families afford coverage. It contains information on the change in the premium cost associated with the tax credit for individuals who made Marketplace plan selections through the Federally-facilitated Marketplace (FFM) during the initial open enrollment period. Also, it analyzes over 19,000 Marketplace plans for 2014, within four metal levels (bronze, silver, gold, and platinum) for each of the 501 rating areas across 50 states and the District of Columbia. Tax credits reduced premiums by approximately 76 percent, on average, for individuals who selected plans in the FFM with tax credits. Competition, as measured by the number of issuers in a rating area, was associated with more affordable benchmark plans (the second-lowest cost silver plan).
  • Extension for complex cases. Regular open enrollment for individuals to purchase health insurance ended Mar. 31, 2014. However, on March 26, 2014 HHS officials issued new guidelines for those that attempted to buy health insurance, but missed the March 31 deadline.  Many could request an extension and still apply, as described in Guidance for Issuers on "People In Line” and for "Complex Cases." This process allowed some applicants to complete the enrollment process into mid-April.
  • Essential Health Benefits State Benchmark Plans | Health plans offered both inside and outside of the health insurance exchanges as of Jan. 1, 2014, must offer a comprehensive package of Essential Health Benefits (EHB) based on provisions in the Patient Protection and Affordable Care Act (PPACA). EHBs are required to include items and services within at least 10 broad categories.  By September 2012, states could chose their EHB package based on existing health insurance plans, or defer to a federally defined but state-based template plan. This link to NCSL resources provides more information on EHBs and state benchmark selections.
  • Health Reform 2014 State Legislative Tracking Database  | The latest listings, with summaries and status for more than 1,140 filed measures. Updated very two weeks through December 2014. Archive available: Health Reform 2011-13 State Legislative Tracking Database
  • The ACA: a 2014 Interim Report Card; an NCSL presentation -

U.S. Department of Health and Human Services
U.S. Department of Labor

State Table 2: Snapshot of Exchange State Actions and Figures

(also see table and map above)

Nationwide Summary [also available HHS Enrollment Report & HHS State Profile (May 1, 2014).

"Number of Individuals"  As published by HHS May 1, 2014. State totals include individuals later determined not eligible, and others who obtained employer-based coverage. An estimated 400,000 policies provide dental coverage. 
                                                           TOTAL         State-Run   Fed.-Facilitated
Eligible for Medicaid/CHIP                 4,377,932        2,706,404     1,378,871

(As determined by a Marketplace)
      Key: Allow Renewal: 1st "Y"= now: 2013 state policy; 2nd "Y" or "N"= updated state policy for plan year 2014. 
        ~ = not decided; not available

The box allows you to conduct a full text search or use the dropdown menu option to select a state.





Did Not Pass

2014 Enrollment
health insurance
Selected a Plan

as of date listed

Eligible for 2014 Enroll-
ment for  Medicaid/CHIP

as of date listed

now / futur
as of 12/31/2013



2011, 2012


97,870 (4/19/14)

22,564 (3/31/14) Y / Y


  2011, 2012   12,890 (4/19/14) 4,172 (3/31/14) Y / N



2011, 2012   120,071 (4/19/14) 101,282 (3/31/14) Y / ~



2011   43,446 (4/19/14) 73,681 (3/31/14) Y / N



    1,405,102 (4/19/14)

1,700,000 (3/31/14)
(630,000 from
Low Income Health Program

N / N
 Colorado 2011    

125,402 (4/19/14)

181,983 (3/31/14) Y / Y



    79,192 (4/19/14) 138,908 (3/1/14) Y / N



  Exec. action 14,087 (4/19/14)

7,663 (3/1/14)

Y / N
 District of Columbia 2012    

 10,714 (4/19/14)

19,464 (3/1/14) Y / N



-   983,775 (4/19/14) 180,479 (3/31/14) Y / Y



2011, 2012   316,543 (4/19/14) 91,914 (3/31/14) Y / Y
 Hawaii 2011     8,592 (4/19/14) 39,282 (1/10/14)
2,148 eligible via CHIP
 Idaho   2012   76.061 (4/19/14) 10,709 (3/31/14) Y / ~


2011 (intent)

    217,492 (4/19/14) 181,070 (3/31/14) ~ / Y



2011   132,423 (4/19/14) 94,495 (3/31/14) Y / N
 Iowa   2011, 2012   29,163 (4/19/14) 36,891 (3/31/14) Y / N
 Kansas   2011   57,013 (4/19/14) 13,961 (3/31/14) Y / Y



  Exec. order 82,747 (4/19/14)  
+475 employers

357,990 (3/31/14) 

Y / Y



2012   101,778 (4/19/14) 14,359 (3/31/14)  Y / Y



2011, 2012   44,258 (4/19/14) 7,103 (3/31/14) Y / Y



-   67,757 (4/19/14)  163,602 (3/31/14) Y / N



-   31,695 (4/19/14) n/a N* / N



2012   272,539 (4/19/14) 40,347 (3/31/14)  Y / Y


2011, 2012

    48,495 (4/19/14) 144,481 (3/31/14) Y / N



  state run SHOP only 61,494 (4/19/14)  13,779 (3/31/14) Y / N
 Missouri       152,335 (4/19/14) 45,513 (3/31/14)  
 Montana       36,584 (4/19/14) 4,638 (3/31/14)  
 Nebraska - -   42,975 (4/19/14)  9,879 Y / N
 Nevada   - Exec. action 45,390 (4/19/14) 182,946 Y / N

 New  Hampshire


2011   40,262 (4/19/14) 7,235 Y / Y

 New Jersey

2012 vetoed

2012   161,775 (4/19/14) 179,872 ~ / Y
 New Mexico 2011 vetoed 2012 state run SHOP only 32,062 (4/19/14)
   166 SHOP
30,147 Y / ~

 New York


- Exec. order 960,762 (3/16/14)
370,451 HHS (4/19)
646,018 (3/31/14)  N / N

 North Carolina

2011 (intent)

2011   357,584 (4/19/14) 73,898 Y / Y

 North Dakota


2011   10,597(4/19/14) 6,843 ~ / Y



2012   154,668 (4/19/14)  156,899 Y / Y
 Oklahoma   2011, 2012   69,221 (4/19/14) 17,374 Y / N



  will use federal in 2015 68,308 (4/19/14) 207,329 N / N
 Pennsylvania   2012   318,077 (4/19/14) 42,335 ~ / Y

 Rhode Island


2011   28,485  (4/19/14) 
SHOP: 107 employers = 658
70,243 N / N

 South Carolina


2011, 2012   118,324 (4/19/14) 28,359 Y / Y
 South Dakota       13,104 (4/19/14) 3,850  



    151,352 (4/19/14)  83,591 Y / Y



2011   733,757 (4/19/14) 141,494 Y / Y



  state run SHOP only

84,601 (4/19/14) 
357 SHOP employers

50,268 Y / Y~
 Vermont 2011     38,048 (4/19/14) 41,704 Y / N


2011 (intent)


216,356 (4/19/14)


Y / N

 Washington 2011     163,207 (4/19/14) 628,893 N / N
 West Virginia 2011     19,856 (4/19/14) 21,019 Y / N



2012   139,815 (4/19/14) 81,274 Y / Y



-   11,970 (4/19/14) 2,216 (3/31/14) Y / Y

[Disclaimer: NCSL provides links to third-party sources for information only and is not responsible for opinions or links contained on such websites.]


Notes for "Health Insurance Exchanges or Marketplaces: State Actions" 50-state tables

1 Declaration refers to the decision the state made in regards to developing a state based health insurance exchange. This section provides links to the declaration letter and the approval or conditional approval from HHS. Resource: The Center for Consumer Information and Insurance Oversight, HHS, Jan. 4, 2013.

2Structure refers to where the exchange will be housed in the state.

3 Governance refers to the governing board outlined in the law.

4 Selection of Carriers is regarding how a state will operate the exchange. States have options to operate their exchange from an “active purchaser” model in which the exchange operates as large employers often do, using market leverage and the tools of managed competition to negotiate product offerings with the exchange..To the “open marketplace” in which the exchange operates as a clearing house that is open to all qualified insurers and relies on market forces to generate product offerings as is the case in CO and UT. For these states, This means that any insurer that meets the Qualified Health Plans standard can participate in the exchange. On the other hand, a state governing board can participate in selective contracting and pick and choose which insurers are allowed to participate as is the case in CA, MA, and CT.

5 Highlights include announcements, unique facts, etc.

6 Federal Grants are a part of the Affordable Care Act and are available to states to plan and implement exchanges. State exchanges must be self sufficient by 2015.

7 California was the only state to enact exchange establishment in 2010.
***For details on 2011-2013 bills that did not pass, please click here to access the NCSL bill tracking database.  
Massachusetts and Utah passed laws prior to the enactment of the Affordable Care Act in March 2010.

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