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State Actions to Implement the Health Benefit

State Actions to Address Health Insurance Exchanges

Richard Cauchi, Health Program 10/30/2014

Gearing up for 2015 | 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. Coming up next: 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 implementation steps and enrollment results in year one (2014).

Plans and Actions for 2015:

On November 15, 2014 health marketplaces or exchanges will begin 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.  

  • 2014 Marketplace Enrollment by the Numbers - 

According to HHS reports dated May 1, 2014.  8,019,763 people selected Marketplace plans from October 1, 2013, through March 31, 2014, (as well as the Special Enrollment Period activity through April 19th). Nearly 2.6 million signed up in the State Based Marketplaces and over 5.4 million enrolled through the Federally-Facilitated Marketplace. 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 7,300,000, 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 5/1/2014, 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, posted by the Robert Wood Johnson Foundation. 

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 $94,000 for a family of four). 

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 October 22, 2014; total = 59 pages) Includes all information in the map.

MAP OF HEALTH INSURANCE EXCHANGE STRUCTURES - 2014-2015

Use this interactive map to view individual state snapshot information. Hover on state for quick facts; Click on state for details on legislation and 2013-15 implementation.

State-Run Exchange

State/Federal Partnership

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

Federally Facilitated Marketplace (Exchange)

Cyan box

State-run authority;

interim Federal role 

 

Overview of State Actions

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 mid-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 healthcare.gov, 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 and New Mexico requested that the federally facilitated exchange provide some initial assistance to their exchange operation and enrollment while they continue building a fully state run exchange. New Mexico will run the SHOP exchange first, with their own individual marketplace scheduled to launch October 2014.
  • Seven states 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 receive approval of partnership exchanges.
  • Arkansas's health exchange board voted to delay until 2016 the launch of its own state-run exchange for individual coverage. It plans to operate a state-run SHOP exchange for 2015.
  • 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 ye
  • - NEW - 2014 State Legislation to Establish a State-Run Exchange - NCSL analysis report, updated October 10, 2014.
  • Oregon voted April 26, 2014 to abandon its state-run website for plan year 2015 and convert to the federal Healthcare.gov. Nevada also is using Healthcare.gov in 2015.  Both states retain their HHS approved status as a state-run marketplace.

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.

Read More on Recent Developments

ACA Updates Icon

  • NCSL 50-state snapshot table (below)
  • Enrollment Summaries for 2014: Regular open enrollment for individuals to purchase health insurance ended Mar. 31, 2014. However, on March 26, 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.
  • 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 and November.
  • 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 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 policy affects 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.
    • Larger employers with 100 or more employees (about 2% of employers): The overwhelming majority of these companies with 100 or more employees already offer quality coverage.  Today’s rules phase in the percentage of full-time workers that employers need to offer coverage to from 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.
    • Employers with 50 to 99 employees (about 2% of employers): Companies with 50-99 employees that do not yet provide 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.
  • -NEW- Explanation of Renewal Options, 2014 to 2015 (released Oct. 16, 2014)
    CMS description to help Marketplace enrollees stay covered 

    • "Consumers should come back to HealthCare.gov, 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 HealthCare.gov 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 HealthCare.gov 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.

    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)
  • Federal Health Reform News: NCSL News and information on President Obama’s ACA proposal addressing insurance cancelations, including material on congressional measures, the president's statements and responses from several sources including the NAIC and AHIP.
  •  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 HealthCare.gov to browse and compare plans and pricing information."  More.
  • An HHS report provided examples of the health plan choices and premiums that are available in the federally involved marketplaces. The report also includes similar information that is publicly available from the states and the District of Columbia that are implementing their own marketplace.

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

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 of 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).
  • 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 provides more information on EHBs and state benchmark selections.
  • Federal Guidance and Regulation of State Health Benefit Exchanges | Information and summaries of federal guidance and regulations affecting state health benefit exchange implementation.
  • Health Reform 2014 State Legislative Tracking Database  | The latest listings, with summaries and status for more than 1,120 filed measures. Updated very two weeks -- Aug. 26, 2014. 
  • Health Reform 2011-13 State Legislative Tracking Database  | A 3-year archive record, with summaries and status for more than 2,550 measures filed throughout 2011-2013 in all 50 states and DC.
  • The ACA - a 2014 Interim Report Card - www.ncsl.org/Portals/1/Documents/Health/Cauchi-AHCJ-HIRC.pdf
  • Health Reform: State Actions Newsletter | The Affordable Care Act: State Action Newsletter highlighted state actions related to the federal Affordable Care Act. 68 archive editions cover Feb. 2011 through Jan. 2014.

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
                                                           TOTAL         State-Run   Fed.-Facilitated
Enrolled in a Marketplace plan           8,019,763        2,573,585     5,446,178

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.

STATE ACTIONS AND FIGURES

State

Enacted 
Exchange

Statute

Did Not Pass
Exchange
Legislation***

Notes;
Events
Enrollment
health insurance
Selected a Plan

as of date listed

Eligible for Enrollment
for  Medicaid/CHIP

as of date listed

Allow
Renewal:
now / futur
e
as of 12/31/2013

 Alabama

 

2011, 2012

 

97,870 (4/19/14)

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

 Alaska

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

 Arizona

 

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

 Arkansas

 

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

 California

2010

    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

 Connecticut

2011

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

 Delaware

 

  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

 Florida

-

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

 Georgia

 

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 / ~

 Illinois

2011 (intent)

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

 Indiana

 

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

 Kentucky

 

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

357,990 (3/31/14) 

Y / Y

 Louisiana

 

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

 Maine

 

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

 Maryland

2011

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

 Massachusetts

2006

-   31,695 (4/19/14) n/a N* / N

 Michigan

 

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

 Minnesota

2011, 2012

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

 Mississippi

 

  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

 Ohio

 

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

 Oregon

2012

  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  

 Tennessee

 

    151,352 (4/19/14)  83,591 Y / Y

 Texas

 

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

 Utah

2009

  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

 Virginia

2011 (intent)

2012  

216,356 (4/19/14)

48,660

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

 Wisconsin

 

2012   139,815 (4/19/14) 81,274 Y / Y

 Wyoming

-

-   11,970 (4/19/14) 2,216 (3/31/14) Y / Y
HHS Enrollment Report, 3/1/14            

[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. Please see State Table 1 for information on these two states.

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