Final update made on September 26, 2013 (no further updates will be made )

Establishing the Marketplace

On June 16, 2011, Nevada’s Governor Brian Sandoval (R) signed SB 440 into law establishing the Silver State Health Insurance Exchange.¹  In March 2013, the state announced that the online marketplace would be called Nevada Health Link.

Structure: The legislation defines Nevada’s Exchange as a quasi-governmental organization.

Governance: The Marketplace is governed by a 10-member board, including three ex officio, non-voting members (or their designees): the Director of the Department of Health and Human Services, the Director of the Department of Business and Industry, and the Director of the Department of Administration. The Governor appoints five of the voting members, while the Senate Majority Leader and the Speaker of the Assembly each appoint one voting member. The legislation specifies that voting members should possess subject expertise in areas such as: individual or small employer health insurance markets; health care administration, financing, or information technology; health care delivery system administration; or experience of consumers that would benefit from the Exchange. Voting members cannot be Legislators or hold an elected office in Nevada state government, nor can they be affiliated with, have ownership interest in, or be a representative of a health insurer.

On September 23, 2011, the final board members were appointed.²  The voting members are:

• Lynn Etkins, Legal Aid Center of Southern Nevada
• Dr. Judith Ford, Canyon Gate Medical Group
• Leslie Ann Johnstone, Health Services Coalition
• Marie Martin Kerr, Kerr Intellectual Property Law Group
• Dr. Ronald Kline, Comprehensive Cancer Centers of Nevada
• Elsie Lavonne Lewis, Clark County Urban League
• Barbara Smith Campbell, Consensus

The Marketplace Board hired an Executive Director in December 2011. The Board is required to submit fiscal and operational reports to the Governor and legislature by June 30 and December 31 of each year.

The Board established five advisory committees to provide recommendations on Marketplace implementation in the following areas: finance and sustainability; plan certification and management; Small Business Health Options Program (SHOP) Exchange; reinsurance and risk adjustment programs; and consumer assistance. The Advisory Committees met regularly starting in March 2012, and the Board approved 35 of their recommendations. As of May 2013, the Advisory Committees were disbanded and will no longer meet.³ 

The Marketplace Board completed a Tribal Interaction and Impact Assessment and is using the information to reach out to the state’s Tribes. The Marketplace has also signed a Tribal consultation agreement with the Indian Health Board of Nevada.⁴ 

Contracting with Plans: In April 2012, the Nevada Health Link Board approved guiding principles recommended by the Plan Certification and Management Advisory Committee, which included adopting a “Free Market Facilitator” model that “ensures the maximum participation by insurers and the widest choice for consumers.”⁵  In September 2012, the Board approved allowing carriers to offer Qualified Health Plans (QHPs) in either or both the Individual and SHOP Marketplaces at their discretion and that QHPs not be required to be identical in each Marketplace.⁶  Carriers are required to offer one silver level plan and one gold level plan, and silver level plans must offer cost-sharing variations of 73%, 87%, and 94% actuarial value. Carriers must also offer a zero cost-sharing version of all plans for American Indians as well as child-only plans at the same level of coverage as any other plan offered through the Marketplace. Catastrophic plans may only be offered in the individual market and to individuals under the age of 30 or to individuals with a certification for hardship exemption in effect.⁷  Also, each licensed carrier may not offer more than five QHPs in each metal tier (including a catastrophic tier) in each Marketplace.

In April 2013, the Board approved network adequacy standards that require carriers to ensure sufficient numbers and types of providers to meet the needs of the enrolled population, to comply with the Affordable Care Act’s Essential Community Provider requirement, and to include at least one community hospital in the provider network, if available. The Board established network adequacy ratios and travel standards according to county and provider specialty. Carriers may employ telemedicine to meet these accessibility requirements.⁸  Carriers must make their provider directories available to the Exchange for publication online and to enrollees in hard copy, if requested.

Four carriers will offer plans on Nevada Health Link in 2014. Individual market QHPs will be in place for one year and changes to plans may only be made prior to the open enrollment period. In September 2013, the DOI approved rates for plans that will be available in the individual and SHOP Marketplaces.

Risk Adjustment, Reinsurance, and Risk Corridors: The Board approved plans to conduct an analysis to determine whether Nevada-specific factors should be used in a risk adjustment model and continues to discuss whether the state should administer the reinsurance program or defer to the federal government.⁹ 

Dental and Vision Benefits: In March 2013, the Board decided that all QHPs that provide the pediatric dental essential health benefit must submit the dental benefit as a rider for the product. In April, however, the Centers for Medicare and Medicaid Services (CMS) determined it would not recognize riders for the pediatric dental essential health benefit. The Plan Certification and Management Advisory Committee met twice in May and ultimately recommended that the Marketplace allow the pediatric dental benefit to be embedded in a QHP, bundled with a QHP, or sold as a stand-alone plan.¹⁰  All children enrolled in a QHP through Nevada Health Link must purchase the pediatric EHB. Annual out-of-pocket maximums will be limited to $700 for one child and $1,400 for two or more children enrolled in stand-alone plans.¹¹ 

Consumer Assistance and Outreach: In December 2012, the Board approved a Navigators, Enrollment Assisters, Certified Application Counselors (CACs), and Producers Plan, detailing how the four entities will work together to enroll eligible individuals through Nevada Health Link. The primary function of Navigators will be to provide enrollment assistance and educational outreach, while Assisters will focus solely on application and enrollment assistance. Certified Application Counselors (CACs) will provide enrollment assistance and will largely work in hospitals.¹²  CACs will not be compensated by the Marketplace. In June 2013, Nevada Health Link announced the eight organizations that have been selected as Navigator/Enrollment Assister grantees.¹³  Navigators, Enrollment Assisters, and CACs must receive Exchange Enrollment Facilitator (EEF) Certification from the DOI prior to enrolling individuals or employers in a QHP. Certification requirements include taking a 20 hour training course, passing a test with a score of 70% or better, and undergoing a background check.¹⁴  The first assisters were certified the first week of September. After becoming certified, Navigators, Enrollment Assisters, and CACs must complete a four-hour training course run by the Marketplace.

Over 1,200 agents and brokers intend to sell coverage through Nevada Health Link.¹⁵  In order to sell insurance products through the Marketplace, producers must register with the Marketplace, fulfill training and testing requirements, and satisfy the Marketplace’s privacy and security standards. Most training will be completed during the last week of September, although training courses will be available year-round. Producers will not be compensated by Nevada Health Link but will continue to receive compensation from carriers, in the same or similar manner as is done today in Nevada. The Board approved a recommendation that web-brokers will not be able to sell QHPs and access Advanced Premium Tax Credit and Cost Sharing reductions through their portals.

The state released an RFP in September 2012 for help planning a marketing and branding campaign in English and Spanish for the Marketplace, and in January 2013 entered into a contract with a vendor.¹⁶  The campaign is broken out into three phases: Marketplace branding, education, and call to action. In March 2013, the Board approved Nevada Health Link as the new Marketplace name and in April approved the logo, color palettes, and taglines.¹⁷  In June 2013, Nevada Health Link launched a website for consumers, including a subsidy calculator.

The marketing campaign launched July 1 and uses a mix of mediums to reach target audiences, including television, radio, print, and digital media. Nevada Health Link awareness advertising will run from July 2013 through March 2014, with three distinct waves of messaging. Television advertising launched on September 15 and will run through mid-October. Messaging for the “call to action” phase of the campaign is being developed and will be launched mid-October.¹⁸  Nevada Health Link will also partner with non-profit, state-based, and school-based organizations throughout the state to perform outreach activities through September 30.¹⁹  Hispanics, families with children, and male young adults with incomes between 138-400% FPL are the target populations for the marketing and outreach campaign.²⁰ 

On September 16, the state opened the consumer call center.  In September 2013, Nevada Health Link announced that the launch of the Spanish-language portal will be delayed until mid-November. However, consumers will have access to Spanish-speaking call center representatives, in-person assisters, and producers.²¹ 

Small Business Health Options Program (SHOP) Marketplace: In April 2012, the Nevada Health Link Board approved guiding principles recommended by the SHOP Advisory Committee. In September 2012, the Board approved keeping the Individual and SHOP markets separate, as well as keeping the market for small groups (1-50) and mid-sized groups (51-100) separate until they have to be merged in 2016. The Marketplaces’s certification requirements for QHPS in the Individual and SHOP Marketplaces will be the same.

The SHOP Marketplace will offer three options to employers. The ‘Open SHOP’ option allows an employee to access all SHOP QHPs. The ‘Open Metal Tier’ option will allow an employer to select a specific metal tier for his/her employees. The ‘Package Option’ will let an employer select a specific package for his/her employees. Employers must contribute at least 50% of premiums for the lowest cost QHP available to employees.  The minimum employee participation rate is 75%.²² 

Financing: In June 2012, the Board approved exempting insurers from being taxed on fees charged by the Exchange.²³  The Board also rejected a proposal by the Committee to use a General Fund appropriation as a supplementary source of Exchange revenue by subsidizing individuals’ enrollment fees.²⁴  In January 2013, the Board adopted a regulation establishing a monthly fee charged to insurers for each member enrolled in the insurer’s plans.²⁵   The Marketplace established separate fees for QHPs that do not include a dental component, QHPs that include dental, and stand-alone dental plans.²⁶ 

Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through Nevada Health Link, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. On December 14, 2012, the Insurance Commissioner announced the selection of Health Plan of Nevada POS C-XV-500-HCR as the EHB benchmark plan, the Children’s Health Insurance Plan (CHIP) as the pediatric dental supplement, and the Federal Employee Vision Plan (FEDVIP) as the pediatric vision supplement.²⁷ 

Marketplace Funding

In September 2010, the Nevada State Department of Health and Human Services received a federal Exchange Planning grant of $1 million. The Department has since received four federal Level One Establishment grants: $4 million in August 2011, $15.3 million in February 2012, $4.4 million in May 2012, and $9 million in July 2013. The grants will be used to develop a rules-based eligibility engine that will serve as the single, streamlined eligibility process for all medical assistance programs in the state, to support information technology security requirements, and to fund training for EEFs. In August 2012, the state received a federal Level Two Establishment grant for $50 million; this will fund Exchange operations through December 2014.²⁸ 

Next Steps

On January 3, 2013, Nevada received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a State-based Marketplace.²⁹  The Nevada Health Link Marketplace portal will become operational on October 1 and will begin enrolling qualified individuals, families, and small businesses into coverage.

Additional information about the Silver State Health Insurance Marketplace can be found at:http://exchange.nv.gov/

1. SB440 (Chapter 439), Nevada’s 2011 Act creating the Silver State Health Insurance Exchange.  ↩︎
2. “Gov. Sandoval Makes Appointments to Health Insurance Exchange Board.” Nevada News Bureau. September 23, 2011.  ↩︎
3. Executive Director’s Report. May 9, 2013.  ↩︎
4. Blueprint 2.0 Consumer Stakeholder Engagement and Support. October 4, 2012.  ↩︎
5. Plan Certification and Management. Recommendation 1: Key Principles. Silver State Health Insurance Exchange. Approved April 12, 2012.  ↩︎
6. Advisory Committee Recommendations Approved by the Board. December 10, 2012.  ↩︎
7. Qualified Health Plan Certification Checklist. April 18, 2013.  ↩︎
8. Network Adequacy Standards for Qualified Health Plans Marketed in the Silver State Health Insurance Exchange.  ↩︎
9. Summary of Recommendations approved by the Board. June 14, 2012.   ↩︎
10. Pediatric Dental EHB Requirements. May 16, 2013.  ↩︎
11. Pediatric Dental Essential Health Benefit on the Silver State Health Insurance Exchange. June 5, 2013.  ↩︎
12. Navigators, Enrollment Assisters, Certified Application Counselors and Producers in the Silver State Health Insurance Exchange. March 1, 2013.  ↩︎
13. Exchange Enrollment Facilitator Program. June 12, 2013.  ↩︎
14. Silver State Health Insurance Exchange. Navigator and Enrollment Assister Contracting and Training. August 8. 2013. ↩︎
15. Silver State Health Insurance Exchange. Executive Director’s Report. September 12, 2013.   ↩︎
16. “State approves $6 million contract to publicize health insurance exchange.” January 8, 2013.  ↩︎
17. Silver State Health Insurance Exchange Board Meeting Minutes. April 11, 2013.  ↩︎
18. Silver State Health Insurance Exchange. Executive Director’s Report. September 12, 2013.   ↩︎
19. Nevada Health Link. Marketing & Outreach Update. July 11, 2013.  ↩︎
20. Nevada Health Link: Media Presentation. May 1, 2013.  ↩︎
21. Silver State Health Insurance Exchange. Executive Director’s Report. September 12, 2013.   ↩︎
22. Silver State Health Insurance Exchange Board Meeting Minutes. April 11, 2013.  ↩︎
23. Financial Sustainability Recommendation 4 Tax on Exchange Fees. Silver State Health Insurance Exchange. Approved June 14, 2012.   ↩︎
24. Whaley, Sean. “State Board Rejects Proposal to Seek State Funding to Subsidize Nevada’s Health Insurance Exchange.” Nevada News Bureau. August 16, 2012.  ↩︎
25. Adoption of the Silver State Health Insurance Exchange Regulation: EX-01-A. January 10, 2013.  ↩︎
26. Fees to be Charged to Insurers for Calendar Year 2014 in the Silver State Health Insurance Exchange. January 10, 2013.  ↩︎
27. Letter from Insurance Commissioner to HHS, December 14, 2012.  ↩︎
28. Nevada Affordable Insurance Exchange Grants Awards list.  ↩︎
29. Letter from HHS to Governor Sandoval. January 3, 2013.  ↩︎

Final update made on July 24, 2013 (no further updates will be made)

Establishing the Exchange

On May 26, 2011, Governor Peter Shumlin (D) signed into law HB 202, a far-reaching health reform law that puts the state on a path toward establishing a single-payer health care system.¹  As an interim step, the law created the Vermont Health Benefit Exchange to meet the requirements of federal health reform. The state plans to put into place the components of federal health reform, including the exchange, and in 2017 apply for a federal Waiver for State Innovation to transition to Green Mountain Care, the new public-private single-payer system that will provide coverage for all state residents. In May 2012, the Governor signed additional health system reform legislation further defining the role and duties of the Green Mountain Care Board and the Exchange (HB 559).²  The Vermont Health Insurance Exchange was branded as Vermont Health Connect.

Structure: HB 202 defines Vermont’s Exchange as a state-operated division within the Department of Vermont Health Access and headed by a Deputy Commissioner.

Governance: The Exchange will be administered by the Department of Vermont Health Access in consultation with a 22-member Medicaid and Exchange Advisory Committee. The Commissioner of Vermont Health Access will serve on the Advisory Committee and appoint members including, a representative of health insurers; five beneficiaries of Medicaid or Medicaid-funded programs; five individuals or representatives of small businesses eligible for or enrolled in the Exchange; five advocates for consumer organizations; and five health care professionals. The Vermont Exchange will be overseen by the Green Mountain Care Board, which is charged with moving the state through several stages of health care system change, ultimately leading to the establishment of a single-payer system. The Green Mountain Care Board consists of a chair and four members appointed by the Governor. Members cannot be affiliated with entities supervised or regulated by the Board, except for health care practitioners; participate in issues in which there is a financial interest; discuss future employment or appear before the Board of other state agencies on behalf of a person subject to supervision or regulation by the Board for a year after leaving the Board. The Chair and all members of the Board are state employees. Current appointed Board members are:

• Anya Rader Wallack (Chair)
• Al Gobeille
• Karen Hein, M.D.
• Con Hogan
• Allan Ramsay, M.D.

The Green Mountain Care Board began work on October 1, 2011 and in December, a Deputy Commissioner of the Exchange was hired. As required by the Vermont Health Reform Law of 2011, the Board and Governor Shumlin’s administration submitted reports to the House Committee on Health Care and the Senate Committee on Health and Welfare in January 2012.³  In July 2012, the Department of Vermont Health Access merged the existing Exchange Advisory Group with the Medicaid Advisory Board so as to create the Medicaid and Exchange Advisory Committee and maintain compliance with HB 202. The new Advisory Group includes representatives from consumer advocacy organizations, legislators, providers, brokers, and insurance associations.

Contracting with Plans: Vermont Health Connect will selectively contract with carriers according to criteria developed by the Commissioner of the Department of Vermont Health Access and will offer qualified health plans (QHPs) from at least two private carriers, plus two multi-state plans. There are few carriers in Vermont’s non-group and small group markets; therefore, the state is working to ensure adequate participation. Carriers will be required to offer at least silver and gold level plans and bronze plans will be allowed to be sold in the Exchange.⁴  Carriers will also be required to offer six standard plans designs and will have the option of offering non-standard “choice” plans within set parameters. The state released a Request for Proposals in November 2012 for qualified health plans and stand-alone dental plans to be sold in the Exchange; the state selected QHPs and premium rates will be available to the public in July 2013.⁵ 

In July 2013, the Green Mountain Care Board announced the approved rates for the two insurers, BlueCross BlueShield of Vermont and MVP Health Care, that will participate in Vermont Health Connect, which were 4-5% lower than the initial rate filings.⁶  Earlier in May 2013, the Commissioner of the Vermont Department of Financial Regulation announced that the Vermont Health CO-OP had failed to meet the state’s insurance standards and had been denied a license to sell insurance in the state. Recommendations for quality requirements were developed for the state in August 2012 by subcontractors, including that the state continue using a higher standard to evaluate quality and wellness data for QHPs using Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) standards as well as additional state requirements for consumer protections.⁷  This would be a higher standard than required by the Affordable Care Act.

Dental and Vision Benefits: The Green Mountain Care Board considered dental options assessed by the Department of Vermont Health Access and voted not to mandate the inclusion of adult dental coverage through the Exchange for 2014. Consumer Assistance and Outreach: Vermont Health Connect contracted for the development of a comprehensive outreach and education plan.⁸  As of July 2013, Vermont Health Connect had launched its outreach campaign with a YouTube channel, Facebook page, Twitter account, new printed educational materials, as well as radio and television ads. It had also scheduled a number of forums and is developing partnerships with community organizations, providers, and businesses.⁹ 

On April 10, 2013, Vermont Health Connect released a Notice of Application for Navigator Organizations that will manage individual Navigators.¹⁰  To ensure sufficient distribution of Navigator Organizations throughout the state, grants are divided into three tiers: Tier 1 organizations will receive up to $40,000 and will target a specific geographic area or population; Tier 2 organizations will received grants of $40,000-$100,000 and will target a specific geographic are or population; Tier 3 organizations will receive grants up to $200,000, will have statewide reach, and will coordinate with other Navigator Organizations as well as state and local partners. On May 21, 2013, Vermont Health Connect announced it had awarded $2 million to 18 Navigator Organizations throughout the state. Four organizations receiving grant awards will serve as statewide coordinating Navigator Organization with two focusing on individuals and families and two serving small businesses.¹¹  Navigators must complete 24 hours of training and pass a certification exam. The In-person training for Navigators was offered in early July. Vermont Health Connect contracted with the vendor supporting the existing Medicaid Support Center to expand the call center to include Exchange customers and to improve the quality of the service. The Support Center staff will be increased to 70 and the hours will be extended to include weekend hours. The Support Center will include dedicated lines for enrollment assisters and carriers and will be able to accept credit/debit payments. Training of Support Center staff will begin in July and the call center will go live in September.¹² 

Small Business Health Options Program (SHOP) Exchange: HB 559 opens Vermont’s SHOP Exchange to small businesses with 50 or fewer employees in 2014, 100 or fewer employees by 2016, and to all employers by 2017. The state is working with subcontractors to finalize various aspects of the SHOP Exchange including, administrative requirements for the small businesses, broker management, premium billing and collection, and eligibility verification. In January 2012, the Green Mountain Care Board concluded that the individual and small group markets should be merged in 2014. Additionally, the Board recommended that insurance plans for small groups and individuals should only be sold through the Exchange so as to increase Exchange sustainability and promote payment reforms. Based on these recommendations, HB 559 merges the individual and small group health insurance markets into one market and requires plans to be sold only through the Exchange. The law allows for brokers to assist with enrollment through the Exchange. Small business employers will have the option of choosing between two different models for their employees. One option is to give the full choice of insurers and plans to their employees; the other is to give employees the choice of metal level from one insurer’s offerings.¹³ 

Information Technology (IT): Vermont intends to use a single, streamlined process for determining eligibility for the Exchange, Medicaid, CHIP, and other public programs. The state’s new system, Vermont Integrated Eligibility and Workflow Solution (VIEWS ), will integrate required components first and then incorporate other benefit programs in the future. The Department of Vermont Health Access has solicited various subcontractors to develop and implement the proposed system.¹⁴  The state plans to begin system testing July 1, 2013 and intends to be ready for open enrollment in October 2013. Vermont is also participating as part of a consortium of New England states in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use. The state is actively exploring opportunities to leverage Oregon’s Oracle-based Exchange architecture. Financing: The Board has solicited a subcontractor to develop a plan for financial sustainability. The Exchange Board must recommend two financing plans to the Legislature by January 15, 2013. One plan will recommend financing amounts and mechanisms that must be in place by January 1, 2014 and the second will address the financing of Green Mountain Care. On January 24, 2013, Governor Shumlin submitted the financing plan to the state legislature.¹⁵  The plan proposes to fund Vermont Health Connect operations for fiscal years 2014-2016 through reinvestment of ACA savings and increasing the health care claims assessment by one percent. In 2017, the state will move to a single payer system with a separate financing mechanism.

Essential Health Benefits (EHB): The Affordable Care Act requires that all individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The Green Mountain Care Board held two public hearings on essential health benefits, the benchmark plan, and plan design and is considering potential market disruptions and how plan design could cause selection problems. The state solicited subcontractors to examine plan designs in the state’s individual and small group markets. The state recommended the Vermont Health Plan- BlueCare, HMO to serve as the benchmark plan. In addition, the Children’s Health Insurance Program (CHIP) will serve as the pediatric dental supplement and the Federal Employee Vision Plan (FEDVIP) will be the pediatric vision supplement.

Exchange Funding

In September 2010, the Vermont Agency of Human Services received the federal Exchange Planning grant of $1 million. In addition, Vermont is a member of the consortium of New England states that received a federal Early Innovator Grant of $44 million to develop, share, and leverage insurance exchange technology. The multi-state consortium also includes Connecticut, Rhode Island, Maine, and Massachusetts with the University of Massachusetts Medical School as the grant holder. The state has received three Level One Establishment grants: $18 million in November 2011 to further plan and develop the Exchange; $2.2 million in January 2013 to implement and operate an In-person Assister program; and $42.7 million in July 2013 to support the implementation of an integrated eligibility system, consumer support center functionality, and individual and SHOP premium processing. In August 2012, Vermont received a $104.2 million Level Two Establishment grant to fund Exchange development and operations through December 2014.¹⁶ 

Next Steps

On January 3, 2013, Vermont received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange.¹⁷  Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time, complying with future guidance and regulations, and receiving legislative approval for a self-sustainability financing plan. The state must also develop a contingency plan by February 1, 2013 if the state is unable to meet timelines and milestones, particularly relating to implementation of the IT infrastructure. For more information on Vermont’s Health Benefit Exchange planning, visit: http://healthconnect.vermont.gov/

1. Act 48 (HB 202). An Act Related to Universal and Unified Health System in Vermont. Signed May 26, 2011.  ↩︎
2. House Bill 559. Introduced 2012 session.  ↩︎
3. Act 48 Integration Report: The Exchange. Submitted by the Agency of Administration, January 17, 2012  ↩︎
4. Vermont Exchange Advisory Group Meeting minutes. May 14, 2012. http://dvha.vermont.gov/administration/hbe-advisory-group-minutes-05-14-12.pdf and Overview H.559. Exchange Advisory Meeting. May 14, 2012. http://dvha.vermont.gov/administration/hbe-h559-overview.pdf  ↩︎
5. Department of Vermont Health Access. RFP Selection of Qualified Health Plans. November 1, 2012. http://www.vermontbusinessregistry.com/bidAttachments/9464/Vermont%20QHP%20RFP%200341011313.pdf  ↩︎
6. Green Mountain Care Board press release, July 8, 2013. http://gmcboard.vermont.gov/sites/gmcboard/files/Exchange_rate_decision%20release_revised.pdf  ↩︎
7. Roadmap for Implementing Quality Requirements: Recommendations for Vermont’s Health Benefit Exchange. August 3, 2012. http://dvha.vermont.gov/administration/qualityimplereportfinal.pdf  ↩︎
8. Vermont Health Benefit Exchange Outreach and Education Plan, prepared by GMMB http://healthconnect.vermont.gov/sites/hcexchange/files/For%20Websitevermont-health-connect-outreach-and-education-plan.pdf  ↩︎
9. Medicaid and Exchange Advisory Board presentation, Outreach and Education Update http://healthconnect.vermont.gov/sites/hcexchange/files/MEAB%20O%20and%20E%2003July2013%20%282%29.pdf  ↩︎
10. Vermont Navigator Organization Grants, Notice of Application, April 10, 2013 http://www.vermontbusinessregistry.com/bidAttachments/9802/VT%20Navigator%20Organization%20Application.pdf  ↩︎
11. Vermont Heatlh Connect Selects 18 Navigator Organizations, press release May 21, 2013 http://healthconnect.vermont.gov/sites/hcexchange/files/Press_Release_Navigator_Organization_Grant%205_21_13.pdf  ↩︎
12.  Customer Support Update, presentation to Medicaid and Exchange Advisory Board, May 6, 2013 http://healthconnect.vermont.gov/sites/hcexchange/files/CSC%20Slides%20for%20MEAB_02May2013v3.pdf  ↩︎
13. The Vermont Health Benefit Exchange: An Update for Small Business Owners. November 28, 2012. http://dvha.vermont.gov/administration/exchange-update-small-biz-11.28.12-final.pdf  ↩︎
14. Planning Review: Vermont Health Benefit Exchange. May 10-11, 2012. http://dvha.vermont.gov/administration/hbe-powerpoint-presentation-for-vermonts-planning-review-with-hhs-05-2012.pdf  ↩︎
15. Health Care Reform Financing Plan, January 24, 2013 http://hcr.vermont.gov/sites/hcr/files/2013/Health%20Care%20Reform%20Financing%20Plan%202014%20and%202017_FINAL.pdf  ↩︎
16. Vermont Affordable Insurance Exchange Grants Awards List. http://www.cms.gov/cciio/Resources/Marketplace-Grants/vt.html  ↩︎
17. Letter from HHS to Governor Shumlin, January 3, 2013. http://www.cciio.cms.gov/resources/files/vt-blueprint-exchange-letter-01-03-2013.pdf  ↩︎

Final update made on December 10, 2012 (no further updates will be made)

Establishing the Exchange

On November 15, 2012, Governor Nikki Haley (R) informed federal officials South Carolina would default to a federally-operated health insurance exchange.¹ This decision was largely based on findings from the South Carolina Health Planning Committee which had concluded the state cannot implement a state-based exchange as required by the Affordable Care Act (ACA) and should instead encourage the establishment of private exchanges.² The Governor created the Committee via Executive Order to assist with policy recommendations regarding whether and how South Carolina should establish a health insurance exchange; however, her influence over the Committee’s findings was called into question in December 2011.^3,4Prior to the announcement that the state would not operate its own exchange, the Governor signed into law S 0102, a bill prohibiting plans in a state exchange from offering abortion coverage, except in cases of rape, incest, or to avert the death of a pregnant woman.⁵

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since South Carolina has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Blue Cross Blue Shield of South Carolina- Business Blue Complete, PPO.

Exchange Funding

In September 2011, the South Carolina Department of Insurance received a federal Exchange Planning grant of $1 million. Governor Haley stated South Carolina would not pursue any more federal grant money to fund a possible state-run exchange.⁶

Next Steps

The federal government will assume full responsibility for running a health insurance exchange in South Carolina in 2014.

1. Letter from Governor Haley toHHS. November 15, 2012.http://governor.sc.gov/Documents/Gov%20Nikki%20Haley%20Letter%20to%20HHS%20Secretary.pdf2. “Improving the Health Care Marketplace in South Carolina: Strategies and Policies Recommended by the South Carolina Health Planning Committee.” November 2011.http://doi.sc.gov/Documents/ACA%20Grants/SCHPCFinalReport.pdf3. Executive Order 2011-09: http://www.scstatehouse.gov/reports/executiveorders/exor1109.htm4.  ‘Harkin Blasts South Carolina Over Exchange’. December 23, 2011. Kaiser Health News.http://www.kffhealthnews.org/daily-reports/2011/december/23/south-carolina-exchange-grant.aspx5. S 0102. 2012 Legislative session. Signed June 7, 2012.http://www.scstatehouse.gov/sess119_2011-2012/bills/102.htm6. Largen, Stephen. ‘Haley to shun federal funds.’ Go Upstate. July 1, 2011.http://www.goupstate.com/article/20110701/ARTICLES/110709990

Final update made on November 11, 2013 (no further updates will be made)

Establishing the Marketplace

On July 17, 2012, Governor Steven L. Beshear (D) issued Executive Order 587 establishing the Kentucky Health Benefit Exchange (KHBE) after the Supreme Court ruled to uphold the Affordable Care Act (ACA).¹  In May 2013, the state announced that its online Marketplace would be called kynect.

Prior to the Executive Order, the Kentucky Cabinet for Health and Family Services led Marketplace planning in the state. Working collaboratively with the Department for Medicaid Services and the Kentucky Department of Insurance, the state developed an interagency team that met regularly to define issues of governance, information technology (IT), and eligibility.²  In June 2012, the state released survey results revealing stakeholder support for a State-based Marketplace with an independent governing board.³ 

Structure: The Executive Order establishes the Office of the Kentucky Health Benefit Exchange “within the Cabinet for Health and Family Services.” The Order also creates four divisions within the Office: the Division of Health Care Policy and Administration, the Division of Information Systems, the Division of Financial and Operations Administration, and the Division of Communication and Outreach.

Governance: The Office of the Kentucky Health Benefit Exchange will review and discuss issues with an Advisory Board. Executive Order 587 called for an 11-member board; however, the Governor expanded the size of the Board to 19 members prior to announcing the appointments. The Advisory Board includes three ex-officio members (or their designees): the Commissioner of the Department of Medicaid Services, the Commissioner of the Department of Insurance, and the Commissioner of the Department for Behavioral Health and Developmental and Intellectual Disabilities. The Commissioner of the Department of Insurance serves as Chair of the Board. The Governor appointed 16 members, three representatives of insurers that offer plans in the state, one representative of insurance agents licensed to sell in the state, three representatives of non-facility based health care providers licensed in the state, four representatives of facility based health care providers licensed in the state, one small business representative, one representative of an individual purchaser of health plans, and three consumer representatives. Board members are required to have relevant experience in health benefits administration, health care finance, health plan purchasing, health care delivery system administration, public health, or health policy issues related to the small group and individual markets and the uninsured.

On September 19, 2012, Governor Beshear appointed members to the Advisory Board.⁴  The appointed Board members are:

• Deborah Moessner, Anthem Blue Cross and Blue Shield
• Jeff Bringardner, Humana
• Carl Felix, Bluegrass Family Health
• Marcus Woodward, Woodward & Associates
• Connie Hauser, P.T. Pros Inc
• John Thompson, Lee & Lee P.S.C.
• Dr. Michael Huang, Kentucky Clinic South
• Ruth Brinkley, KentuckyOne Health
• Julie Paxton, Mountain Comprehensive Care Center
• Ed Erway, University of Kentucky Healthcare
• Donna Ghobadi, Central Baptist Hospital
• Joe Ellis, Eye Care Associates of Kentucky
• Gabriela Alcalde, Foundation for a Healthy Kentucky
• David Allgood, Center for Accessible Living
• Andrea Bennett, Kentucky Youth Advocates
• Tihisha Rawlins, AARP

An Executive Director for the Office of the Kentucky Health Benefit Exchange has been appointed by the Governor.⁵  The Secretary of the Cabinet for Health and Family Services will appoint a Director for each newly created Division within the Office. The Board established advisory sub-committees consisting of consumers or other stakeholder groups to study specific policy issues and advise the Board.⁶ 

Contracting with Plans: The KHBE functions as a clearinghouse and works in partnership with the Department of Insurance (DOI) to certify Qualified Health Plans (QHPs). In May 2013, Kentucky released final regulations detailing requirements for certification and participation of QHPs and dental plans on the Marketplace.⁷  Issuers may offer QHPs in the individual Marketplace or the SHOP. In both markets, issuers may not offer more than four QHPs within a metal level of coverage. KHBE considers the same plan offered with dental benefits and without dental benefits to be one QHP. Issuers are not required to participate both inside and outside the Marketplace; however, rates must be the same for plans offered in both markets. The KHBE will conduct final certification of QHPs no later than August 31 for the following plan year, and QHPs will be recertified every two years. Five carriers currently participate in kynect, and consumers may browse plans and rates using the Marketplace portal.

Issuers must ensure that a QHP’s provider network is available to all enrollees within the QHP service area and includes providers that specialize in mental health and substance abuse services. At least 20% of available essential community providers (ECPs) in the QHP service area must participate in the provider network and issuers must contract with at least one ECP in each ECP category in each county in the service area. Issuers must also make provider network directories for QHPs available to the KHBE for online publication.

Issuers must submit information on enrollment, denied claims, rating practices, cost-sharing, and payments for out-of-network coverage to the KHBE, DOI, and HHS and provide public access to the data. Issuers are also required to establish and report on quality improvement strategies.

Dental and Vision Benefits: QHPs with embedded dental benefits, QHPs without dental benefits, and stand-alone dental plans may be sold through kynect. Stand-alone dental plans must offer one variation with 70% actuarial value and one variation with 85% actuarial value. Insurers must also limit annual cost-sharing to $1,000 for a plan with one child enrollee or $2,000 for a plan with two or more child enrollees. Insurers may offer a stand-alone plan that covers individuals regardless of age, as long as it includes the pediatric dental essential health benefit required under the Affordable Care Act.⁸ 

Consumer Assistance and Outreach: Navigators, In-Person Assisters (IPAs), and Certified Application Counselors are collectively known as kynectors and are responsible for conducting public education activities and facilitating enrollment into health coverage through the Marketplace. In August 2013, the KHBE awarded a total of $4.3 million in IPA grant funding to two kynector organizations that will provide education and enrollment assistance to individuals and small businesses in five of the state’s eight Medicaid regions.⁹  The state issued a Request for Proposals in early September for kynector organizations in the remaining three regions,¹⁰  and in November awarded a total of $2.15 million to three grantees.¹¹   Consumers may search for a kynector by name, organization, location, or language on the kynect website.

Licensed agents and brokers also play a role in enrolling individuals and small employers into coverage through kynect. Agents/brokers must be appointed by at least two issuers selling coverage through kynect to participate on the Marketplace, unless they are directly employed by a participating issuer. Agents/brokers are also required to take an online training course and complete a registration and verification process.¹²  Consumers may use an online tool to search for an agent by name, agency, location, or language. Web brokers will not initially be allowed to sell on kynect but their participation may be considered in the future.

In May 2013, the KHBE introduced kynect as the state’s health insurance Marketplace and launched a public education and awareness campaign. As part of the branding effort, the KHBE also launched a website that now serves as a portal to enrollment for consumers and features tools such as a health plan savings calculator. In August 2013, the state began initial marketing efforts, including online advertisements targeting young adults and establishing a presence at the state fair and local events. Kynect launched a broader marketing campaign at the beginning of open enrollment, including television, newspaper, billboard, hospital kiosk, and bus advertisements. The messaging of the advertisements shifted from general awareness to directing consumers how to take action and enroll into coverage.¹³  The KHBE has also established partnerships with local agencies, such as the Department for Public Health, to assist in education and outreach activities.¹⁴ 

In April 2013, Kentucky procured a subcontractor to design, implement, and maintain a contact center.¹⁵  The contact center opened in mid-August and has a staff of 100 representatives that are available via phone, email, or live online chat. Services are available in English, Spanish, and other languages.¹⁶ 

Small Business Health Options Program (SHOP) Marketplace: As defined by regulations approved in September 2013, small employers will be limited to groups of fewer than 50 employees through 2015 and 1 to 100 employees for 2016 and beyond. The SHOP requires a 75% minimum group participation rate. Employers will offer employees a single QHP, all available QHPs in one metal level of coverage, or one or more QHPs at more than one metal level of coverage, if the metal levels are contiguous. If an employer offers more than one QHP, the employer will select a QHP to serve as a reference plan for purposes of determining premium contributions. Employers will contribute a minimum of 50 percent toward the premium for employee-only coverage under the reference plan. Employers that choose to offer employees a single QHP must also contribute a minimum of 50% toward the premium. ¹⁷ 

Financing: Kynect will cost an estimated $39.5 million to operate in its first year. The KHBE is considering funding the Marketplace through an assessment of insurers inside and outside of kynect, which is the current funding mechanism for Kentucky’s high risk pool. The Marketplace will not be financed through the General Fund.¹⁸ 

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Marketplace, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. Kentucky recommended the state use the Anthem Preferred Provider Organization (PPO) as the benchmark plan and KCHIP as the pediatric dental and vision supplement.¹⁹ 

Marketplace Funding

In September 2010, the Kentucky Cabinet for Health and Family Services’ Office of Health Policy received a federal Exchange Planning grant of $1 million and in August, the same agency was awarded a federal Level One Establishment grant for almost $7.7 million to fund IT systems. In February 2012, the agency was awarded a $57.8 million grant to continue planning and building the requisite IT systems which will provide integrated eligibility and enrollment with the Medicaid program. In September 2012, Kentucky received a third Level One grant of $4.4 million to support the development of a Navigator program and assess access to health care services. The state was awarded a Level Two Establishment Grant for $182.7 million in January 2013 to develop a consumer and stakeholder support network and to complete an interoperable IT system that will integrate Kentucky’s Health Benefit Exchange with all of Kentucky’s existing health and human services programs.²⁰ 

Next Steps

On December 14, 2012, Kentucky received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a State-based Marketplace.²¹  The kynect Marketplace portal became operational on October 1 and began enrolling qualified individuals, families, and small businesses into coverage.

For more information on kynect, visit: http://healthbenefitexchange.ky.gov/ and https://kyenroll.ky.gov/.

1. Executive Order 587. July 17, 2012.  ↩︎
2. Exchange Planning Grant Third Quarterly Report. Submitted September 1, 2011.  ↩︎
3. Office of Health Policy. Stakeholder Perspectives on Health Benefit Exchanges. Kentucky Cabinet for Health and Family Services, June 2012.  ↩︎
4. “Gov Beshear Appoints Members to Health Exchange Board.” September 18, 2012. Governor Beshear’s Communications Office.   ↩︎
5. ‘Beshear Issues Executive Order Creating Kentucky Health Benefit Exchange.’ July 17, 2012. Lex18.com.   ↩︎
6. See Kentucky Health Benefit Exchange Subcommittees.  ↩︎
7. 900 KAR 10:010E. Exchange Participation Requirements and Certification of Qualified Health Plans and Qualified Dental Plans. May 13, 2013.  ↩︎
8. 900 KAR 10:010E. Exchange Participation Requirements and Certification of Qualified Health Plans and Qualified Dental Plans. May 13, 2013.  ↩︎
9. Kentucky Cabinet for Health and Family Services. “Cabinet Awards kynector Grants.” August 20, 2013. ↩︎
10. Kentucky Health Benefit Exchange. “kynector/In-Person Assister Program Request for Proposal (RFP) has been issued.” September 5, 2013.  ↩︎
11. “Additional funding awarded for contractors to help with health care coverage.” November 2, 2013.  ↩︎
12. 900 KAR 10:050E. Individual Agent or Business Entity Participation with the Kentucky Health Benefit Exchange. July 3, 2013.  ↩︎
13. “In glare of spotlight, Kentucky’s Obamacare program is ready, experts say.” September 28, 2013. ↩︎
14. Kentucky Cabinet for Health and Family Services. “Cabinet Awards kynector Grants.” August 20, 2013. ↩︎
15. Kentucky Health Benefit Exchange Advisory Board Navigator/Agent Subcommittee Meeting Minutes. April 18, 2013.  ↩︎
16. “Gov. Beshear celebrates opening of kynect customer service center in Lexington.” August 16, 2013.  ↩︎
17. 900 KAR 10:020. Kentucky Health Benefit Exchange Small Business Health Options Program. September 12, 2013.  ↩︎
18. Kentucky Health Benefit Exchange Advisory Board Meeting Minutes. December 20, 2012.  ↩︎
19. Kentucky Department of Insurance Statement on Recommendation for Benchmark Plan. October 1, 2012.  ↩︎
20. Kentucky Affordable Insurance Exchange Grants Awards List.  ↩︎
21. Letter from HHS to Governor Beshear. December 14, 2012.  ↩︎

Final update made on December 11, 2012 (no further updates will be made)

Establishing the Exchange 

On November 16, 2012, Governor Scott Walker (R) notified federal officials that Wisconsin would default to a federally-facilitated health insurance exchange.¹ After initial efforts to develop a state-based health insurance exchange, Governor Walker announced in July 2012, he would not take any action to implement federal health reform until after the November elections.²

In 2011, Walker had issued an executive order to create the Office of Free Market Health Care to develop a plan for a Wisconsin health benefit exchange; however, almost a year later he closed the Office.^3,4 Exchange establishment legislation failed to pass at the end of the 2012 legislative session. Prior to closing, the Office of Free Market Health Care had been seeking subcontractor assistance with the state’s marketing and outreach strategy and had completed actuarial and economic analyses to determine next steps in designing an exchange.⁵

Under former-Governor Jim Doyle (D), Wisconsin’s Department of Health Services had investigated the information technology necessary for a state-run exchange and based on insight from over 40 healthcare stakeholders, created an exchange prototype to simulate eligibility determinations and the consumer enrollment process. The prototype was launched in December 2010, with much of the functionality required of an exchange website.

On April 5, 2012, Governor Walker signed into law SB 92, a bill prohibiting plans in a state exchange from offering abortion coverage, except in cases of rape, incest, or to avert severe physical impairment or death of the pregnant woman.⁶

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since Wisconsin has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, United- Choice Plus, POS.

Exchange Funding

The Wisconsin Department of Health Services received a federal Exchange Planning grant of $1 million in September 2010 and a federal Early Innovator grant of $37.7 million in February. Wisconsin planned to use the Early Innovator grant to refine their exchange prototype into a single portal through which residents could access subsidized and non-subsidized health care and other state-based programs.⁷ In January 2012, the Governor announced the state would be returning the Early Innovator grant funding.⁸

Next Steps

The federal government will assume full responsibility for running a health insurance exchange in Wisconsin beginning in 2014.

1. Scott Walker Office of the Governor. Letter to Secretary Sebelius. November 16, 2012.http://www.walker.wi.gov/Documents/11.16.12%20Letter%20to%20Secretary%20Sebelius.pdf2. Governor Scott Walker. Governor Walker’s Reaction to the US Supreme Court Ruling on ObamaCare, June 28, 2012. http://www.wisgov.state.wi.us/Default.aspx?Page=8533b724-db36-4bce-9b24-3b408bfe3206.3. Wisconsin Executive Order #10. January 27, 2011. http://www.wisgov.state.wi.us/journal_media_detail.asp?locid=177&prid=56494. Wisconsin Executive Order #57:http://docs.legis.wisconsin.gov/code/executive_orders/2011_scott_walker/2012-575. Office of Free Market Health Care. Office of Free Market Health Care Releases Report on Impacts of Patient Protection and Affordable Care Act (PPACA), August, 24,2011.http://www.iiaw.com/index.php?module=cms&folder=16&cmd=cmsproxy&filename=files/0824freemarket.pdf6. SB 92. 2012 Legislative session. Enacted April 5, 2012.http://docs.legis.wisconsin.gov/2011/related/acts/2187. Early Innovator Grant Awards. HHS announcement. February 16, 2011.http://www.healthcare.gov/news/factsheets/exchanges02162011a.html (Accessed August 23, 2011)8. Office of the Governor Press Release. “Governor Walker Turns Down Obamacare Funding.” January 18, 2012. http://165.189.60.210/Default.aspx?Page=84c6be7e-6bf7-47bb-949a-7330dd644579

Final update made on December 11, 2012 (no further updates will be made) 

Establishing the Exchange

On November 14, 2012, Governor Matt Mead (R) acknowledged Wyoming would default to a federally-operated health insurance exchange for 2014, with the possibility of moving to a state-run exchange in the future.¹

Governor Mead had signed HB 0050 into law in 2011 establishing the Wyoming Health Insurance Exchange Steering Committee to study the feasibility of creating a health insurance exchange in the state.² The Steering Committee was comprised of four members from the Legislature and 17 appointees, including representatives of businesses, insurers, providers, hospitals, consumers, and state agencies.³ The Steering Committee received approval for an extension to continue researching exchange implementation until 2013; however, in March 2012, the Committee voted unanimously not to file an extension for federal funds.⁴ Exchange planning was suspended despite Governor Mead’s support for Wyoming continuing to pursue establishment of “some components of a state-run benefit exchange.”⁵ The Governor also indicated that the exchange should be established by the Legislature, and not through an executive order, as had been discussed by the Committee.⁶ Since Wyoming’s 2012 legislative session was a budget session, requiring a two-thirds majority vote, exchange legislation would not have been possible until the 2013 General Session.

Information Technology (IT): In June 2012, the Wyoming Department of Health released a Request for Proposals (RFP) soliciting subcontractors to upgrade the state’s Medicaid and Children’s Health Insurance Program (CHIP) eligibility and enrollment system which will integrate with an exchange.⁷ Wyoming has received approval from the Centers for Medicare and Medicaid Services (CMS) for an enhanced federal match to assist with financing IT upgrades of the state’s Medicaid and CHIP eligibility systems.⁸

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since Wyoming has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Blue Cross Blue Shield of Wyoming- Blue Choice Business, PPO.

Exchange Funding

In September 2010, the Wyoming Department of Insurance received a federal Exchange Planning grant of $800,000. Additionally, HB 0050 appropriated $145,000 from the General Fund for any portions of the study not paid for by the federal grant. In his 2013 budget proposal to the Legislature, Governor Mead included a request for $100,000 to assist in the state in evaluating exchange options beyond 2014.⁹

Next Steps

The federal government will assume full responsibility for running a health insurance exchange in Wyoming beginning in 2014.

1. Brown, Trevor. “Feds to control Wyoming health care.” November 14, 2012. WyomingNews.http://www.wyomingnews.com/articles/2012/11/14/news/01top_11-14-12.txt2. HB 0050. Wyoming act to study a state health insurance exchange. Signed March 10, 2011.http://legisweb.state.wy.us/2011/Enroll/HB0050.pdf3. Wolfson, J. “Wyoming’s Insurance Exchange Committee Members.” Casper Star-Tribune. July 1, 2011. http://trib.com/news/opinion/blogs/wolfjammies/article_66b88eb8-c1cc-5426-bad4-f8febf79bbed.html4. Bleizeffer, Dustin. “Lawmakers put the brakes on health insurance exchange effort.” WyoFile. April 3, 2012. http://wyofile.com/2012/04/health-on-hold-lawmakers-put-the-brakes-on-health-insurance-exchange-effort/5. Wolfson J. “Wyoming Gov. Mead Supports State Health Exchange Recommendations.” Casper Star-Tribune. October 10, 2011. http://trib.com/news/state-and-regional/wyoming-gov-mead-supports-state-health-exchange-recommendation/article_3f3d6b73-af00-5a86-8193-bc34eb10e31d.html6. Brown T. “Health Insurance Exchange Could Bypass Legislature.” Wyoming Tribune Eagle. October 5, 2011. http://www.wyomingnews.com/articles/2011/10/05/news/19local_10-05-11.txt7. White, T. “Wyoming Making Moves on Health Insurance Exchange Efforts.” GovWin from Deltek. May 9, 2012. http://iq.govwin.com/index.cfm?fractal=blogTool.dsp.blog&blogname=public&alias=Wyoming-making-moves-on-health-insurance-exchange-efforts.8. Performing Under Pressure: Annual Findings of a 50-state survey of Eligibility, Enrollment, Renewal, and cost-sharing policies in Medicaid and CHIP. January 2012. Kaiser Family Foundation. http://www.kff.org/medicaid/upload/8272.pdf9. Governor Matt Mead. 2013-2014 Supplemental Budget Letter. November 30, 2012.http://governor.wy.gov/Documents/2013-14%20Supplemental%20Budget%20Letter%20and%20Message.pdf

Final update made on September 27, 2013 (no further updates will be made) 

Establishing the Marketplace

On July 1, 2011, Governor Dan Malloy (D) signed SB921 (Public Act 11-53) into law establishing the Connecticut Health Insurance Exchange.¹   Legislation altering the composition of the Exchange Board passed in June 2012.^2 3  In December 2012, the Exchange announced that its new name would be “Access Health CT.”

Structure: The legislation defines Connecticut’s Health Insurance Exchange as a quasi-governmental organization, specifically “a body politic and corporate, constituting a public instrumentality and political subdivision of the state…which shall not be construed to be a department, institution or agency of the state.”

Governance: Access Health CT is governed by a 14-member board including six ex-officio members. Elected officials appoint eight of the twelve voting members. The Governor appoints two members, one with expertise in individual health insurance coverage and one with expertise in small employer health insurance coverage; the President pro tempore of the Senate appoints an expert in health care finance; the Speaker of the House of Representatives appoints someone knowledgeable in health care benefits plan administration; the Majority Leader of the Senate appoints an expert in health care delivery systems; the Majority Leader of the House of Representatives appoints a health care economist; the Minority Leader of the Senate appoints a person with expertise in health care access issues facing self-employed individuals; and the Minority Leader of the House appoints someone knowledgeable in barriers to individual health care coverage. The four voting ex officio Board members (or their designees) include, the Commissioner of Social Services, the Special Advisor to the Governor on Healthcare Reform, the Healthcare Advocate, and the Secretary of the Office of Policy and Management; non-voting ex officio Board members (or their designees) include, the Insurance Commissioner and the Commissioner of Public Health.

Board members cannot have affiliations with any of the following entities while on the Board: an insurer, an insurance producer or broker, a health care provider, a health care facility or clinic, or trade associations for these entities. Also, members cannot be health care providers receiving compensation for services nor have ownership interest in a professional health care practice. These conflicts of interest provisions apply to Marketplace staff as well as the Board, though Board Members are also prohibited from working for a health care carrier that offers a plan through the Marketplace for the year after serving on the Board.

Current appointed Board members are:

• Nancy Wyman (Chair), Lieutenant Governor
• Mary Fox, formerly with Aetna Product Group
• Robert Scalettar, MD, formerly with Anthem Blue Cross Blue Shield
• Bob Tessier, Connecticut Coalition of Taft Hartley Health Funds
• Cecilia Woods, Permanent Commission on the Status of Women
• Grant Ritter, Schneider Institutes for Health Policy at Brandeis University
• Paul Philpott, Quo Vadis Advisors, LLC
• Maura Carley, Healthcare Navigation, LLC

The Board hired its first Marketplace CEO in June 2012 after holding meetings for nearly a year prior. Consumer groups continue to express concerns that a number of Marketplace Board members have close affiliations with the insurance industry while consumers and small businesses remain under represented.^4 5 

Connecticut’s Exchange legislation requires the Marketplace Board to report annually to the Governor and General Assembly on a variety of issues. The Board must also make any necessary legislative recommendations to reduce the negative impact on the sustainability of the Marketplace. The first annual draft report by the Marketplace Board to the General Assembly was released in January 2012 and updated in February.⁶ 

Advisory committees established in March 2012 meet monthly to assist in Marketplace policy development and evaluation in four key areas: health plan benefits and qualifications; Small Business Health Options Program (SHOP); consumer experience and outreach; brokers, agents, and Navigators.Contracting with Plans: The Marketplace has the legal authority to function as an active purchaser, “limit[ing] the number of plans offered, and us[ing] selective criteria in determining which plans to offer, through the exchange, provided individuals and employers have an adequate number and selection of choices.” In October 2012 however, the Board decided to allow any (Qualified Health Plan) QHP meeting selected criteria to be sold on Access Health CT for 2014. The Marketplace acknowledges that for 2015 and later, they can still opt for a competitive bidding process and develop selective contracting criteria.⁷ 

The legislation does not describe the contracting requirements, but requires the Board to adopt written procedures to explain requirements for certification of qualified health plans. At a minimum, carriers participating in Access Health CT must offer one standard plan for each of the bronze, silver, and gold tiers. Issuers in both Marketplaces may opt to offer a standard plan for the platinum tier, and issuers in the individual Marketplace may choose to offer a catastrophic coverage plan. Plans participating in the individual Marketplace must submit three silver alternative standard plans that reflect cost sharing reductions, two zero cost-sharing plans for American Indians, and a child-only plan.⁸  Plans offered within the Marketplace must charge the same premium as when offered outside the Marketplace, whether sold by an insurance producer or directly by the carrier. Carriers must publicly justify any increase in premiums of plans offered within the Marketplace.

Issuers may choose to participate in the individual Marketplace, the SHOP Marketplace, or both. Issuers meeting certification standards will be certified to participate on Access Health CT for two years; however, issuers that stop participating will not be allowed to re-enter the Marketplace for at least two years. Four carriers were certified to offer coverage through Access Health CT, but in August 2013, one carrier withdrew.⁹  QHP benefits and plans must be filed and certified annually.¹⁰  The Connecticut Insurance Department (CID) is responsible for reviewing and approving rate filings and rate increases. Issuers may rate based on age and geography, but tobacco rating will be prohibited in the individual market for 2014. In August 2013, the CID approved final rates for plans that will be offered through the individual and SHOP Marketplace.

Provider networks for each QHP must meet Utilization Review Accreditation Commission (URAC) or National Committee for Quality Assurance (NCQA) standards and satisfy the requirements of the Special Rules For Network Plans of the Public Health Service Act. Issuers must ensure that the network of providers for standard plan offerings is comparable to the network of providers available for a similar product offered outside Access Health CT. The network must also include a sufficient number of Essential Community Providers and providers that specialize in mental health and substance abuse services.

Issuers will be required to report quality information to Access Health CT, as well as results from the enrollee satisfaction survey system developed by HHS. Access Health CT will use the information to develop and maintain a quality rating system that will relate quality of care to price, per metal-level tier.¹¹ 

Risk Adjustment, Reinsurance, and Risk Corridors: Connecticut intends to administer its risk adjustment and reinsurance programs.¹²  In June 2012 Governor Malloy signed Public Act 12-166 into law establishing the requirement for an all-payer claims database (APCD), which will  provide data to state agencies, including the Marketplace, for purposes of reviewing health care utilization, cost, and quality data. Such a database will provide the baseline information to create a risk adjustment program, as well as to provide outcome quality data and enable analyses of Marketplace policy initiatives. The Office of Health Reform and Innovation is developing the APCD program and established an APCD Advisory Group to guide the implementation process. Access Health CT received $6.5 million in Establishment Grant funding for the APCD program in August 2012.¹³  The APCD Advisory Group released a Request for Proposals (RFP) for a data manager in late July of 2013 and will select a vendor in November. The APCD is expected to be operational and collecting monthly data submissions by August of 2014.¹⁴ 

Dental and Vision Benefits: In order to offer a stand-alone dental plan through the Access Health CT Marketplace, issuers must provide three plan design options: high (85% Actuarial Value), low (75% Actuarial Value), and wellness (limited set of preventive and diagnostic services). Access Health CT requires all carriers submitting a QHP to separately price their pediatric dental essential health benefit.

Consumer Assistance and Outreach: In August 2013, Access Health CT awarded grants to six regionally-based Navigator organizations that will be responsible for developing and implementing regional outreach strategies. Navigators will also provide support and direction to Assisters in their region. The Access Health CT Marketplace has awarded $6,000 grants to approximately 300 Assisters statewide who work at community-based organizations and will provide one-on-one education and enrollment services to consumers. Assisters are distributed based on concentrations of the uninsured throughout the state. Navigators and Assisters must complete up to 40 hours of training, pass a certification test and a background check, and carry photo identification badges.¹⁵  In February 2013, Access Health CT contracted with a vendor to build and service the call center, and the call center launched in September. Over 70 call center representatives are available to serve consumers seeking information about coverage through Access Health CT.¹⁶ 

Brokers who intend to sell coverage through the Access Health CT Marketplace must complete a certification program as well as a training program specific to the market in which they wish to sell (individual and/or SHOP). They must pass a comprehension test after completing the training curricula.¹⁷  As of mid-September, over 600 brokers had been certified and trained.¹⁸ 

In November 2012, Access Health CT hired a marketing vendor and developed a marketing and community outreach plan and timeline. The outreach campaign includes the use of media, direct mail, in-person events, social media, public relations, and brokers.¹⁹   In February 2013, Access Health CT unveiled their logo and launched their website, including a subsidy calculator. In mid-June, Access Health CT launched a marketing campaign, including television, print, outdoor, and online advertising, to raise awareness about the Marketplace. Access Health CT also began community outreach efforts in June and connected with almost 7,000 individuals, half of whom will qualify for subsidies through the Marketplace, at fairs, festivals, concerts, retail outlets, and “Healthy Chat” events.²⁰  In September 2013, the Marketplace launched a television series titled Mercado de Salud, that will engage and educate the Hispanic community about Access Health CT.²¹  Access Health CT is also working to build two Marketplace retail locations, where consumers will have access to in-person education and enrollment services. The storefronts are expected to open in mid-October.

Small Business Health Options Program (SHOP) Marketplace: In 2012, the Access Health CT Board decided to establish separate risk pools for the small group and individual markets but to use a single administrative Marketplace to operate both programs. The Board also decided Connecticut should limit the definition of small employers to groups of 50 or fewer employees until it is required to expand the definition to groups of 100 or fewer employees in 2016.²²  Employers will be able to choose between employee choice, employer choice, and sole source coverage models for their employees. In April 2013, Access Health CT hired a subcontractor to develop and manage the front-end and administrative platform for the SHOP. Access Health CT plans to launch the SHOP on October 1, 2013, despite the decision by HHS to allow states to delay implementation until 2015.

Financing: Public Act 11-53 authorizes the Marketplace to charge health carriers capable of offering a qualified health plan through Access Health CT an assessment or user fee. In May2013, the Board approved a 1.35% marketplace assessment on all small group and individual market insurers, as well as dental carriers.²³  The assessment rate is based on Access Health CT’s estimated annual operating cost of $34.5 million.²⁴ 

Basic Health Program (BHP): Connecticut is considering establishing an optional bridge program available through the Affordable Care Act (ACA) which allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139 and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through the Marketplace. The Office of Health Reform and Innovation established Work Groups, including one on the Basic Health Program, which began meeting in April 2012 to develop recommendations. Legislation establishing a Basic Health Program was introduced but tabled for the 2012 legislative session (HB 5450).²⁵  Due to the lack of federal guidance, it has been difficult for the state to move forward with planning a BHP.²⁶ 

Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Marketplace, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The Access Health CT Board recommended the state use ConnectiCare’s HMO plan as the benchmark plan, the Children’s Health Insurance Program (CHIP) as the pediatric dental supplement, and the Federal Employee Vision Plan (FEDVIP) as the pediatric vision supplement.²⁷ 

Marketplace Funding

The Connecticut State Office of Policy and Management received a federal Exchange Planning grant of $1 million in September 2010 and a federal Level One Establishment grant of $6.7 million in August 2011 to work on IT systems and develop appropriate capacity for consumer assistance and reporting requirements. The state filed a Level One grant application request for $21.9 million in September 2013. The Exchange was awarded a Level Two Establishment grant in August 2012 for $107.3 million to fund Exchange development through December 2014. In February 2013, the state was awarded a second Level One Establishment grant for $2.1 million to fund the implementation of an In-Person Assisters program.²⁸ 

In addition, Connecticut is a member of the consortium of New England states that received a federal Early Innovator Grant of $44 million to develop, share, and leverage insurance exchange technology. The multi-state consortium also includes Rhode Island, Maine, Vermont, and Massachusetts with the University of Massachusetts Medical School as the grant holder.²⁹ 

Next Steps

On December 7, 2012, Connecticut received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a State-based Marketplace.³⁰  The Access Health CT Marketplace portal will become operational on October 1 and will begin enrolling qualified individuals, families, and small businesses into coverage.

Additional information about Access Health CT can be found here.

1. SB921, Connecticut’s 2011 Health Insurance Exchange Act.  ↩︎
2. HB 5013. An Act Concerning the Board Members of the Connecticut Health Insurance Exchange. February Session, 2012.   ↩︎
3. Bill No. 6001. An Act Implementing Provisions of the State Budget for the Fiscal Year Beginning July 1, 2012.  ↩︎
4. Bordonaro, Greg. “CT group pushes health exchange shakeup.” November 30, 2011. Hartford Business.  ↩︎
5. McQuaid, Hugh. ‘McKinney to Advocates: Time to Blame Someone Else.’ June 13, 2012. CT News Junkie.   ↩︎
6. Draft Exchange Plan: Recommendations for the Successful Implementation of the Connecticut Health Insurance Exchange. 2/1/12.  ↩︎
7. Memorandum Plan Management Overview. Connecticut Health Insurance Exchange. October 10, 2012.  ↩︎
8. Access Health CT. Initial Solicitation to Health Plan Issuers For Participation in the Individual and SHOP Exchanges. April 6, 2013.   ↩︎
9. “In Wake of Aetna’s Decision to Withdraw from the Exchange, CEO Kevin Counihan says the Exchange ‘retains broad choice for consumers.'” August 5, 2013.   ↩︎
10. Access Health CT. Initial Solicitation to Health Plan Issuers For Participation in the Individual and SHOP Exchanges Questions and Answers. April 19, 2013.  ↩︎
11. Access Health CT. Initial Solicitation to Health Plan Issuers For Participation in the Individual and SHOP Exchanges. April 6, 2013.   ↩︎
12. Access Health CT. Board of Director’s Meeting. April 18, 2013.  ↩︎
13. Connecticut Health Insurance Exchange Plan. Calendar Year Update. January, 2013.  ↩︎
14. Access Health CT. Connecticut APCD Advisory Group Quarterly Meeting. June 25, 2013.  ↩︎
15. “Access Health CT’s Navigator and Assister Outreach Program reaches consumers in their communities. August 23, 2013.   ↩︎
16. “Access Health CT Opens Call Center.” September 3, 2013.  ↩︎
17. “Access Health CT Has Great News for Brokers Looking to Expand Business.” August 19, 2013. ↩︎
18. Access Health CT. Board of Director’s Meeting. September 19, 2013.  ↩︎
19. Access Health CT. Marketing and Community Outreach Plan Introduction. March 6, 2013.  ↩︎
20. Access Health CT. Board of Director’s Meeting. September 19, 2013.  ↩︎
21. “Access Health CT Launches MERCADO DE SALUD.” September 3, 2013.   ↩︎
22. Connecticut Health Insurance Exchange Plan. Calendar Year Update. January, 2013.  ↩︎
23. “New health insurance fee will raise $26 million.” June 3, 2013. ↩︎
24. Access Health CT. Board of Director’s Meeting. May 16, 2013.  ↩︎
25. HB 5450. 2012 Legislative session.  ↩︎
26. Letter to HHS from Governor Malloy. October 12, 2012.  ↩︎
27. Connecticut Health Insurance Exchange. Board of Directors Meeting. September 27, 2012.  ↩︎
28. Connecticut Affordable Insurance Exchange Grants Awards List.  ↩︎
29. Early Innovator Grant Awards. HHS announcement. February 16, 2011. (Accessed August 23, 2011) ↩︎
30. Letter from HHS to Governor Malloy. December 7, 2012.  ↩︎

Final update made on December 14, 2012 (no further updates will be made)

Establishing the Exchange

In December 2012, Governor Rick Scott (R) announced that Florida would not be pursuing efforts to implement a state-based health insurance exchange.¹ Governor Scott has been a vocal opponent of federal health reform and the state has refused multiple funding opportunities available through the Affordable Care Act (ACA).² Florida was also the lead plaintiff in a lawsuit brought by 26 states seeking to declare parts of federal health reform unconstitutional.³

At the same time, Florida has been proceeding with an initiative, Florida Health Choices, to create a new marketplace for small businesses that predates the passage of federal health reform.^4,5The initiative, begun in 2008 with the enactment of SB 2534, will include a web portal where employers with 50 or fewer employees and some individuals, such as state retirees, can shop for health plans offered in their county.^6,7 The state provided a one-time appropriation of $1.5 million for start-up funding, with on-going support provided through a fee of 2% of the premium for every policy sold through the marketplace paid by participating health plans and a $300 annual payment from agents who sell policies through the marketplace. Florida Health Choices has appointed a Board of Directors, hired staff, and appointed two steering committees to advise the Board- one for vendors and another for agents. In May of 2012, Florida Health Choices identified a third party administrator to provide a web portal, online plan selection tools, and a statewide customer contact center.⁸ In September 2012, the state began beta testing the web portal.⁹ Florida Health Choices does not currently comply with provisions in the ACA, such as providing subsidies to assist eligible low-income individuals with purchasing insurance or mandating that health plans sold through the exchange cover certain health benefits.

In 2011, the Governor signed HB 97/SB 1414, which prohibits coverage of abortions when insurance is purchased through an exchange using state or federal funds, except in cases of rape, incest, or life endangerment of the pregnant woman.¹⁰ The legislation allows health insurance policies to offer separate coverage for abortions not purchased with state or federal funds.

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since Florida has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Blue Cross Blue Shield of Florida- BlueOptions, PPO.

Exchange Funding

Florida’s Agency for Health Care Administration received a federal Exchange Planning grant of $1 million in 2010, but has since returned the grant.¹¹

Next Steps

The federal government will assume full responsibility for running a health insurance exchange in Florida beginning in 2014.

1. Young, Jeffrey. “Obamacare: Florida GOP Gov. Rick Scott Won’t Implement health Care Reform.” HuffingtonPost. December 14, 2012. http://www.huffingtonpost.com/2012/12/13/obamacare-2. “Florida Shuns Funds Tied to Health Care Reform.” Florida Today. March 26, 2012.http://www.wtsp.com/news/article/247143/19/Florida-shuns-funds-tied-to-health-care-reform3. Baribeau S. “Florida’s Scott May Press for U.S. Health Aid.” Bloomberg. August 9, 2011.http://www.bloomberg.com/news/2011-08-09/florida-s-scott-may-press-for-u-s-health-aid.html4. Scott, Rick. “ObamaCare: One Year Too Many.” http://www.flgov.com/2012/01/03/obamacare-one-year-too-many/5. Galewitz P. “Florida to Launch Its Own Health Insurance Marketplace.” The Washington Post. October 8, 2011.http://www.washingtonpost.com/national/health-science/florida-to-launch-its-own-health-insurance-marketplace/2011/10/07/gIQA1Ns8VL_story.html6. SB 2534 (Chapter 2008-32). Florida act related to health insurance and Cover Florida Health Care Access Program. 2008. http://laws.flrules.org/files/Ch_2008-032.pdf7. See: http://myfloridachoices.org/about/8. Florida Health Choices Names Xerox as Program Administrator.” May 2012. Health Choices.http://myfloridachoices.org/florida-health-choices-names-xerox-as-program-administrator/9. See Florida Health Choices: https://www.floridahealthchoices.com/10. HB 97/SB 1414 (Chapter 2011-11). Florida’s 2011 act related to health insurance.http://laws.flrules.org/files/Ch_2011-111.pdf11. Baribeau S. “Florida’s Scott May Press for U.S. Health Aid.” Bloomberg. August 9, 2011.http://www.bloomberg.com/news/2011-08-09/florida-s-scott-may-press-for-u-s-health-aid.html

Final update made on February 11, 2013 (no further updates will be made)

Establishing the Exchange

In October 2011, Mississippi’s elected Commissioner of Insurance Mike Chaney (R) announced that the state would establish a Health Insurance Exchange that would be operated by the Mississippi Comprehensive Health Insurance Risk Pool Association and regulated by the Insurance Department.¹ However, Governor Phil Bryant (R) has opposed the effort to establish a state-based exchange.

The Comprehensive Health insurance Risk Pool Association was created by the Mississippi Legislature in 1991 to operate the state’s high risk pool, which provides coverage for people who want to purchase insurance but cannot obtain it due to health conditions. Mississippi found that the Association has legal statutory authority to operate the Exchange, subject to regulation and supervision by the Department of Insurance. On March 30, 2012, Governor Phil Bryant (R) signed SB 2589, which redefined the number and requirements for the Association’s Board of Directors.²

In a Request for Proposals (RFP) released on May 22, 2012, the Risk Pool Association described a strategy to develop and implement the Exchange exclusively using outsourced services with a multi-phased approach.³ The first phase focused on creating the web portal with shop and compare functionality, with the RFP for this task already awarded. Phase 2 focuses on Exchange functionality for unsubsidized Qualified Health Plans (QHPs), specifically the plan and premium calculation data that will enable consumers to shop, compare, and enroll in a carrier’s plan through the Exchange portal. This phase also includes marketing and outreach, navigator, call center, and other services necessary to support non-subsidized Exchange functions. Phase 3 includes most plan management, eligibility, and enrollment functionality. The selected vendor for this RFP will coordinate with the Mississippi Division of Medicaid, which continues to be responsible for eligibility determination services for Medicaid and the Children’s Health Insurance Program (CHIP). The fourth and final phase is for other supportive services and may be procured together or as a series of individual procurements. Example tasks that may be included in Phase 4 are collection and reporting of claims and encounter data; accountability and performance monitoring; and calculation, processing, and reporting of reinsurance payment and risk adjustment assignment.

Once the Exchange has been implemented, the Association would be responsible for tasks including operation of telephone hotline, maintaining the website for prospective enrollees to compare QHPs, assigning a rating to QHPs, and establishing a consumer outreach program. The Insurance Department would be responsible for plan management, including the procedure for QHP certification.

Structure: The Risk Pool Association operating the Exchange is a non-profit entity that is regulated by the Insurance Department.

Governance: The Risk Pool Association is governed by an 11-member Board of Directors. The Commissioner of Insurance appoints six members, including: two representatives of providers, one representative of businesses with fewer than 100 employees, one representative of agents, and two not associated with a medical profession, hospital, or insurer. Three members are appointed by participating insurers.⁴ The final two non-voting, ex officio members are the Chairs of the Senate and House Insurance Committees. The Board of Directors elects one of its members as chairman.

Separate from the Board of Directors of the Association, the Insurance Department established an Exchange Advisory Board to assist the Insurance Department in developing policy, rules, and regulations governing the Exchange.⁵ The Advisory Board is comprised of one member from each of the 11 Advisory Board Subcommittees, which represent the following stakeholder groups: consumers, individuals with experience facilitating enrollment in health coverage, advocates for hard-to-reach populations, small businesses and self-employed individuals, large employers, state government agencies, tribes, public health experts, providers, health insurers, and agents or brokers. Two additional Advisory Board Members were selected at-large from the Advisory Board Subcommittees and the Commissioner of Insurance (or his designee) serves as chairman of the Advisory Board.

In the first year, the Commissioner of Insurance appointed the Advisory Board members.⁶Beginning in 2013, the members of the Subcommittees will elect representatives to the Advisory Board. The Commissioner of Insurance will retain appointment of two at-large seats on the Advisory Board and approve the qualifications of other subcommittee applicants.

Though the Exchange Advisory Board meets quarterly, the Subcommittees meet once or twice per month depending partly on the complexity and urgency of the topic area. In addition, the Subcommittees are able to create Technical Advisory Groups to address specific issues, with the approval of the Advisory Board.⁷

Contracting with Plans: In November 2012, the advisory subcommittees on exchange market regulations presented initial plan management recommendations, based in part on subcontractor analyses and stakeholder interviews.^8,9 The recommendations include that carriers in the small group market should be required to participate in the individual market; carriers can choose plan coverage areas but should cover the same areas inside the Exchange that they do outside the Exchange; carriers should be given flexibility to offer plans at additional metal levels and are expected offer bronze and platinum plans in response to market demand; and plans should not be subject to additional standardization beyond minimum federal requirements.

Risk Adjustment, Reinsurance, and Risk Corridors: In October 2012, a subcontractor analysis concluded that One, Mississippi should defer the risk adjustment model to the federal government initially, but develop a state-based model in subsequent years.¹⁰ The reinsurance program should be deferred to the federal government for three years as well. In November 2012, Mississippi confirmed that federal government is expected to operate both the risk adjustment and reinsurance programs.¹¹

Consumer Assistance and Outreach: On May 23, 2012, the Insurance Department released an RFP to develop a statewide community outreach strategy and implement a campaign to inform state residents about the Exchange.¹² In October 2012, the selected vendor launched an outreach campaign targeting small businesses.¹³ In addition, this vendor will work with another subcontractor focusing on branding and messaging. In July, the web portal went live, along with a call center provided by the website’s platform vendor. The Association and Insurance Department began soliciting participation from insurance carriers to make their plans available immediately through the portal. Vision and dental policies will be offered on this website in the future.

In June 2012, the subcommittees on outreach, education, adoption, and enrollment submitted recommendations on the Navigator Program to the Advisory Board.¹⁴ They concluded that agents and brokers should not be Navigators. Agents and brokers should be trained and certified, and receive compensation directly from the carriers and not the Exchange. Navigators should also receive comprehensive training and certification, but licensure is too restrictive. A subcontractor analysis also recommended that carriers assign One, Mississippi as their managing general agent and pay a flat fee for each plan sold.¹⁵

Small Employers Health Insurance Options Program (SHOP): The Risk Pool Association plans to establish a single, statewide exchange for both individuals and the small group market. In addition, employers with less than 50 employees will be eligible for the SHOP, until 2016 when the Exchange is required to increase the threshold to 100 employees.¹⁶The subcommittees of the Exchange Advisory Board also examined rules for employer participation, considered the value of the defined contribution model, and discussed the benefits of premium aggregation. Their recommendations were compiled and released in a single document in November 2012.¹⁷

Information Technology (IT): The Risk Pool Association laid out a four stage process to develop the Exchange’s IT infrastructure. The Risk Pool Association awarded the Phase 1 RFP for assistance in creating a health insurance web portal.¹⁸ The Association’s RFP for Phases 2 and 3 was awarded to a single vendor at the end of 2012.¹⁹ In addition, Mississippi intends to allow the federal government to perform eligibility determinations for the Advanced Premium Tax Credit (APTC) and Cost Sharing Reductions (CSR).²⁰

Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through an exchange, cover certain defined health benefits. Mississippi recommended that the Blue Cross Blue Shield Network Blue, a small group plan, be the state’s benchmark EHB plan.²¹

Exchange Funding

The Mississippi Department of Insurance received a federal Exchange Planning grant of $1 million in September 2010 and a federal Level One Establishment grant of $20 million in August 2011. The Establishment Grant will be used to conduct public education and outreach programs, plan the Exchange’s  IT infrastructure, and continue to coordinate with other public programs such as Medicaid and CHIP.²² Former Governor Haley Barbour (R) provided a letter of support for the Level One grant application. The Insurance Department anticipates submitting an application for additional federal funds to continue Exchange implementation through 2013.²³

Next Steps

Despite objections from Governor Phil Bryant (R), on November 14, 2012, Commissioner Chaney issued a declaration letter stating Mississippi’s intent to implement and operate a state-based health insurance exchange.²⁴ To complete the Exchange blueprint, Mississippi also submitted an application to the U.S. Department of Health and Human Services (HHS), with information about the state’s plans to operate a fully state-based exchange. In late December, Governor Bryant sent a letter to HHS stating that only he has the authority to act on behalf of Mississippi to establish an exchange.²⁵ On February 7, 2013, HHS rejected the state’s blueprint application.

Additional information about Mississippi’s Exchange from the Department of Insurance can be found at http://www.mid.state.ms.us/pages/health_care_reform.aspx and from the Comprehensive Health Insurance Risk Pool Association at http://www.mshie.org/index.php and from the web portal at http://www.onemississippi.com/index.php .

1. Mississippi Insurance Department Bulletin 2011-9. “Application Requirements and Appointment Procedure for Establishment of Health Insurance Exchange Advisory Board and Subcommittees. October 18, 2011. http://www.mid.state.ms.us/bulletins/20119bul.pdf2. SB 2589. Mississippi bill increasing membership of the Comprehensive Health insurance Risk Pool Association Board of Directors. 2012.http://billstatus.ls.state.ms.us/documents/2012/pdf/SB/2500-2599/SB2586SG.pdf3. Request for Proposals for a Health Insurance Exchange Portal (Phases 2 and 3). Released by the Mississippi Comprehensive Insurance Risk Pool Association on May 22, 2012.http://www.mshie.org/images/CHIRPA-Association_HIX_RFP_002-FINAL-5-22-12_BEF.docx4. Miss. Code Ann. § 83-9-211 (2011). Creation of the Mississippi Comprehensive Health Insurance Risk Pool Association; membership, board of directions, adoption of plan, articles, bylaws and operating rules.5. Mississippi Insurance Department Bulletin 2011-9. “Application Requirements and Appointment Procedure for Establishment of Health Insurance Exchange Advisory Board and Subcommittees.” Amended January 25, 2012. http://www.mid.state.ms.us/bulletins/20119bul.pdf6. Mississippi Health Insurance Exchange Advisory Board 2012 Appointments. January 16, 2012.http://www.mid.state.ms.us/pdf/msheab.pdf7. Leavitt Partners. “Exchange Advisory Board: Organizational Structure and Reporting Schedule.” Presented to the Mississippi Insurance Advisory Board. January 31, 2012.http://www.mid.state.ms.us/pdf/ExcMtgSlideShow013112.pdf8. Presentation my Commissioner Chaney at the Mississippi Health Insurance Exchange Advisory Board. November 14, 2012.http://www.mid.ms.gov/pdf/ExchAdvisoryBoadMtgPresentation11142012.pdf9. Leavitt Partners and Cicero. “The Mississippi Health Insurance Exchange: Health Reform Recommendations.” October 2012.http://www.mid.ms.gov/pdf/ExchAdvisoryBoadMtgPresentation10102012.pdf10. Ibid.11. Letter from Insurance Commissioner Michael Chaney to Deputy Administrator and Director Gary Cohen. Re: Exchange Declaration Letter for the State of Mississippi. November 14, 2012.http://www.mid.ms.gov/pdf/ExchDecLtr.pdf12. Mississippi Insurance Department Request for Proposals. “Mississippi Health Insurance Exchange Community Education and Outreach Program.” Issued May 23, 2012.http://www.mid.state.ms.us/pdf/rfpcommedoutprog.pdf13. Minutes from the Mississippi Health Insurance Exchange Advisory Board Meeting. October 10, 2012. http://www.mid.ms.gov/pdf/ExcAdvBoardMtgMinutes11142012.pdf14. “Mississippi Health Insurance Exchange Advisory Board. Final Recommendations: Outreach, Education, Adoptions, and Enrollment.http://www.mid.ms.gov/pdf/FinalRecomExchAdvBoardOEAE.pdf (Accessed October 24, 2012.15. Leavitt Partners and Cicero. “The Mississippi Health Insurance Exchange: Health Reform Recommendations.” October 2012.16. Questions and responses regarding the Mississippi Comprehensive Health Insurance Risk Pool Association Request for Proposals for a Health Insurance Exchange Portal (Phase 2&3). June 13, 2012.http://www.mshie.org/images/user_files/files/MS%20Association%20HIX%20RFP%20%23002%20Response%20to%20Proposer%20Questions%2006_13_12%20links1.pdf17. Mississippi Health Insurance Exchange Advisory Board, Final Recommendation on Employer Participation. November 2012. http://www.mid.ms.gov/pdf/EABFinalRecEmployerPart.pdf18. Request for Proposals for a Health Insurance Exchange Portal (Phase 1). Released by the Mississippi Comprehensive Insurance Risk Pool Association on November 16, 2011.http://www.mshie.org/images/user_files/files/MS%20CHIRPA%20EXCHANGE%20PORTAL%20RFP%2011-16-2011.pdf19. Request for Proposals for a Health Insurance Exchange Portal (Phases 2 and 3). Released by the Mississippi Comprehensive Insurance Risk Pool Association on May 22, 2012.http://www.mshie.org/images/CHIRPA-Association_HIX_RFP_002-FINAL-5-22-12_BEF.docx20. Letter from Insurance Commissioner Michael Chaney to Deputy Administrator and Director Gary Cohen. Re: Exchange Declaration Letter for the State of Mississippi. November 14, 2012.21. Mississippi Insurance Department. EHB Benefit Description.http://www.mid.ms.gov/pdf/EHBIssuerBMInfo.pdf andhttp://www.mid.ms.gov/pdf/EHBIssuerBMInfoOther.pdf22. Mississippi Insurance Department Application for Level I Establishment Grant (Funding Opportunity Number IE-HBE-11-004). June 29, 2011.http://www.mid.state.ms.us/pdf/MS_Exchange_Establishment_Grant_Application.pdf23. Mississippi Insurance Department Request for Proposals. “Mississippi Health Insurance Exchange Community Education and Outreach Program.”24. Letter from Insurance Commissioner Michael Chaney to Deputy Administrator and Director Gary Cohen. Re: Exchange Declaration Letter for the State of Mississippi. November 14, 2012.25. Pettus EW. “Mississippi Health Insurance Exchange Proposal in Limbo.” Associated Press. January 3, 2012.http://www.hattiesburgamerican.com/viewart/20130103/NEWS01/130103013/Mississippi-health-insurance-exchange-proposal-limbo-

Final update made on September 29, 2013 (no further updates will be made)

Establishing the Marketplace

On April 12, 2006, former Governor Mitt Romney (R) signed into law comprehensive health reform legislation designed to provide near-universal health coverage for state residents.¹  The Massachusetts health reform law became the model for national health reform.

An important component of the law was the creation of the Massachusetts Health Connector, a health insurance marketplace that manages several coverage programs. Commonwealth Care provides subsidized coverage for individuals with incomes below 300% of the federal poverty level ($33,510 for an individual and $69,150 for a family of four in 2012) and Commonwealth Choice enables those who are not eligible for Commonwealth Care to shop for and purchase insurance offered by private health plans. In 2010, the Massachusetts Connector launched the Business Express program for businesses with 50 or fewer employees. As of August 2013, the Connector enrolled over 254,000 individuals in coverage—over 207,000 in Commonwealth Care and more than 42,000 in Commonwealth Choice, including approximately 5,000 enrollees in Business Express.²  Enrollment is expected to continue to increase in fiscal year 2013, in part due to reintegration of legal immigrants who became eligible for enrollment in the Connector after a recent Massachusetts Supreme Court decision.

In 2012, Governor Deval Patrick (D) enacted two laws affecting the Health Connector.^3 ,4  The first authorized the Health Connector to be certified as a state-based exchange as defined in the Affordable Care Act (ACA) and gave the Health Connector authority to perform key tasks, such as establishing a Navigator program and administering appeals related to the federal exchange. The second law included a number of provisions related to the ACA, including: designating the Connector as the entity to conduct risk adjustment; authorizing the Health Connector to sell stand-alone dental, vision, catastrophic, and child-only plans; and designating the Health and Human Services Department (known as MassHealth) to administer the Basic Health Plan option.

Structure: The Massachusetts Health Connector was established as a quasi-governmental organization, specifically a “public entity not subject to the supervision and control of any other executive office.”

Governance:  The Health Connector is governed by an 11-member Board, including four ex officio members (or designees): Secretary for Administration and Finance, Director of Medicaid, Commissioner of Insurance, and Executive Director of the Group Insurance Commission.  The Governor appoints an actuary, a health economist, a representative of small business, and an underwriter. The Attorney General appoints an employee health benefits specialist, a representative of health consumers, and a representative of organized labor. Appointees cannot be employed by an insurance carrier licensed in Massachusetts.

Current appointed Board members are:

• George Gosner Jr, Spring Insurance Group

• Jonathon Gruber, Massachusetts Institute of Technology

• Andrés López, AJL Consultants

• Louis Malzone, Massachusetts Coalition of Taft-Hardly Funds

• Nancy Turnbull, Harvard School of Public Health

• Celia Wcislo, 1199 SEIU United Healthcare Workers East
• Ian Duncan, Solucia Inc.

Contracting with Plans:  The Health Connector acts as an active purchaser and requires health insurance carriers offering plans through the Connector to receive the “Seal of Approval” by meeting requirements such as participation in all Commonwealth Choice offerings (meaning individual and small group) and offering all standardized benefit packages for all plan benefit levels (gold, silver, bronze, and young adult plans). Carriers may also offer non-standardized products to consumers, and the Health Connector is considering displaying these plans within the corresponding metal tiers (as suggested by an actuarial review).⁵  For 2013 plan year, the Connector received proposals from all eight existing Commonwealth Choice carriers and one new entrant, and granted the Seal of Approval to all standardized and non-standardized plans.

The Seal of Approval process provides the framework for the Health Connector’s certification, recertification, decertification, and ongoing performance monitoring processes. It is substantially in compliance with the Affordable Care Act’s (ACA) qualified health plan certification standards and only a few refinements are necessary.

On February 21, 2013, the Health Connector released the 2014 Seal of Approval Request for Responses (RFR). Participating insurers must offer seven standardized plans on their broadest commercial network, including two Platinum plans, three Gold plans, one Silver plan, and one Bronze plan. In addition, issuers with at least 1,000 members must offer a tiered-network Platinum or Gold plan. Issuers may also offer additional standardized plans with narrower networks and up to seven non-standardized plans. Issuers must also propose a Catastrophic plan and Wrap-Compatible Silver Plan, though not all of the proposed plans will be selected by the Health Connector.⁶ 

The Wrap-Compatible Silver Plans will be available to those with incomes up to 300% of the federal poverty level and will provide additional subsidies to lower premiums and cost-sharing so that the costs are in line with what individuals currently pay for coverage through the Commonwealth Care program. All Wrap-Compatible Silver Plans must meet the network adequacy standards that currently apply to Commonwealth Care.

On September 12, 2013, the Health Connector’s Board of Directors awarded the Seal of Approval for plans offered by ten health insurers and five dental carriers to be sold on the Health Connector for coverage beginning January 1, 2014. These insurers will offer 114 medical plan options and 24 dental plan options. Seven carriers will offer plans in the new ConnectorCare program.⁷ 

Dental and Vision Benefits: The Health Connector plans to include stand-alone dental plans beginning in 2014 and using a dental Seal of Approval program in parallel with the medical benefit. The Connector released the RFR for stand-alone dental plans on February 21, 2013. Stand-alone dental issuers are required to offer three standardized plans, including a pediatric plan, and a low and high cost adult plan. The adult plans will be sold to single adults as well as families. For families choosing one of the adult plans, any children will receive the scope of benefits and cost-sharing associated with the pediatric dental essential health benefit. In addition to the stand-alone dental plans, carriers may offer plans that integrate the medical and dental benefits or that bundle and price together a medical and dental plan.⁸ 

Risk Adjustment, Reinsurance, and Risk Corridors: Massachusetts will administer the Connector’s risk adjustment program. A multi-agency workgroup, co-chaired by the Connector and Division of Insurance, is developing the methodology and plans to leverage the state’s existing All-Payer Claims Database.⁹  In June 2013, the Health Connector, in collaboration with the Center for Health Information Analytics conducted comprehensive risk adjustment simulation and completed data quality assessments for all carriers. The Division of Insurance will also oversee administration of the transitional reinsurance program.

Consumer Assistance and Outreach: The Health Connector has developed a multi-faceted outreach and marketing campaign. The Outbound Calling campaign will target 215,000 current and newly eligible Health Connector members transitioning to new coverage. Calls will be made by the customer service vendor and will enable consumers to apply over the phone. There will also be a direct mail and an e-mail campaign to run from August 2013 through March 2014 that will include important messages, as well as notifications and reminders. The Health Connector also launched a Public Information Unit to respond to questions from the public and legislators.  The unit identifies recurring issues that will inform other outreach activities, including Navigator training, road shows, etc.¹⁰  The Health Connector will also conduct “Road Shows” targeting small employers and is partnering with Health Care for All to conduct a grassroots, public education campaign.

Over the summer, the Health Connector did a soft-launch of the new branding campaign, including the new logo and website, and in September 2013, the new Contact Center was launched. In addition, two walk-in centers to provide in-person support will be available. Paid and earned media campaigns will launch in the fall while the Health Connector re-launched its social media presence on Twitter, Facebook, and Google+ in August.

On July 22, 2013, the Health Connector announced the ten organizations selected to serve as Navigators. These organizations will target the remaining uninsured and will focus on populations transitioning from existing programs to new coverage available beginning in January 2014.¹¹  Navigators must complete required training programs and be certified before they can begin assisting consumers. Initial training of Navigators began in August 2013 and continued through September. A third phase of training is anticipated in November/December in support of additional system functionality. Navigators must also attend quarterly policy and operation check-in meetings.

In addition to Navigators, the Health Connector is leveraging MassHealth’s existing Virtual Gateway program and its network of 200 hospitals and health centers to serve as Certified Application Counselors. It has also provided regional training to brokers

Small Business Health Options Program (SHOP) Marketplace: The Division of Insurance has identified a subcontractor to evaluate the impact on the insurance market of broadening the definition of small employer to those with 100 or fewer employees before 2016.¹²  The Health Connector currently offers the Business Express program, which allows small employers to select a Connector plan to offer to their employees. As the Health Connector converts its Business Express program to the SHOP, the Connector will offer small employers three plan selection options: selection of single plan offered by a single insurer; selection of all plans offered at a particular metal tier; or selection of multiple metal tier plans offered by a single insurer. All QHPs, including both standardized and non-standardized plans, except for catastrophic plans will be available to small employers.

The Health Connector is creating “Sub-connectors,” an alternative distribution channel for small employers (and the brokers who serve them) to purchase coverage through the Health Connector while retaining aspects of their current shopping experience. The goal is to allow more small businesses to access QHPs through the Connector.¹³  The Health Connector has issued a Request for Information (RFI) to collect feedback on licensing requirements for Sub-connectors.

The Connector hopes to leverage knowledge acquired from the Contributory Plan pilot, which was frozen shortly before the Business Express was introduced in 2010. The Contributory Plan allowed employers to fix their contribution to premium costs, while still providing meaningful plan choice to employees. Previous experience with the Contributory Plan indicated that the concept appealed to employers but there were opportunities for improvement to make the methodology consistent across carriers and ensure the shopping experience was simple and intuitive.

Basic Health Program (BHP): In June 2012, MassHealth was authorized to create a BHP.¹⁴   The BHP is an optional coverage program available through the ACA that allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139% and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through an Exchange. In addition, the Connector was authorized to make wrap-around premium and cost-sharing subsidies available to individuals covered by qualified health plans through the Health Connector if their incomes were between 200% and 300% FPL. The wrap-around subsidy was meant to hold the new premiums for individuals with incomes up to 300% of FPL in line with the current premiums for Commonwealth Care.

However, HHS delayed issuing regulations for the BHP forcing the state to consider an alternative approach. given the delay in federal guidance detailing the administration of a BHP, Massachusetts developed an alternative approach. The QHP Wrap program provides state-based wrap-around subsidies for individuals with incomes between 139% and 300% FPL who are enrolled in specified QHPs.¹⁵  Only carriers that offer the lowest-priced QHPs will be qualified to offer the wrap plans. The state submitted an amendment to its Medicaid Section 1115 demonstration waiver to obtain federal funding to support the state wrap-around subsidies.

Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Marketplace, cover certain defined health benefits. Along with collecting stakeholder feedback, the Division of Insurance compared the ten possible EHB benchmark plans and concluded that the three largest small group plans offered in Massachusetts offer similar benefits and have virtually the same relative value.¹⁶  Massachusetts selected Blue Cross Blue Shield’s HMO Blue, the largest small group plan, as the EHB benchmark.¹⁷   The DOI also recommended that the benchmark plan be supplemented with the state’s CHIP pediatric dental benefit plan.

Financing: Massachusetts initially appropriated $25 million to operate the Health Connector, but it is now financially self-sustaining and authorized to apply a surcharge to all health benefit plans offered through the Connector. The collected funds pay for the Health Connector’s administrative and operational expenses, not premium assistance payments, under Commonwealth Care.

The Health Connector is developing a long-term financing strategy that involves continued state funding and a carrier administrative fee targeted at or below 2.5% of premium. Because of the availability of federal Establishment Grant funding to support Health Connector operations in 2014, the carrier administrative fee for 2014 has been temporarily eliminated.¹⁸ 

Marketplace Funding

In September 2010, the Massachusetts Commonwealth Insurance Connector Authority received a federal Exchange Planning grant of $1 million. In February 2012, the Connector Authority also received a Level One Establishment grant of $11.6 million to analyze coverage transitions and the operational interface between the Exchange and the state’s Medicaid program.¹⁹   In addition, Massachusetts is a member of the consortium of New England States Collaborative Insurance Exchange Systems that received a federal Early Innovator grant of $36 million to develop, share, and leverage insurance exchange technology.²⁰  The University of Massachusetts Medical School is the grant holder.  In September 2012, Massachusetts received a second Level One grant of $41.7 million dollars to create a risk-adjustment program and support IT development lead by the HIX/IES. In January 2013, the Connector received a Level Two grant of $81.3 million to support creation of a state-specific risk adjustment program, development of an outreach and education campaign, and the first year of operations of the Connector as an ACA-compliant exchange.²¹ 

Next Steps

On December 7, 2012, Massachusetts received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a State-based Marketplace.²²   Until new coverage begins on January 1, 2014, the state will continue providing coverage to eligible individuals through existing programs, including Commonwealth Care and Commonwealth Choice. Beginning October 1^st, the state will start to transition consumers to their new coverage options.

Additional information about the Massachusetts Connector can be found at:  https://www.mahealthconnector.org/ and http://bettermahealthconnector.org/

1. Chapter 58. An Act Providing Access to Affordable, Quality, Accountable Health Care. April 12, 2006. Part I, Chapter 176Q. Administration of the Government, Commonwealth Health Insurance Connector.  ↩︎
2. Massachusetts Connector Quarterly Program Summary Report, August 2013. September 6, 2013.  ↩︎
3. Chapter 96. An Act Making Appropriations for the Fiscal Year 2012 to Provide for Supplementing Certain Existing Appropriations and For Certain Other Activities and Projects.  ↩︎
4. Chapter 118. An Act Making Appropriations for the Fiscal Year 2012 to Provide for Supplementing Certain Existing Appropriations and For Certain other Activities and Projects.  ↩︎
5. Stephany S and Yang J. “Commonwealth Choice 2013 Seal of Approval.” Presented to the Health Connector Board of Directors. September 13, 2012.  ↩︎
6. The Health Connector Team “2014 Seal of Approval Launch” presented to the Health Connector Board of Directors, February 14, 2013.  ↩︎
7. The Health Connector press release, “Health Connector Announces Seal of Approval for Health Insurance Plans Effective January 2014” September 12, 2013.  ↩︎
8. “2014 Seal of Approval Launch” presentation. ↩︎
9. Apicella D and Berardi C. “National Health Care Reform Update” Presented to the Health Connector Board of Directors, September 13, 2012.  ↩︎
10. “Outreach and Communications Strategy and Contract Extension” presentation to the Board of Directors, June 13, 2013.  ↩︎
11. Health Connector Announces Awardees of Massachusetts Navigator Grant Program, July 22, 103.  ↩︎
12. Massachusetts Executive Office of Health and Human Services. “Health Insurance Reform Working Group: ACA Changes to Small Employer Definition and Rating Factor Rules.” March 23, 2012.  ↩︎
13. Mansur R. “Licensing Procedures Request for Information.” November 16, 2012.  ↩︎
14. Chapter 118.  An Act Making Appropriations for the Fiscal Year 2012 to Provide for Supplementing Certain Existing Appropriations and For Certain other Activities and Projects. ↩︎
15. Yang J and Hague A. “2014 Seal of Approval Introduction (III): Subsidized Health Insurance and the QHP Wrap.” December 13, 2012.  ↩︎
16. Executive Office of Health and Human Services. “Analysis of Three Largest Small Group Plans for EHB Benchmark.” September 19, 2012.  ↩︎
17. Essential Health Benefits, Benchmark Plan for Massachusetts. Accessed January 8, 2013.  ↩︎
18. Board of the Commonwealth Health Insurance Connector Authority meeting minutes, February 14, 2013.  ↩︎
19. Massachusetts Health Insurance Connector Authority application for Level One Establishment grant. Project Abstract. December 27, 2011.  ↩︎
20. Massachusetts application for the Cooperative Agreement to Support Innovative Exchange Information Technology Systems. IE-HBE-11-001. The New England States Collaborative Insurance Exchange Systems (NESCIES)  ↩︎
21. Massachusetts Affordable Insurance Exchange Grants Awards List. ↩︎
22. Letter from Secretary Sebelius to Governor Patrick. December 7, 2012. ↩︎