KFF designs, conducts and analyzes original public opinion and survey research on Americans’ attitudes, knowledge, and experiences with the health care system to help amplify the public’s voice in major national debates.
Final update made on July 12, 2013 (no further updates will be made)
Establishing the Exchange
On December 14, 2012, Governor Bob McDonnell (R) informed federal officials that Virginia would not continue to plan for a state-based health insurance exchange.1
Prior to the decision, Governor McDonnell had signed HB 2434 into law declaring the state’s intent to establish a state-based health insurance exchange.2 The legislation was based on a recommendation by the Virginia Health Reform Initiative Advisory Council, housed within the Virginia Department of Health and Human Resources.3 HB 2434 required the Governor to submit recommendations regarding establishment of an exchange in Virginia for consideration during the 2012 session of the General Assembly and prohibited qualified health insurance plans offered through the exchange from covering abortions, except in cases of rape, incest, or life endangerment of the pregnant woman.
On November 25, 2011, the Advisory Council’s exchange recommendations were submitted to the General Assembly by the Governor.4 The Council voted in favor of establishing a state-based exchange as a quasi-governmental agency with a governing board.5 However, Governor McDonnell opposed passing the additional legislation needed for the establishment of a state-based exchange until after the Supreme Court ruled on the Affordable Care Act (ACA) in late June 2012.6 Numerous bills to establish a state-run health insurance exchange were introduced in the Virginia Legislature in 2012; however, all were tabled for the next legislative session.7 In the absence of establishment legislation, the Advisory Council temporarily suspended its meetings.
Contracting with Plans: On February 14, 2013, Governor McDonnell sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO) announcing the state’s intent to perform plan management activities despite not having entered into a state-federal partnership exchange.8 On March 21, 2013 Governor McDonnell approved legislation authorizing the State Corporation Commission (SCC) to perform plan management functions, including collecting and analyzing information on plan rates, benefits, and cost-sharing and ensuring continued plan compliance. The SCC was also granted the authority to manage consumer complaints, provide technical assistance, and decertify issuers. The legislation authorizes the Virginia Department of Health to assist in plan management functions.9 Premium rates will vary based on family composition, age, tobacco use, and geographic area.10 Virginia will have 12 geographic rating areas, determined by the federal default mechanism.11
Consumer Assistance and Outreach: In April 2013, Governor McDonnell signed into law HB 2246 and SB 1261 to prohibit navigators from performing activities that would require an insurance agent license. Navigators must be selected in accordance with federal law and may not act as intermediaries between employers and insurers offering QHPs or dental plans through the Exchange. The SCC will monitor Navigator activities and submit findings to the Governor and the Senate and House Commerce and Labor Committees in November of 2014 and 2015.12
Information Technology (IT): Virginia is focusing on a significant Medicaid IT system upgrade and has received approval from the Centers for Medicare and Medicaid Services (CMS) for an enhanced federal match. In May 2012, the state released a Request for Proposals soliciting subcontractors to streamline eligibility and enrollment for all existing social service benefits, including Medicaid, TANF, and food stamps. State officials envision eventual interoperability between the upgraded system and an exchange.
Essential Health Benefits (EHB): The ACA 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. Drawing input from multiple stakeholders and various analyses, the Advisory Council recommended in June 2012 that a subcommittee be established to consider Anthem, the state’s small-group PPO as the state’s benchmark plan. The subcommittee recommended Anthem as the EHB benchmark plan and the Children’s Health Insurance Program (CHIP) dental benefit plan (Smiles for Children) as the pediatric dental supplemental plan.13
Exchange Funding
In September 2010, the Virginia State Department of Medical Assistance Services received a federal Exchange Planning grant of $1 million. The state planned to submit a Level One Establishment grant application in June 2012; however, the Governor announced in a letter to the Legislature in July, he decided not to submit the application.14In February 2013, Virginia received a $4.3 million Level One Establishment grant to support plan management functions, including hiring IT consultants and engaging stakeholders. In July 2013, Virginia received a second Level One Establishment grant for $1.2 million to fund the actuarial analysis needed to support the certification, decertification, and recertification of QHPs and stand-alone dental plans.15
Virginia, along with nine other states, received technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance exchanges, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.16
Next Steps
On March 29, 2013, Virginia received approval from CCIIO to perform plan management activities. The federal government will retain control over all other Exchange functions.17
Final update made on April 19, 2013 (no further updates will be made)
Establishing the Exchange
On September 26, 2012, Governor Dennis Daugaard (R) announced that South Dakota would not establish an exchange.1However, the state intends to maintain regulatory authority over the health insurance market and perform the plan management function for the exchange.2 The decision to have a federally-facilitated exchange was made after an inter-agency work group and a taskforce of stakeholders and legislators explored the possibility of establishing a state-based exchange.3,4
On March 19, 2012, South Dakota enacted a law prohibiting plans in a state exchange from offering abortion coverage, except when it is necessary to preserve the life or health of the pregnant woman.5
Contracting with Plans: On March 11, 2013, Director of the Division of Insurance Merle Scheiber sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO) requesting to maintain control over plan management functions despite not having entered into a state-federal partnership exchange. The Division of Insurance (DOI) has the legal authority and operational capacity to oversee certification of Qualified Health Plans (QHPs). DOI will use the System for Electronic Rate and Form Filing (SERFF) to collect and analyze information on plan rates, covered benefits, and cost-sharing requirements. DOI will also ensure continued plan compliance, manage consumer complaints, and oversee decertification of issuers.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. In the fall of 2012, Governor Daugaard selected the Wellmark Blue Cross Blue Shield’s Blue Select plan to be the South Dakota’s EHB benchmark.7
Exchange Funding
The South Dakota Office of the Governor received a federal Exchange Planning grant of $1 million in 2010. In May 2012, the Division of Insurance was award a Level One Establishment grant of $5.9 million to further the state’s planning and design of an exchange, including creation of a risk adjustment and reinsurance plan, studying the effects of adverse selection, designing an outreach and education plan, and writing an RFP for a comprehensive IT development plan.8
Next Steps
On March 29, 2013, South Dakota received approval from CCIIO to perform plan management activities. The federal government will retain control over all other Exchange functions.9
Final update made on May 21, 2013 (no further updates will be made)
Establishing the Exchange
After making health system reform one of the state’s top policy priorities, Utah’s former Governor Jon Huntsman (R) signed legislation in 2008 (HB 133) and 2009 (HB 188) which directed the Office of Consumer Health Services to create the Utah Health Exchange.1 Current Governor Gary Herbert (R) signed into law additional legislation amending provisions related to health system reform in 2010 (HB 294) and 2011 (HB 128); the latter reauthorized the Health System Reform Task Force to evaluate options for bringing the state’s already existing exchange into compliance with the Affordable Care Act (ACA).2 Additional health system reform legislation was introduced in February 2012 (HB 144).3 The Utah Exchange allows small employers to participate in a defined contribution arrangement and compare, select, and enroll in commercial health insurance online. In 2012, the Utah Exchange was renamed to Avenue H.
In early 2012, Governor Herbert stated Utah was in negotiations with the federal Department of Health and Human Services (HHS) regarding the extent to which the state would have to modify its existing health insurance exchange to meet new federal requirements under the Affordable Care Act (ACA). Although the state received conditional approval from HHS in January 2013 for a fully state-run exchange, Governor Herbert subsequently proposed that the state continue running Avenue H as the state’s SHOP exchange for small employers while the federal government operate a federally-facilitated individual exchange in the state.4 HHS granted approval for this proposal in May 2013.5
In March 2011, Governor Herbert also signed HB 354 into law which bans abortion coverage in any private plan sold in the state, including the Exchange, except in cases of life endangerment or severe impairment of the pregnant woman, rape, incest, or fetal abnormality effective January 1, 2012.6
The following describes the structure and governance of Avenue H, the state’s SHOP exchange.
Structure: Avenue H is administered by the Office of Consumer Health Services, which is housed within the Governor’s Office of Economic Development.
Governance: The Office of Consumer Health Services runs Avenue H, and is responsible for ensuring performance and resolving policy issues. State law requires Avenue H to operate with input from two distinct boards: an Exchange Advisory Board and a Defined Contribution Risk Adjuster Board. HB 294 requires Avenue H to create an Advisory Board to counsel staff on the operation of the Exchange and transparency issues. An Exchange Advisory Board met monthly until June 2011, at which time it was replaced by an Executive Steering Committee. Consumer advocates have raised concerns over the lack of consumer representation on the Executive Steering Committee.7
Current Executive Steering Committee members are:
Greg Bell (Co-Chair), Lt. Governor
Greg Poulsen (Co-Chair), Intermountain Healthcare
Richard Broadbent, Utah Association of Health Underwriters
Marc Bennett, HealthInsight
Rich McKeown, Salt Lake Chamber’s Health Committee & Leavitt Partners
Gordon Crabtree, University of Utah
Pam Gold, United HealthCare
Pat Richards, SelectHealth
Jennifer Cannaday, Regence BlueCross/BlueShield
Howard Headlee, Utah Bankers Association
David Patton, Department of Health
Mark VanOrden, Department of Technology Services
Spencer Eccles, Governor’s Office of Economic Development
Patty Conner, Avenue H, Office of Consumer Health Services
Norm Thurston, Office of Consumer Health Services
Responsibility for managing the risk sharing mechanisms for Avenue H’s defined contribution market lies with the Utah Defined Contribution Risk Adjuster Board which meets monthly and is composed of up to nine members.8 The Governor appoints between five and seven members, including: three to five members who possess actuarial experience and represent insurers that participate in the defined contribution market in Utah and one to two of whom represent insurers that have a small percentage of lives in the defined contribution market; a representative of an individual employee or employer; and a representative of the Office of Consumer Health Services. The Director of the Public Employees’ Benefit and Insurance Program appoints one member with actuarial experience to represent that program. The Insurance Commissioner (or designee) is the final member and can only vote in the event of a tie.
Current Risk Adjuster Board members are:
Jim Pinkerton (Chair), Regence Blue Cross Blue Shield of Utah
John Borer, Public Employees’ Benefit and Insurance Program
Dave Jackson, First West Benefit Solutions
Jim Murray, SelectHealth
Kim Miller, United Health Care
Norman Thurston, Office of Consumer Health Services
Tomasz Serbinowski, Utah Insurance Department
Contracting with Plans: Per Utah’s agreement with HHS, the state will maintain oversight of Qualified Health Plans (QHPs) participating in the state’s individual exchange operated by HHS, as well as those participating in Avenue H. On March 28, 2013, the Utah Insurance Department (UID) issued a bulletin providing information on the filing requirements for plans issued or renewing on or after January 1, 2014, as well as the timeline for the QHP approval process.9
Avenue H acts as a market clearinghouse and accepts all insurers meeting minimum standards. HB 128 gives the Insurance Department authority to conduct rate reviews to verify that insurers price plans similarly within and outside of the Exchange. There are currently over 140 plans offered through Avenue H with varying prices, copays and deductible levels. Brokers play an integral role in assisting small employers with selecting plans.
Consumer Assistance and Outreach: By May 2013, 344 employer groups were enrolled in Avenue H with over 8,000 covered lives.10 To increase enrollment, the state is undertaking initiatives to enhance the consumer experience, including improving the user interface and providing education and decision support to consumers.
As part of its agreement to operate Avenue H as the SHOP exchange, the state must run a SHOP-specific Navigator program and fund a minimum of two Navigators. The state has the option of limiting the role of the SHOP-specific Navigators to consumer outreach and education functions only. HHS will finance and run a Navigator program in the individual exchange.
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. 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 Health System Reform Task Force collected public comments on EHB and in mid-August 2012 voted to recommend the Public Employee Health Plan’s Utah Basic Plus as the benchmark.11 The Utah Insurance Department issued a final rule, effective October 25, 2012, designating this plan as the state’s EHB benchmark plan.12
Information Technology (IT): The state already has in place the technology backbone necessary to support Avenue H. Now that the state will not be operating the individual exchange, it will need to develop an interface between the state’s public programs and the federal exchange. Prior to the recent developments, in July 2012, subcontractors completed two reports on exchange design and functionality.13
Financing: Avenue H began with an initial appropriation of $600,000 and ongoing funding is through annual appropriation and monthly fees assessed on every subscriber. Avenue H also receives support from the Governor’s Office of Economic Development for the Exchange’s staff members.
Exchange Funding
In September 2010, the Governor’s Office of Economic Development was awarded a $1 million federal Exchange Planning grant.
Next Steps
On May 10, 2013, Utah received approval to operate Avenue H as the state’s SHOP exchange and to perform plan management functions in the federally-facilitated individual exchange.14 The federal government will perform all other functions for the individual exchange.
For more information about Utah’s existing health insurance exchange, Avenue H, visit: http://www.avenueh.com/
House Bill 133. Health System Reform. 2008 General Session. House Bill 188. Health System Reform- Insurance Market. 2009 General Session. ↩︎
House Bill 294. Health System Reform Amendments. 2010 General Session. House Bill 128. Health Reform Amendments. 2011 General Session. ↩︎
House Bill 144. Health System Reform Amendments. 2012 General Session. Introduced February 3, 2012. ↩︎
Final update made on December 13, 2012 (no further updates will be made)
Establishing the Exchange
In November 2012, Governor-elect Mike Pence (R) announced that he would not move forward with setting up a state-based health insurance exchange when he takes office in 2013.1
During his term, Governor Mitch Daniels (R) had signed Executive Order #11-01 in 2011 to conditionally establish and operate the Indiana Insurance Market, Inc., a nonprofit corporation to serve as the Indiana health insurance exchange.2 The Executive Order defined Indiana’s exchange as a nonprofit incorporated by the Secretary of the Indiana Family and Social Services Administration, working with the Indiana Department of Insurance. An interagency group including, the Department of Insurance, the Family and Social Services Administration, and the Office of Medicaid Policy and Planning, worked on exchange planning in the state. However, since issuing the Executive Order, Indiana began to move away from a state-based exchange.3 While the state had assembled two pieces of draft exchange legislation, the Department of Insurance did not propose either during the 2012 legislative session, which ended in March 2012.4
On May 5, 2011, Governor Daniels signed HB 1210, which prohibits qualified health plans purchased through an exchange in Indiana from covering abortions, except in the case of rape, incest, or to avert impairment or death of the 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 Indiana has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Anthem Blue Cross Blue Shield of Alaska- Blue Access PPO.
Exchange Funding
In May 2011, Indiana was among the first three states to be awarded a federal Level One Establishment grant.6 The Indiana Department of Insurance and Family and Social Services Administration received of $6.9 million to update their information technology systems, develop a financial management plan, and acquire legal, actuarial, and financial expertise.7 The Indiana Family and Social Services Administration also received a federal Exchange Planning grant of $1 million in September 2010.
Next Steps
The federal government will assume full responsibility for running a health insurance exchange in Indiana beginning in 2014.
Final update made on December 4, 2012 (no further updates will be made)
Establishing the Exchange
On November 28, 2012, Governor Jan Brewer (R) informed federal officials that Arizona would default to a federally-facilitated health insurance exchange.1
Prior to her decision to default, the Governor had established the Office of Health Insurance Exchange to “organize the health insurance marketplace for easier evaluation by individuals and small businesses to acquire affordable health insurance.”2 While legislation establishing a state-run health insurance exchange failed in 2011, the Governor’s Office and legal counsel had researched non-legislative options for establishing an exchange.3,4
The Arizona Health Insurance Exchange Steering Committee was established to coordinate exchange planning activities across state agencies and met regularly. Members included Directors and senior staff from the Office of Health Insurance Exchange, the Department of Insurance, the Arizona Health Care Cost Containment System, the Department of Economic Security, the Department of Health Services, and the Director of Health Care Innovation Infrastructure Management. Stakeholder feedback was gathered through five work groups including, a health plans work group led by the Department of Insurance and focused on plan management requirements; a health brokers and agents group, concentrating on broker licensing and compensation; a tribal work group, which was developing outreach and education plans; an information technology infrastructure work group led by the Arizona Health Care Cost Containment System; and a legislative work group.5
On April 24, 2010, Arizona enacted a law prohibiting plans in a state exchange from offering abortion coverage except in cases of life endangerment or severe health impairment of the pregnant woman.6
Contracting with Plans: Prior to defaulting to a federal exchange, the Department of Insurance took the lead in researching and developing the plan management functions for the exchange, including certification of qualified health plans, quality rating systems, risk adjustment and transitional reinsurance. Their work was informed by the health plans work group meetings. Arizona expressed support for adopting a market facilitator approach, whereby the exchange would contract with all qualified health plans meeting certain criteria.7,8 In February 2012, the state released a Request for Proposals soliciting subcontractor assistance with exchange management functions including, plan management, plan selection, data management and reporting, consumer support services, and financial management.9
Information Technology (IT): Arizona had planned to design and build the individual and small business exchange components, upgrade its Medicaid eligibility systems, and integrate everything into one seamless system. Arizona submitted an Advanced Planning Document which was accepted by CMS, indicating the state intends to make major Medicaid eligibility systems upgrades. In 2011, the state released a Request for Information to identify viable available or proposed solutions for aligning its Medicaid and Children’s Health Insurance Program (CHIP) enrollment and eligibility systems with an exchange as well as estimated pricing.10 Arizona also participated in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use.11
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 Exchange, cover certain defined health benefits. The Department of Insurance examined the state’s EHB options and solicited subcontractors to complete an analysis on options for the final benchmark plan.12 The state selected the State Employee Benefit- United Healthcare EPO with pediatric and vision coverage supplemented by the FEDVIP plans as the benchmark package.13
Exchange Funding
In September 2010, the Arizona Governor’s Office of Economic Recovery received a federal Exchange Planning grant of $1 million. In November 2011, the Governor’s Office was awarded a $29.8 million Level One Establishment grant to further secure IT infrastructure and assist in finalizing plan management functions for the exchange.14
Next Steps
The federal government will assume full responsibility for running a health insurance exchange in Arizona beginning in 2014.
Final update made on December 10, 2012 (no further updates will be made)
Establishing the Exchange
On December 7, 2012, Governor Chris Christie (R) vetoed A 3186/S 2135, which would have established a health insurance exchange within the Department of Banking and Insurance and announced that the state would default to a federal exchange.1Governor Chris Christie (R) vetoed similar legislation earlier in 2012.2
In 2011, the New Jersey Interagency Working Group on the ACA, led by the Health Care Policy Advisor to the Governor, had contracted with Rutgers University’s Center for State Health Policy to assist in the planning effort. In December 2011, the Center for State Health Policy released a summary of a multi-stakeholder forum convened to examine governance options for a New Jersey exchange.3 The results of the forum build on the Center’s compilation of stakeholder views of a state-based exchange released in August 2011.4 Though there was agreement that the state should establish an exchange, there was less consensus around the composition of the governing board and whether the exchange should be an active purchaser or clearinghouse.5
At the same time, the New Jersey Department of Banking and Insurance and the Robert Wood Johnson Foundation funded the Center for State Health Policy, in collaboration with Seton Hall University School of Law, to examine critical exchange design issues. The Center, completed a policy analysis of governance options and released a report recommending that New Jersey establish an exchange as a government agency, overseen by a Board of Directors with seven to nine members, and guided by insight from a larger advisory board.6 The Center released several additional reports on numerous topics: merging the non-group and small-group risk pools, establishment of a defined contribution strategy in the Small Business Health Options Program (SHOP) exchange, incorporating quality measures into exchange ratings of health plans, creation of Basic Health Plan in New Jersey, background information related to selection of an Essential Health Benefits plan, and prevention of adverse selection.7,8,9,10,11,12 The Center has also collaborated with Seton Hall University on a number of studies, including an assessment of the ACA’s impact on health coverage of New Jersey residents, an evaluation of federal and state regulation of rating factors, a comparison of the clearinghouse versus active purchaser model, and an investigation into eligibility and enrollment issues related to an exchange and Medicaid.13,14,15,16Essential 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 New Jersey has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Horizon Blue Cross Blue Shield- HMO Access.
Exchange Funding
The New Jersey Department of Banking and Insurance received a federal Exchange Planning grant of $1 million in 2010. On February 22, 2012, the Department of Banking and Insurance also received a Level One Establishment grant of $7.7 million to address gaps in information technology and to continue the planning efforts and policy analysis of issues such as reinsurance, projected plan cost and utilization, standards for plan management, and the essential health benefits.17
Next Steps
The federal government will assume full responsibility for running a health insurance exchange in New Jersey beginning in 2014.
1. A 3186/S 2135. New Jersey Health Benefit Exchange Act of 2012.http://www.njleg.state.nj.us/2012/Bills/A3500/3186_R1.PDF2. A 2171. New Jersey Health Benefit Exchange Act of 2012.http://www.njleg.state.nj.us/2012/Bills/A2500/2171_R2.PDF3. “Summary of Proceedings. Stakeholder Forum to Discuss Governance Options for a New Jersey Health Insurance Exchange.” Rutgers Center for State Health Policy. December 2011.http://www.cshp.rutgers.edu/Downloads/9160.pdf4. Cantor J, et al. “Stakeholder Views about the Design of Health Insurance Exchanges for New Jersey: Volumes I, II, and II.” Rutgers Center for State Health Policy. August 2011.http://www.cshp.rutgers.edu/Downloads/8980.pdf,http://www.cshp.rutgers.edu/Downloads/9000.pdf, http://www.cshp.rutgers.edu/Downloads/8990.pdf5. Fitzgerald B. “Countdown to NJ’s Health Insurance Exchange.” NJSpotlight. January 3, 2012.http://www.njspotlight.com/stories/12/0103/0316/6. Jacobi J. “Health Insurance Exchanges: Governance Issues for New Jersey.” Rutgers Center for State Health Policy. September 2011. http://www.cshp.rutgers.edu/Downloads/9020.pdf7. Cantor J. “Combining New Jersey’s Individual and Small Group Health Insurance Risk Pools. Rutgers Center for State Health Policy. December 2011.http://www.cshp.rutgers.edu/Downloads/9140.pdf8. Chou J, et al. “Examining a Defined Contribution Strategy in the SHOP Exchange.” Rutgers Center for State Health Policy. December 2011. http://www.cshp.rutgers.edu/Downloads/9130.pdf9. Michael M and Gaboda D. “Incorporating Quality Measures in Health Insurance Exchange Ratings of Health Plans. Rutgers Center for State Health Policy. December 2011.http://www.cshp.rutgers.edu/Downloads/9150.pdf10. Gaboda D and Farnham J. “The Basic Health Plan Option in New Jersey.” Rutgers Center for State Health Policy. December 2011. http://www.cshp.rutgers.edu/Downloads/9120.pdf11. Greenwood K, Ragone TA, Jacobi JV. “Implementing the Essential Health Benefits Requirements in New Jersey; Decision Points and Policy Issues.” Rutgers’ Center for State Health Policy and Seton Hall’s Center for Health and Pharmaceutical law and Policy. August 2012.http://www.cshp.rutgers.edu/Downloads/9540.pdf12. Canto J “Preventing Adverse Risk Selection in New Jersey’s Health Insurance Exchange and the Outside Individual and Small-Group Markets.” Rutgers Center for State Health Policy. August 2012. http://www.cshp.rutgers.edu/Downloads/9510.pdf13. Cantor J, et al. “Health Insurance Status in New Jersey after Implementation of the Affordable Care Act.” Rutgers’ Center for State Health Policy and Seton Hall’s Center for Health and Pharmaceutical law and Policy. August 2011. http://www.cshp.rutgers.edu/Downloads/8970.pdf14. Ragone TA. “Evaluating Federal and New Jersey Regulation of Rating Factors and Rating Bands. Rutgers’ Center for State Health Policy and Seton Hall’s Center for Health and Pharmaceutical law and Policy. August 2012. http://www.cshp.rutgers.edu/Downloads/9490.pdf15. Jacobi J. “Active or Passive: The Role of a New Jersey Health Insurance Exchange.” Rutgers’ Center for State Health Policy and Seton Hall’s Center for Health and Pharmaceutical law and Policy. August 2012. http://www.cshp.rutgers.edu/Downloads/9530.pdf16. Greenwood K. “The Health Insurance Exchange, the Medicaid program, and the Apportionment of Responsibility for Determining Eligibility and Effectuating Enrollment in New Jersey.” Rutgers’ Center for State Health Policy and Seton Hall’s Center for Health and Pharmaceutical law and Policy. August 2012. http://www.cshp.rutgers.edu/Downloads/9500.pdf17. U.S. Department of Health and Human Services Factsheet. “Creating a New Competitive Marketplace: Health Insurance Exchange Establishment Grants Awards List.” (Accessed February 22, 2012) http://www.healthcare.gov/news/factsheets/2011/05/exchanges05232011a.html
Final update made on December 13, 2012 (no further updates will be made)
Establishing the Exchange
On November 19, 2012, Governor Mary Fallin (R) announced that Oklahoma would not pursue the creation of a state-based health insurance exchange.1
Prior to the announcement, Oklahoma had established the Joint Committee on Federal Health Care Law to explore the state’s options regarding federal health reform, including exchange implementation in the state.2 The Joint Committee convened in 2011 and released final exchange recommendations to the Governor and the Legislature in late February 2012.3,4 Committee recommendations included establishing a state-based private marketplace network to avoid federal involvement in the state; this would resemble a Utah model for small-businesses but would not include an individual exchange. A bill based on these recommendations was introduced in the 2012 legislative session (SB 1629) but failed at the end of the legislative session.5
The Oklahoma Health Insurance Exchange Project, led by the Secretary of Health as liaison to the Governor’s Office and State Legislature, the Oklahoma Department of Mental Health and Substance Abuse Services, the Insurance Department, and the Oklahoma Health Care Authority, began planning efforts in early 2011; however, the Project suspended activities in 2012 due to the exhaustion of federal grant funds.
On April 4, 2011, Governor Fallin signed into law a measure prohibiting any health insurance plans offered in the exchange from covering abortions except in cases of rape, incest, or life endangerment of the pregnant woman (SB 547).6 The bill allows health plan enrollees the option to purchase additional abortion coverage if desired.
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 Oklahoma 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 Oklahoma- BlueOptions PPO.
Exchange Funding
Oklahoma’s Department of Mental Health and Substance Abuse Services received a $1 million federal Exchange Planning grant. In addition, the Oklahoma Health Care Authority received a $54.5 million Early Innovator grant to develop model technological infrastructure for a health insurance exchange.7 In April 2011, Governor Fallin announced that Oklahoma planned to return the Early Innovator grant funding.8
Next Steps
The federal government will assume full responsibility for running a health insurance exchange in Oklahoma beginning in 2014.
Final update made on December 11, 2012 (no further updates will be made)
Establishing the Exchange
On November 16, 2012, Governor Nathan Deal (R) announced that the Georgia had stopped planning for an exchange.1 In the previous year Governor Deal issued an Executive Order to create the Georgia Health Exchange Advisory Committee to assess whether and how Georgia should establish a health benefit exchange.2 The 25-member Committee included state officials, insurers, brokers, business representatives, consumers, and providers.3 The Committee also formed subgroups to develop recommendations on governance, operations and finance, and insurance markets. In October 2011, the subgroups released reports that included recommendations to establish a ‘Georgia Health Insurance Marketplace Authority’ as a quasi-governmental, non-profit corporation with a single governing body that maintains two separate risk pools for businesses and individual consumers.4,5,6 In December 2011, the Committee submitted final recommendations to the Governor in support of creating a small business health insurance marketplace through a wholly private or limited quasi-governmental entity, but did not commit to building an individual exchange.7
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 Georgia did 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 Georgia- HMO Urgent Care 60 Copay.
Exchange Funding
The Georgia State Office of Planning and Budget received a federal Exchange Planning grant of $1 million in 2010.
Next Steps
The federal government will assume full responsibility for running a health insurance exchange in Georgia beginning in 2014.
Final update made on February 12, 2013 (no further updates will be made)
Establishing the Exchange
On November 15, 2012, Governor Beverly Perdue (D) declared the state’s intent to establish a state-federal partnership health insurance exchange.1 However, on February 12, 2013, newly-elected Governor Pat McCrory (R) issued a statement indicating that North Carolina will abandon efforts to establish a partnership exchange and will instead allow the federal government to operate the exchange.2
In 2011, Governor Perdue had signed into law HB 22 which indicated the General Assembly’s intent to establish and operate a state based health insurance exchange.3 Legislators introduced three bills to establish a state-based health insurance exchange in 2011; however, all failed at the close of the legislative session in July 2012.
In the absence of exchange legislation, the North Carolina Department of Insurance (NCDOI), the North Carolina Department of Health and Human Services (NCDHHS), and the North Carolina Institute of Medicine (NCIOM) led exchange planning in the state. As of January 2012, the Department of Insurance leads a Market Reform Technical Advisory Group (TAG) comprised of insurers, agents, consumers, and providers. The NCIOM Health Benefit Exchange and Insurance Oversight Workgroup released a final report in May 2012 on the impact of federal reform on the state.4
Contracting with Plans: In September 2012, the North Carolina Department of Insurance issued a Request for Proposals to solicit work on exchange plan management activities including, technical assistance and training; the Department intends for the contract to begin in October 2012.5 In the spring of 2012, the Department of Insurance’s TAG recommended that North Carolina initially defer to the federal risk adjustment model, but evaluate developing a state model in the future.6The TAG also suggested the state administer the reinsurance program, while deferring the responsibility of collecting contributions to the federal government. In April 2012, the NCIOM Workgroup explored the exchange’s authority to limit the number of plan designs per metal level in 2014.
Consumer Assistance and Outreach: In April 2012, the NCIOM Workgroup identified outstanding issues including, conflict of interest provisions for agents and brokers as well as patient Navigators.7 The Workgroup created a subcommittee to consider the role of Navigators in educating the public and helping them enroll in appropriate coverage.
North Carolina used federal funds to establish a pilot call center that became operational in August 2012. The call center fielded almost 3,000 calls in September and October about various issues, including assistance with enrolling in a health plan and questions about the Affordable Care Act. The call center collects data by county so that concerns can be identified by geographic regions to inform future consumer assistance efforts. The call center hired a Community Resource Manager in October 2012 to work with Navigators and Assisters.
Small Business Health Options Program (SHOP) Exchange: In March 2011, a subcontractor for the Department of Insurance released a report including insurance market analysis of the impact of health reform on enrollment and premiums, the impact of merging the individual and small group health markets, the impact of allowing large groups to participate in the exchange beginning in 2014, and recommended strategies to mitigate adverse selection.8 A year later, the Insurance Department’s TAG recommended that the small group and individual exchange markets maintain separate risk pools and only employers with 50 or fewer employees be allowed participate in the SHOP until the state is required to open the SHOP to employers with 100 or fewer employees in 2016.9
Information Technology (IT): In December 2008, North Carolina hired a contractor to provide a commercial off-the-shelf (COTS) software package that replaced its existing eligibility determination and case management system. The new system, called North Carolina Families Accessing Services Through Technology (NC FAST), currently provides electronic Medicaid/CHIP application, eligibility, and enrollment functionality. North Carolina plans to expand upon the existing system to develop a multiple-service eligibility system to include the Exchange and other public programs.
NCDOI had used federal funding to hire contractors to develop a RFP for all non-eligibility related Exchange systems, including financial management, plan selection functionality, plan management, Navigator/assister management, call center operations, data warehousing, and SHOP eligibility. These services will be required to be interoperable with NC FAST for both Exchange and Medicaid/CHIP functions.10
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 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 Department of Insurance released an analysis of benchmark plan options for the state in May 2012; the report found that all of the state’s options except for the federal employee health benefit plan covered all state mandates, there was relatively little difference in the cost among benchmark plans, and all benchmark options needed to be supplemented for pediatric oral and vision care.11Therefore, the state was comfortable with defaulting to the largest small-group plan, Blue Cross Blue Shield of North Carolina- Blue Options, PPO.
Exchange Funding
In September 2011, the North Carolina Department of Insurance received a federal Exchange Planning grant of $1 million. The Department, working in partnership with the North Carolina Department of Health and Human Services, then received a $12.4 million federal Level One Establishment grant on August 12, 2011. North Carolina will use the grant to engage stakeholders, prepare analyses of outstanding policy decisions, and expand the existing eligibility system of the North Carolina Department of Health and Human Services to accommodate the exchange. In January 2013, North Carolina was awarded a second Level One grant of $74 million to develop an IPA program and support implementation of the HCR Module, including integration of the module with current state IT systems and federal data sources.12
Next Steps
The federal government will assume full responsibility for running a health insurance exchange in North Carolina in 2014.
Final update made on November 22, 2013 (no further updates will be made)
Establishing the Marketplace
On May 11, 2011, Governor Christine Gregoire (D) signed SB 5445 into law establishing the Washington Health Benefit Exchange (HBE).1 Additional legislation signed by the Governor in March 2012, removed limitations on the Board’s governing authority over the Marketplace (HB 2319).2In October 2012, the state announced that the online Marketplace would be called Washington Healthplanfinder.
Structure: The legislation defines Washington’s Marketplace as a quasi-governmental organization, specifically a “self-sustaining public-private partnership separate and distinct from the state.”
Governance: The Marketplace is governed by an 11-member board, including two non-voting, ex officio members (or their designees): the Insurance Commissioner and the Administrator of the Health Care Authority. The Governor appoints eight voting board members from lists of nominees created by the two largest caucuses in the House and Senate. The legislation specifies that appointees must include at least one employee benefits specialist, one health economist or actuary, one representative of small business, and one health consumer advocate. The remaining voting members should possess related expertise in areas such as individual or small employer health care coverage, health benefit plan administration, or health care finance. The Governor appoints a ninth member to the Board who will serve as chair and vote only when needed in case of a tie. Voting board members cannot be legislators or employees of the state or its political subdivisions. The Governor cannot appoint members whose participation in Board decisions would benefit their own financial interests or those they represent. Members developing these conflicts of interest should resign or be removed from the Board.
Current appointed Board members are:
Margaret Stanley (Chair), formerly with Puget Sound Health Alliance and Regence Blue Shield
Steve Appel, farmer and formerly with Washington Farm Bureau
Bill Baldwin, The Partners Group
Don Conant, Valley Nut and Bolt and School of Business at St. Martin’s University
Doug Conrad, University of Washington School of Public Health
Melanie Curtice, Stoel Rives LLP
Ben Danielson, MD, Odessa Brown Children’s Clinic
Phil Dyer, Kibble & Prentice/USI and former state legislator
Teresa Mosqueda, Washington State Labor Council and Healthy Washington Coalition
The Board held their first meeting in early January and assumed governing authority over the Marketplace on March 15, 2012. A few months later the Board hired a CEO.
Marketplace legislation specifies the Board should establish advisory committees to represent the views of the health care industry and other stakeholders, and may also establish technical advisory committees or seek advice of technical experts. In addition, it requires the Marketplace to consult with the American Indian Health Commission. In May 2012, the Board selected 17 Advisory Committee members to provide expertise and experience on various issues. Members include carriers, brokers, small employers, consumer advocates, a Tribal representative, and providers.3
Contracting with Plans: In February 2013, HBE released guidance that detailed requirements for Qualified Health Plan (QHP) participation in Healthplanfinder.4 The Marketplace allows all QHPs meeting the minimum standards to participate on Healthplanfinder in 2014. HB 2319 created new insurance market rules for plans sold inside and outside Healthplanfinder. If an insurer offers a Bronze plan in the individual or small group markets outside the Marketplace, it must also offer plans in the Silver and Gold levels for that same market. Catastrophic plans may only be sold on Healthplanfinder. Issuers may participate in Healthplanfinder’s individual market, SHOP market, or both and are not required to participate in the same markets inside and outside of the Marketplace. Federal requirements specify that issuers must offer at least one QHP at the silver level and one QHP at the gold level in order to participate in Healthplanfinder. Issuers are also required to offer a child-only plan at the same level of coverage as any QHP offered through Healthplanfinder. The Office of the Insurance Commissioner (OIC) requires issuers to offer contracts to all Indian Health centers in their service area, and issuers must notify HBE of all such contracts. There are five geographic rating areas in the state.5
In September 2013, the OIC and the Board certified eight health insurance carriers to offer 38 QHPs for individuals through Washington Healthplanfinder. Eight multi-state plans will also be available. One carrier will offer five plans in the SHOP Marketplace, and SHOP plans will only be available in two counties.6 No platinum level plans are offered in either market. The Board will certify QHPs annually and issuers will offer QHPs for a term of one year.7 Information on plan rates for 2014 is available on the Marketplace website. HBE will aggregate subscriber premiums and send the aggregated payments to the appropriate issuer. Subscribers enrolled in the individual market will also be allowed to pay premiums directly to the issuer.
HB 2319 required that by the end of 2012, the Board establish a rating system for qualified health plans to assist consumers in evaluating plan choices. In September 2012, the Board approved nine consumer rating factors and the use of specific corresponding data sources including the Consumer Assessment of Healthcare Providers and Systems (CAHPS) data for enrollee satisfaction and Healthcare Effectiveness Data and Information Set (HEDIS) data for provider reimbursement and promotion of primary care.8 QHP issuers must also document implementation of quality improvement strategies outlined by the Affordable Care Act (ACA), and submitted strategies will be posted online for consumers to review.
Issuers must ensure that each QHP’s network is sufficient in the number and type of providers, including mental health and substance abuse specialists. The network must also satisfy the essential community providers standard outlined by the ACA and comply with the provisions set forth by the Public Health Service Act and Washington Administrative Code 284-43-200. QHP issuers may only contract with hospitals with more than 50 beds if the hospital has a patient safety evaluation system in place. The OIC will monitor compliance of network adequacy requirements and HBE will decertify QHPs of issuers that do not adhere to the standards. Issuers must also submit health care provider data to HBE for a network directory.
Dental and Vision Benefits: In March 2013, HBE issued final guidance for participation of stand-alone pediatric dental plans in Healthplanfinder. The Board performed final certification of Qualified Dental Plans (QDPs) in September.9 Four dental issuers each offer one stand-alone pediatric dental plan through Healthplanfinder. All plans have low actuarial value (70%).
Risk adjustment, Reinsurance, and Risk corridors (RRR): In a presentation to the Board in September 2012, the Office of the Insurance Commissioner’s Workgroup on RRR expressed a preference for state operated risk adjustment programs.10 The OIC will monitor issuer compliance with the risk adjustment program; if the OIC determines that an issuer is not in compliance with program requirements, HBE will decertify all of the issuer’s QHPs.
Consumer Assistance and Outreach: In June 2013, the Marketplace awarded $6 million in grant funding to ten entities to serve as Lead Organizations for the state’s In-person Assistance program. Lead Organizations are responsible for building, training, and managing a network of partners in their region to conduct in-person educational activities and enrollment assistance. Lead Organizations are partnering with almost 100 community organizations across the state and, as of early October, had trained 800 individual in-person assisters (IPAs) to perform outreach and facilitate enrollment through Healthplanfinder. The Marketplace also awarded $420,000 in grant funding to five tribal organizations to support outreach and enrollment activities for members of tribal communities.11 The Washington Healthplanfinder website features a tool that allows consumers to search for in-person assistance according to zip code and service language.
Licensed producers that complete a four to six hour training course and register with the Marketplace are authorized to sell coverage to individuals and small businesses through Healthplanfinder. Producers must be appointed by carriers to sell QHPs and will continue to receive compensation from carriers.12 Training sessions began in mid-August and will be offered through November.13 As of early October, there were over 2,000 trained producers selling plans through the Marketplace statewide. Consumers may search for a broker by zip code and service language on the Marketplace website.
In September 2013, HBE launched the Customer Support Program, which includes a toll-free call line and email inquiry system. The center is open from 7:30am through 8:00pm and will be staffed by 80 full-time trained Customer Support Center representatives. A translation service is available to provide interpretation for approximately 175 languages and all representatives are trained on how to route calls to other agencies.14
HBE’s consumer education campaign includes advertising, grassroots activities, social media, business outreach, and partnerships with media outlets and community organizations. In August 2013, HBE began an online advertising campaign to build Healthplanfinder brand awareness and in September launched a comprehensive advertising campaign that emphasizes how consumers may use the online portal to compare plans and enroll into coverage. Healthplanfinder advertisements appear on television, radio, print, billboards, buses, and in other public areas.15 HBE also produced an eight-part “Countdown to Coverage” webinar series to educate consumers on the Affordable Care Act, how Healthplanfinder works, and the coverage options that will be available in 2014. In April 2013, HBE launched the Washington Healthplanfinder website, including a cost-estimate calculator.
The Marketplace has established key partnerships with entities such as business associations, libraries, hospitals, clinics, community-based alliances, and faith-based organizations, to help spread awareness of the Healthplanfinder and facilitate enrollment statewide. The Marketplace has a series of outreach and enrollment events planned throughout the open enrollment period, including a mobile enrollment tour featuring a customized Washington Healthplanfinder bus. The bus will make stops at nine mobile enrollment event locations throughout the state, and IPAs will use laptops to enroll consumers on-site.16 The Marketplace is also partnering with a nonprofit to develop a smartphone application targeted towards young adults.
Small Business Health Options Program (SHOP) Marketplace: The Washington SHOP Marketplace has experienced significant challenges in recruiting insurers to participate. While seven carriers initially submitted letters of intent to participate in the SHOP, all but one have since withdrawn due to concerns about operational readiness and risk. Despite the limited carrier participation, in May 2013, the Board voted to launch the SHOP on October 1, 2013.17 For 2014, the one participating issuer will offer five QHPS in two counties.
Employers may offer a single health plan or a choice of health plans at a single metal level to employees, and employer premium contribution must be at least 50% for employees. HBE requires 100% employee participation for employer groups with three or fewer employees and employee participation of 75% for employer groups with more than three employees. HBE will collect and aggregate employer premium payments.18
Financing: In July 2013, the Legislature passed SHB 1947 to ensure self-sustainability for the Marketplace beyond 2014. The bill funds the Marketplace using two mechanisms. First, HMOs, health care service contractors, and self-funded employers must pay a 2% tax on premiums collected during the preceding calendar year. Taxes on premiums collected through QHPs offered on the Marketplace and on premiums collected through Medicaid plans for the expansion population will be allocated for Marketplace operations rather than deposited into the general fund. If premium taxes for the current year are insufficient to fund Marketplace operations for the upcoming year, assessments on carriers offering QHPs through Healthplanfinder may be used to generate the necessary funds. Assessments will be collected by the Marketplace on a quarterly basis. The legislation also orders the state auditor to conduct an evaluation of Marketplace costs in 2016 and to make a recommendation to the Board and the Legislature about how best to proceed with financing the Marketplace.19
Basic Health Program (BHP) Option: Washington has considered establishing an optional coverage 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 state released a proposal in June 2012 to operationalize a BHP, but awaits final approval from the federal government.20 Washington already operates the Washington Basic Health program, a state-sponsored program that provides low-income residents below 200% FPL with health care coverage through private health plans; however, this program would have to be modified to meet federal criteria for a BHP.21
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. The state recommended the EHB benchmark be Blue Shield- Regence Innova Plan PPO.22 In addition, the Children’s Health Insurance Program (CHIP) will serve as the pediatric dental supplement, and the Federal Employee Vision Plan (FEDVIP) as the pediatric vision supplement. The Insurance Commissioner is required to submit annually to the Legislature a list of state-mandated benefits, the costs of which will be borne by the state.
Marketplace Funding
The Washington Health Care Authority has received two federal grants: an Exchange Planning grant of almost $1 million and a Level One Establishment grant of approximately $23 million to be used for operational planning and to develop an information technology system for critical Marketplace functions related to eligibility, enrollment and information exchange. In May 2012, the state was awarded a $127.8 million Level Two Establishment grant to fund Marketplace development through December 2014.23
Next Steps
On December 7, 2012, Washington received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a State-based Marketplace.24 The Washington Healthplanfinder portal became operational on October 1 and began enrolling qualified individuals, families, and small businesses into coverage.
