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 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.
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/
SB440 (Chapter 439), Nevada’s 2011 Act creating the Silver State Health Insurance Exchange. ↩︎
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.
Final update made on December 13, 2012 (no further updates will be made)
Establishing the Exchange
On November 6, 2012, Missouri voters passed a ballot measure blocking Governor Jay Nixon (D) from establishing an exchange via Executive Order.1 Legislation establishing a state-based health insurance exchange failed in both the 2012 and 2011 legislative sessions. While the Governor initially supported running a state-based exchange, he announced the state would default to a federal exchange in 2014.
Prior to the announcement, the Governor established Missouri’s Health Insurance Exchange Coordinating Council to coordinate the state’s response to federal health reform.2 The Council included executive leadership from multiple state agencies and established four work groups to address exchange components including, Operations; Finance and Coverage; Communications; and Cost-containment and Quality.3 The Council identified a number of consultants to provide background research and insurance market analysis to inform decision-making in the state. In June 2011, the Senate had also created the Senate Interim Committee on Health Insurance Exchanges to explore Missouri’s options to establish a state-based exchange.4
In August 2011, the Missouri Health Insurance Pool Board released a Request for Information for general exchange information technology component solutions and services; however the contract was never awarded.5 Missouri was also participating in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use.6
In August 2010, Governor Nixon allowed a law prohibiting health insurance exchanges established in Missouri from offering insurance policies or riders that provide abortion coverage except in cases of life endangerment of the pregnant woman to become law without his signature (SB 793).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 Missouri has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Healthy Alliance (Blue Cross Blue Shield)- Blue Access Choice PPO.
Exchange Funding
In September 2010, the Missouri Department of Insurance received a federal Exchange Planning grant of $1 million. The Missouri Health Insurance Pool, a quasi-governmental, non-profit insurer that expanded to operate the federal high risk-pool in the state, received a $20.8 million federal Level One Establishment grant in August 2011, to build a coordinated information technology infrastructure with a single portal eligibility and enrollment system.8 However, the Senate Interim Committee, which has been critical of the state’s decision to apply for federal grant money without explicit approval from the legislature, has yet to approve spending the funds. In April 2012, the Missouri legislature rejected a $50 million federal grant to upgrade the state’s Medicaid information technology system because lawmakers saw it as a possible framework for building an exchange.9
Next Steps
The federal government will assume full responsibility for running a health insurance exchange in Missouri beginning in 2014.
Hidden away on page 218 of our annual Employer Health Benefits Survey is a table that shows what employers think of the main strategies they have to control health care costs. More specifically, the table shows what the person in the firm responsible for its health benefits thinks, which is whom we survey. The short answer is, employer confidence in their own ability to control costs is not high.
Not more than about a quarter of employers felt any one strategy was “very effective,” and they were divided on virtually every cost-containment strategy they were asked about. For example, 22% said consumer-driven health plans were “very effective,” and 19% said they were “not at all effective.” Similarly, 18% said tighter managed care restrictions were “very effective,” while 26% said they were “not at all effective.” The “winner” this year seems to be disease management, garnering the most employer confidence, with 26% calling it “very effective” and 19% calling it “not at all effective.” The not very enthusiastic “somewhat effective” was the description often chosen by employers to characterize the cost-containment strategies available to them. Interestingly, many firms said they don’t have a lot of confidence in increasing employee cost-sharing as a way to decrease costs. Many firms also offer wellness programs, and in an answer to a different question, slightly more than half think those programs help to lower costs to some degree. You can see the results in this chart.
With no single magic bullet strategy they have confidence in, employers tend to try multiple strategies at once in the hope that cumulatively they will have a measurable impact. Large employers have more weapons at their disposal than smaller ones, who, for example, are more likely to offer only one type of health plan (85% of small firms vs. 58% of larger ones). Simply switching plans is often the cost-control strategy of last resort for many firms. About six in ten firms shop for a new plan or new insurer each year, and among those, almost half switch carriers and/or change the type of plan they offer. This produces a remarkable amount of churning in the insurance system. This has been our own experience at the Foundation. Premiums for our main PPO rise to unaffordable levels, we make the changes we can to hold on until premiums rise once more to prohibitive levels, we are told our premiums are up because our cost experience is too high, and then we are forced to switch again.Many years ago, before my time in government and foundations, I did a study of corporate attitudes toward health care costs with colleagues at MIT. We did the study because there was a view at the time that corporations were awakening to health costs in a new way and would become willing allies with government in new efforts to take on this growing problem.
To assess that contention, which was gaining momentum at the time, we interviewed CEOs and corporate health benefits officers at 69 companies, including some of the largest corporations in America. We found that the CEOs, in particular, did not have a great deal of faith in the tools they had to control health care costs (their views were often quite different from those of their health benefits managers). They had little confidence in the ability of businesses and their insurance companies, acting on their own to control costs and they believed the answer (whether market-driven solutions or regulation) had to come from the government, feeling that only government could act on a system-wide scale. Logically then, they would lend their support and considerable clout to back government efforts to control health care costs? Not really.
To the contrary, on a personal level, many of the CEOs we spoke to were opposed to a larger role for government generally, and in the other areas of their businesses that they were more familiar with than health care they were no friends of government regulation. These CEOs were trapped between their frustration and concern over rising health costs and their personal, and sometimes ideological, aversion to government intervention. When it came time to support federal legislation, more times than not, business would stand on the sidelines if not oppose. Of course there were exceptions. A few CEOs became heavily involved in the health cost issue on the national stage, at least for a time, such as the late Walter Wriston from what was then Citicorp, and, more recently, Howard Schultz from Starbucks.
The following was our main conclusion in 1981, which incidentally was a year when health premiums soared by double digits: “Major corporations are under no illusion that they can do much individually to alter their health benefit costs… To be sure, firms are no longer totally passive about rising health care costs and continual increases could provoke stronger action than we have observed… However, firms are not, nor are they likely to be the force for systems reform that some have imagined.”
In our employer survey this year, when we asked employers to assess major approaches to controlling health costs and got such lukewarm responses, I think back to that 1981 study, and how little seems to have changed.
The October health tracking poll finds a more negative overall public mood about the health reform law, driven largely by changes in support for the law among Democrats. The poll also asked the public’s impressions of the Massachusetts health reform law enacted under then- Gov. Mitt Romney, who is now a candidate for the Republican presidential nomination. Findings from the poll include:
After remaining roughly evenly split for most of the last year and a half, this month’s tracking poll found more of the public expressing negative views towards the law. In October, about half (51%) say they have an unfavorable view of the Patient Protection and Affordable Care Act (ACA), while 34 percent have a favorable view, a low point in Kaiser polls since the law was passed. While Democrats continue to be substantially more supportive of the law than independents or Republicans, the change in favorability this month was driven by waning enthusiasm for the law among Democrats, among whom the share with a favorable view dropped from nearly two-thirds in September to just over half (52%) in October.
Americans are more than twice as likely this month to say the law won’t make much difference for them and their families as they are to say they’ll be better off under the law. Forty-four percent say health reform won’t make much difference to them personally, up from 34 percent in September. Meanwhile 18 percent say they and their families will be better off, down from 27 percent last month. (The share who thinks they’ll be worse off personally held steady at roughly three in ten, where it has been since the law passed in 2010.) Here, too, changes in views among Democrats helped shape the overall change.
The survey finds that nearly three quarters of the public, including seven in ten likely Republican presidential primary voters, say they don’t know enough about the Massachusetts law to have either a favorable or unfavorable opinion of it. A similar share of the public (71%) cannot say whether the law is similar to, or different from, the national health reform law.
The October poll is the latest in a series designed and analyzed by the Foundation’s public opinion research team.
Moving Ahead Amid Fiscal Challenges: A Look at Medicaid Spending, Coverage and Policy Trends Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2011 and 2012
The 11th annual 50-State Medicaid budget survey from the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured finds that Medicaid officials in virtually every state are enacting a variety of cost cutting measures as states’ spending for Medicaid is projected to increase 28.7 percent in fiscal year 2012 to make up for the loss of federal stimulus money.
The temporary increase in the federal share of Medicaid spending under the American Recovery and Reinvestment Act (ARRA) brought about the only declines in state spending on Medicaid in the program’s history, even as the recession increased Medicaid enrollment and overall Medicaid spending. With that money having expired in June 2011, however, states must ramp up their own spending to replace the lost funds, even though states project total spending in the Medicaid program – which is jointly financed by the federal government and the states — to increase on average by 2.2 percent in FY 2012.
The survey finds cost containment actions ranging from restrictions on payments to providers and benefits, to new copayments for beneficiaries and additional efforts to contain the costs of prescription drugs. States also are trying to make their programs more efficient by increasing their reliance on Medicaid managed care, moving long-term care toward community-based care models, and streamlining enrollment procedures.
The state focus on cutting costs occurs as deficit reduction efforts in Washington could reduce federal support for Medicaid and shift costs to states and at a time when states, still coping with a weak economy, also must prepare for the expansion of Medicaid under the health reform.
Beginning in 2014, health coverage options will significantly expand under health reform through an expansion in Medicaid eligibility and by making tax credits available to help individuals purchase coverage through new Health Benefit Exchanges. Given their high uninsured rate and limited access to private and public coverage, one group who could significantly benefit from this coverage expansion is lawfully residing immigrant families. However, it will be important to address barriers eligible immigrant families often face to enrolling in coverage and accessing needed care.
Based on findings from focus groups conducted with outreach and enrollment workers who serve immigrant communities, this report identifies the role of Medicaid and CHIP for immigrant families; key barriers eligible, lawfully residing immigrant families face to enrolling in coverage and accessing care; successful strategies to overcome these barriers; and considerations for implementing the coverage expansion under health reform.
The American Recovery and Reinvestment Act (ARRA), enacted in February 2009, has provided $103 billion in federal fiscal relief to state Medicaid programs over a period of two-and-a-half years to help them address the effects of the 2007-2009 recession. During a recession, unemployment increases and state revenues decline, making it difficult for states to meet the increased demand for Medicaid coverage among the newly unemployed. This brief reviews the ARRA Medicaid fiscal relief provisions—how they were structured and what impact they had on state Medicaid finances during the recession.
This background paper examines various aspects of the Medicaid program that can expand access to home and community-based services (HCBS) and rebalance long-term care spending in favor of HCBS.
As a result of the long-standing requirement that states cover facility-based care, the majority of Medicaid long-term care (LTC) expenditures historically have been for institutional, rather than home and community-based, services. Over the past two decades, major efforts have been undertaken by states and the Centers for Medicare and Medicaid Services (CMS) to expand access to Medicaid HCBS and the Medicaid program presently offers numerous options for states to do so. These initiatives stem from the growing demand by people with disabilities to receive health care services in their homes for as long as possible, rather than be institutionalized.
