7/29/2019 States Health Insurance Exchanges Are Shaking Out
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States Health Insurance Exchanges Are Shaking Out
The Council of State Governments
CAPITOL EEch
health
ThE counc oF TTE govEnEnT
The last deadline for states to decide just how much
they are going to be involved in operating health in-
surance exchanges passed on Feb. 15, 2013. That was
the last day for governors to send letters to the U.S.
Department of Health and Human Services declaring
that their state would work in partnership with thefederal government.
Under a partnership arrangement, states might
oversee the selection and management of health
plans available in the exchange marketplace. The fed-
eral government would have primary responsibility
to manage the marketplace website and call centers,
to accept applications and to determine eligibility for
federal tax subsidies.
Seven states will operate an exchange in partnership with
the U.S. Department of Health and Human Services. Governors in New Hampshire and West Virginia
submitted letters Feb. 13 and 15, respectively,
declaring their intentions to operate health insur-
ance exchanges in partnership with the federal
government. Federal approval is pending.
Five other statesArkansas, Delaware, Illi-
nois, Iowa and Michiganpreviously submitted
proposals to operate a joint exchange. Federal
approval is pending for Iowa and Michigan.
Seventeen states and the District of Columbia are moving
forward with plans for state-based exchanges. The federal
government has conditionally approved all of them. The
states operating their own exchanges are concentrated in
the Northeast and West. California, Colorado, Connecticut, Hawaii, Idaho,
Kentucky, Maryland, Massachusetts, Minnesota,
Nevada, New Mexico, New York, Oregon, Rhode
Island, Utah, Vermont and Washington will oper-
ate state exchanges.
Massachusetts and Utah already had state health
insurance exchanges established by legislation
before Congress passed the Affordable Care Act
in March 2010. Ten states approved legislation to
operate the exchange in the 2011 or 2012 legisla-
tive sessions.
Three statesKentucky, New York and Rhode Is-
landestablished the exchanges by executive order.
State legislation to establish state exchanges is
still pending in Idaho and Minnesota.
Mississippi is the only state whose plan for a
state-based exchange failed to garner federal
approval because it was submitted by the states
insurance commissioner and not endorsed by the
governor.
The remaining 26 states have deferred to the federal
governments operation of health insurance exchanges. The states that have opted out of state-based ex-
changes include many whose governors have beenoutspoken opponents of the Affordable Care Act
since it passed and who joined the federal lawsuit
seeking to overturn the law.
The states that have opted out of operating ex-
changes include many in the Midwest and South.
Regardless of the administration of the state health
insurance exchanges, two major deadlines established by
the Aordable Care Act loom. The exchanges must begin open enrollment for
individuals and small group health insurance poli-
cies on Oct. 1, 2013.
7/29/2019 States Health Insurance Exchanges Are Shaking Out
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Policy coverage begins Jan. 1, 2014.
Individuals qualify for federal tax subsidies only
by purchasing insurance through the exchanges.
Those subsidies are intended to make health
insurance affordable for those people with in-
comes between 100 and 400 percent of the federal
poverty level.
People who apply to state exchanges for insur-
ance and who are income-eligible for Medicaid
will be seamlessly enrolled in Medicaid. Coopera-
tion will be required between the exchange, no
matter the administrative authority, and states
Medicaid programs. In those states that adopt the
Affordable Care Act option to expand eligibil-
ity to 138 percent of poverty, the exchanges are
likely to encounter a number of Medicaid eligible
applicants.
States decisions on exchanges need not be per-
manent. Federal guidance provides that states can
apply by Nov. 18, 2013, to take more state control
in 2015 or by Nov. 18, 2014, to make a change for
2016. 1October 16, 2012 correspondence from Gov. Pat Quinn to Acting Director Gary Cohen, Centers forMedicare & Medicaid Services. Accessed Feb. 25, 2013 at
http://cciio.cms.gov/Archive/Technical-Implementation-Letters/il-exchange-letter.pdf .
RSORCS
Debra Miller, CSGs Director of Health Policy | [email protected]
In his letter declaring Illinois intention to partner
in the exchange, Gov. Pat Quinn said, I am
committed to working with the Illinois General
Assembly to pass legislation with governance and
nancing language that will allow us to operate a
state-based exchange beginning in 2015.1
Hospitals and health insurance companies will
likely continue to lobby for states to take more
control of their exchanges. Both health care sec-
tors have been outspoken proponents of state-
based exchanges, advocating that states are in the
best position to run exchanges because of their
experience with local markets and insurers and
their proximity to individual and business pur-
chasers of health insurance.
mailto:dmiller%40csg.org?subject=mailto:dmiller%40csg.org?subject=7/29/2019 States Health Insurance Exchanges Are Shaking Out
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Status o State Health Insurance Exchanges Required Under the Afordable Care Act
State Decision on exchange
operation
Status o Federal
Approval, 2/25/2013
State Autho rity or Excha nge Structure o Exchange Exchange Name and Website
labama Defer to federal operation
laska Defer to federal operation
riza Defer to federal operation
rkasas S tat e fed era l p ar tn ers hi p Co nd it ion al a pp ro val G ov. d ec lar at ion l et ter ( 20 12)
califria State run Conditional approval State legislation, SB 900, AB 1602(2010)
Quasi-governmental Covered California
clrad State run Conditional approval State legislation, SB 200 (2011) Quasi-governmental Connect for Health Colorado
cetit State run Conditional approvalState legislation, SB 921; Public Act.
No 11-53Quasi-governmental Access Health CT
Distrit f clmbia State run Conditional approval Legislation/resolution, B19-0002 (2012) Quasi-governmentalDistrict of Columbia Health Care
Exchange
Delaware S tat e fed era l p ar tn ers hi p Co nd it ion al a pp ro val G ov. d ec lar at ion l et ter ( 20 12)
Flrida Defer to federal operation
geria Defer to federal operation
hawaii State run Conditional approval State legislation, SB 1348 (2011) Non-prot Hawaii Health Connector
da State run Conditional approval State legislation pending (2013)
lliis S tat e fed era l p ar tn ers hi p Co nd it ion al a pp ro val G ov. d ec lar at ion l et ter ( 20 12)
diaa Defer to federal operation
wa S tat e fed era l p ar tn ers hi p Pend in g G ov. d ec lar at ion l et ter ( 20 12)
Kasas Defer to federal operation
Ketky State run Conditional approval Executive order, 2012-587 Operated by the state Kentucky Health Benet Exchange
isiaa Defer to federal operation
aie Defer to federal operation
arylad State run Conditional approval State legislation, SB 182 (2011) Quasi-governmental Maryland Health Connection
assasetts State run Conditional approvalState legislation, Chapter 58 of Acts
2006Quasi-governmental
Commonwealth Health Insurance
Connector Authority
iia S tat e fed era l p ar tn ers hi p Pend in g G ov. d ec lar at ion l et ter ( 20 13)
iesta State run Conditional approval Legislation pending (2013) Minnesota Health Benet Exchange
ississippi Defer to federal operation
issri Defer to federal operation
taa Defer to federal operation
nebraska Defer to federal operation
neada State run Conditional approval State legislation, SB 440 (2011) Quasi-governmental Silver State Health Insurance Exchange
new hampsire S tat e fed era l p ar tn ers hi p Pend in g G ov. d ec lar at ion l et ter ( 20 13)new Jersey Defer to federal operation
new exi State run Conditional approval Gov. declaration letter (2012) Quasi-governmentalNew Mexico Health Exchange
Information
new Yrk State run Conditional approval Executive order, #42 (2012) Operated by the state The New York Health Benet Exchange
nrt carlia Defer to federal operation
nrt Dakta Defer to federal operation
oi Defer to federal operation
oklama Defer to federal operation
ore State run Conditional approval State legislation, SB 99 (2011) Quasi-governmental Cover Oregon
Pesylaia Defer to federal operation
de slad State run Conditional approval Executive Order, 11-09 Operated by the state Rhode Island Health Benet Exchange
t carlia Defer to federal operation
t Dakta Defer to federal operation
Teessee Defer to federal operationTexas Defer to federal operation
uta State run Conditional approvalState legislation, HB 188 (2009), HB 133
(2008) (b)Operated by the state Avenue H
vermt State run Conditional approvalState legislation, Public Act No. 48
(2011)Operated by the state Vermont Health Connect
viriia Defer to federal operation
Wasit State run Conditional approval State legislation, SB 5445 (2011) Quasi-governmental Washington Heatlhplannder
West viriia S tat e fed era l p ar tn ers hi p Pend in g G ov. d ec lar at ion l et ter ( 20 13)
Wissi Defer to federal operation
Wymi Defer to federal operation
Notes:(a)Massachusetts already had an exchange for individuals and small groups, 1 to 50 employees. (b)tah already had an exchange f or the small group market, 2 to 50 employees.Sources: CSG research; The Commonwealth Fund http://www.commonwealthfund.org/Maps-and-Data/State-Exchange-Map.aspx; Kaiser State Health Facts,http://www.statehealthfacts.org/comparemaptable.jsp?ind=962&cat=17; .S. Department of Health and Human Services, http://cciio.cms.gov/archive/technical-implementation-letters/index.html
http://www.commonwealthfund.org/Maps-and-Data/State-Exchange-Map.aspxhttp://www.statehealthfacts.org/comparemaptable.jsp?ind=962&cat=17http://www.statehealthfacts.org/comparemaptable.jsp?ind=962&cat=17http://cciio.cms.gov/archive/technical-implementation-letters/index.htmlhttp://cciio.cms.gov/archive/technical-implementation-letters/index.htmlhttp://www.statehealthfacts.org/comparemaptable.jsp?ind=962&cat=17http://www.commonwealthfund.org/Maps-and-Data/State-Exchange-Map.aspxTop Related