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A Closer Look at the Oversight of State-based Marketplaces

September 29, 2015/in Policy California, Connecticut, Massachusetts, Mississippi, Oregon Reports Eligibility and Enrollment, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by NASHP

The 17 states, and the District of Columbia, electing to operate a State-based Marketplace (SBM) are subject to comprehensive oversight from a varied set of federal and state agencies, committees, and regulators. Ongoing reporting, site visits, and auditing spans the full range of SBM functions, including eligibility and enrollment, data security, consumer privacy, financial transactions, business operations, grant monitoring, budget, consumer assistance, and marketplace personnel policies.
For SBM states to cooperate and assist with the numerous inquiries and audits related to their operations, they must utilize staff resources from all marketplace departments. SBMs also frequently need to rely on other agencies such as IT, data, policy, legal, and Medicaid in order to meet all components of an oversight request. In addition to this staff time, SBMs also typically have one staff member who is responsible for coordinating with the auditors and obtaining all the necessary information and data for compliance.

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Promising Practices in Reaching, Enrolling, and Retaining Children in Coverage During Early ACA Implementation

July 28, 2015/in Policy Reports CHIP, CHIP, Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Expansion, State Insurance Marketplaces /by NASHP

This brief shares strategies for finding, enrolling, and retaining children in health coverage, which other states can implement relatively quickly and inexpensively.
Many of these promising practices are the direct result of the strong working relationships between state officials and advocates and coalesce around several themes:

Targeting outreach efforts to specific populations.
Engaging and educating new partners.
Keeping children enrolled in coverage.

For more information about improving children’s coverage, including links to many of the resources and promising practices listed in this paper, please visit the Advancing Children’s Coverage Toolkit.

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The State-based Marketplaces: A Focus on Innovation, Flexibility, and Coverage

July 22, 2015/in Policy California, Colorado, Connecticut, Kentucky, Maryland Reports Eligibility and Enrollment, Health Coverage and Access, State Insurance Marketplaces /by Lesa Rair and Tess Shiras

One of the central elements of the Affordable Care Act (ACA) is to establish “one-stop shopping” through health insurance marketplaces allowing consumers to find and access affordable, high-quality health coverage either through private health insurance, and the subsidies available for those who qualify, or through Medicaid. The ACA and related regulations define a spectrum of marketplace models that can be operationalized: the State-based Marketplace (SBM), where states assume all responsibility for operation and maintenance of a marketplace; the State Partnership Marketplace (SPM), where states assume responsibility for plan management and/or consumer assistance and the Federally-Facilitated Marketplace (FFM) performs remaining functions; and the FFM, in which all marketplace functions are performed by the federal government.
In the wake of the U.S. Supreme Court’s recent decision in King v. Burwell, affirming the availability of federal subsidies to states opting to use the FFM model, there is growing interest in state and federal marketplace options and performance. While states implementing both the FFM and SBM model had to overcome hurdles in building and managing multifaceted IT platforms, both are making significant progress in meeting the ACA’s coverage and access goals. However, the advancements and opportunities of SBMs are not as well known as the challenges state and federal marketplaces have faced. This paper seeks to explore and highlight early developments in states that have implemented the SBM model.
Full Brief

State Enrollment Experience: Implementing Health Coverage Eligibility and Enrollment Systems Under the ACA

July 21, 2015/in Policy Reports Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by NASHP, Alice Weiss and Kaitlin Sheedy

The Patient Protection and Affordable Care Act (ACA) included new eligibility and enrollment requirements, which have presented states with significant implementation opportunities and challenges. Although states had choices about whether to host a health insurance exchange or expand Medicaid, the ACA required all states to make major changes to Medicaid eligibility policy, including adding mandatory coverage of new groups, implementing streamlined eligibility and renewal , incorporating new eligibility and verification requirements, and coordinating enrollment systems with exchanges.
As a result, states had to create or significantly update existing systems, collaborate and coordinate with other state and federal agencies, and develop new processes to support enrollment. States implemented these changes within a constrained timeframe, with much activity occurring between the Supreme Court ruling in NFIB v. Sebelius in summer 2012 and the first open enrollment period in fall 2013. In addressing the challenges of ACA implementation, many states and federal agencies were highly innovative, developing approaches that set a new standard for promoting effective enrollment in public programs.
Drawing on key informant interviews and ongoing engagement with states between 2013 and 2015, this brief examines states’ early experiences implementing ACA’s eligibility and enrollment requirements; highlights promising practices and lessons learned; provides some context on the state experience; and concludes with possible areas of focus for future enrollment and implementation efforts. With the recent Supreme Court decision in King v. Burwell, there is new momentum for state and federal agencies to learn from early experiences with ACA implementation to further improve enrollment systems in future years. This brief offers reflections to support continued growth and movement.

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Retail Enrollment Centers

July 21, 2015/in Policy Charts Health Coverage and Access, State Insurance Marketplaces /by NASHP Staff

With the ACA’s introduction of open enrollment periods for health coverage programs, the time was right for innovative outreach models to reach new populations. Retail enrollment centers (also called “pop-up retail shops”) were one outreach and enrollment tool developed by states that has shown early promising results. In the first two years of ACA open enrollment periods, at least three state-based exchange (SBE) states (Connecticut, Colorado, and Kentucky) created retail enrollment centers. State officials interviewed reported a number of positive impacts from enrollment center experience, including increased visibility, improved outreach impact, a greater than average effectuation rate due to motivated and prepared consumers getting the help they need in a one-stop shop, and ensuring an accessible, central, community-based location to support enrollment. In this chart, we’ve captured information from three states that successfully used pop-up retail shops to inform other states that may be considering them for future years.
The states featured in this chart have demonstrated how to quickly build effective retail enrollment centers. As SBMs, the Connecticut, Colorado, and Kentucky exchanges were uniquely situated to reach target populations and try dynamic, innovative outreach methods to increase enrollment. SBMs have more centralized control over multiple aspects of outreach and enrollment processes than other states because the responsibility and authority for outreach is housed within the SBM, allowing the SBM the ability to tailor communications to the unique enrollment and assistance landscape, opportunities and challenges facing that specific state.
NASHP gathered information to create this chart through key informant interviews, email queries to state officials, and research supported by the Robert Wood Johnson Foundation’s Enrollment 2014 project, a one year project in which NASHP interviewed state leaders and stakeholders in 10 states with early success in enrollment and supported engagement of FFM state officials in Medicaid, CHIP, and Insurance/Exchange agencies. Although the information below reflects the step-by-step considerations of building pop-up shops for outreach and enrollment into health coverage programs by SBE agencies, other state agencies may also use this model to develop retail enrollment centers for other programs. Has your state also used a retail enrollment center approach? Please let us know – we welcome information from other states with similar experience.

State	State Exchange Structure	Number/ Location of Stores; Hours of Operation; Selection Process	Staffing	Operational Costs & Expenses	Physical Plant	Number of People Enrolled at Stores; ROI	Development Timeline
CO	State Agency: Colorado Health Benefit ExchangeExchange Name: Connect for Health ColoradoStructure:Public non-profit established by state law	Number/ Location: 1 store in Downtown Denver (Years 1 and 2) (1) Operating Hours: M-F: 10am-6pm Sat: 12pm-6pm Closed Sunday (except on open enrollment deadline)Location Selection: Identified high uninsured area with data from ACS & Year 1 Close to public transit and high population density to reach target population Reviewed brokers’ and health insurance guides’ existing locations to determine areas of need	Positions: Store manager and greeters Customer service center reps Brokers (not exchange employees Health coverage guides (Navigators) Medicaid program reps (back-end access to Medicaid eligibility system) Employees/ Contractors: FTEs: Co-located 3-5 existing staff Brokers: 4-6 onsite Medicaid rep: 3 days/wk. Note:Usually 4-5 workers at store Staff Shifts: 2 opening shifts 1 swing shift 1 closing shift Increased Staffing: Peak Days (just before 15th of month): 2-3 more staff at the store to respond to on-site news media and to manage line/ direct customers; 2 more staff to manage line/direct consumers Last Two Weeks of OEP2: Customer service center rep. at store full-time	Operational Costs: $16,000 rental$42,314 operational (furniture, wifi, signage, security, etc.) Additional Expenses: Night security (amount not provided)	Machinery/ Technology: Repurposed staff laptops & work cell phones; no new equipment purchased Retail Space: 2,000 sq. ft. 4 month lease (Nov. 1-Feb. 28) Process for Establishing: Site search: Worked with real estate agent to identify available spaces meeting selection criteria Site selection: negotiated contract, rental price with broker Interior space “clean up” of carpets and walls Site set-up: wi-fi, wiring, furniture rental; print/install signage- coordinated by existing marketing staff member Site break-down coordinated by staff member	Enrolled: 238 enrolled1,055 assisted (not including individuals who called or were assisted but didn’t want to be tracked) ROI: (2)$206.06 per enrollee$55 per customer assisted 2 Other Benefits: Direct access to unique population Increased community presence and visibility Prime location for earned media and location for open-enrollment kick-off	Planning: Work-plan fully developed 3 months prior to launch Physical Plant: Scouted physical locations 2 months prior to launch; finalized location 1 month before launch Staffing: 1 month to plan; planning began 3 months prior to launch Identified sign-up tool to fill unique shifts by brokers, navigators, and staff
CT	State Agency: Connecticut Health Insurance Exchange Exchange Name: Access Health CT Structure: Quasi-public entity established bystate law	Number/ Location: 2 stores: New Haven & Hartford (Year 1) Operating Hours: 10am-8pm most days Location Selection: Identified areas with high uninsured rates Temporary site Nimble and cost-effective	Staff Positions: Onsite store managers Retail manager (oversaw operations from main office) Outreach staff- navigators, assisters, brokers signed up for shifts FTEs/ Contractors/ Other: Staff Shifts: 5 people per store Increased Staffing:** End of OEP, added staff to handle volume	Outfitting Stores: $136,000 for both stores Operating Budget (Per Year): $140,000 (not including staff time)	Machinery/ Technology: 20 laptops per store (only about 15 in use at a time) Retail Space: 2,200 sq. ft each; 1-year lease Acquisition: Real estate agent helped survey properties/select space Process for Establishing: Real estate search Real estate selection Installation: contracted with firm that does trade show development -all components of store and signage fabricated before, put up quickly with no permanent work Technology/Machinery purchase	Enrolled: 7,639 enrolled15,191 assisted ROI: (3)$36 per enrollment$18 per individual assisted Other Benefits: 50% closure rate is roughly twice the insurance industry average of 20-25% Individuals who came to the stores were more motivated and prepared to enroll	Planning: **Physical Plant:**Staffing: **
KY	State Agency: Kentucky Health Benefit Exchange Exchange Name: Kynect Structure: Office of the Kentucky Health Benefit Exchange within the Cabinet for Health and Family Service, established by executive order	Number/ Location: 1 store in Fayette Mall, Lexington, KY (Year 2) Operating Hours: 10am-9am (mall hours) Location Selection: Analyzed open enrollment from year 1 Identified areas for improvement Considered population density/size of the city Proximity to the main exchange office (30 mins. from main office)	Positions: 2 Greeters 1 store manager 1 Medicaid case worker (not exchange employee) 1 consumer rep. (to direct applicants to right assisters) (4) 2 in-person assisters (min) 3-4 insurance agents (not exchange employees) FTEs/ Contractors/ Other: 2 FTE greeters (temps) Co-located exchange staff 3-4 Brokers onsite 1 Medicaid caseworker Staff Shifts: Most staff: 2 rotating shifts (9 am – 3:30 pm; 3 pm – 9:30 pm; staffing hours had to align with mall hours) Case workers and managers: 9:30 am – 5 pm Medicaid case worker: 9 am – 6 pm Insurance agents: 9:30 am -3 pm Increased Staffing: Mornings: increased insurance agents to handle higher volume	Outfitting Stores: $60,000 (including reusable materials) Operating Budget (Per Year): Under $100,000	Machinery/ Technology: 4 laptops enrollment kiosk mobile printer paper shredder 5 phones (4 for the state lines) Note:connectors and agents used their own equipment. Retail Space: 1540 sq. ft.; 4 mo. lease (Nov. – Feb.) Acquisition: Worked with a marketing firm and advertisements; approached the mall about a temporary lease. Process for Establishing: Found location Rented space Marketing firm merchandised (painted/ designed space) IT stocked with cable lines, computers and est. direct access to the state system Exchange stocked all materials (brochures, etc.)	Enrolled: Over 5,900 enrolled7,600 visited the store ROI: $27 per enrollment$21 per assisted Other Benefits: Direct access to unique population Physical presence in community/ visibility Also used space for promotional events	Planning: 2 months to plan; planning began 3 months prior to launch Physical Plant: 1 month to install fixtures and prepare physical plant (after the design/layout was finalized); began 1 month prior to launch Staffing: 2 months of planning prior to launch; ongoing changes during first weeks of operation; by 6 weeks following launch the staffing plan was finalized

Notes:

(1) Connect for Health Colorado also worked with five other retail centers staffed by other organizations. This chart only tracks the center fully run and operated by state agency staff.
(2) ROI determined by dividing overall cost by number of people helped ($58,000/1,055=$55); however, this ROI does not reflect actual cost per person assisted given larger volume of individuals that were helped not tracked in the system.
(3) Estimated based on $276 total annual costs divided by number of individuals enrolled or assisted. Note that this does not take into account the staff time invested in developing and supporting the center.
(4) Added consumer representative role 1 month after launch, upon realizing consumers needed help at the beginning of the process to route them to the right assisters for help.

What Governors Are Saying About King v. Burwell

June 30, 2015/in Policy Blogs, Charts Essential Health Benefits, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by NASHP

Last week’s ruling in King v. Burwell affirmed the provision of tax-subsidies through the federally-facilitated marketplace (FFM), a decision which may have affected over 6.4 million Americans currently receiving subsidies in the 34 states that have opted for the FFM model. The ruling has asserted the place of the Affordable Care Act (ACA), with state leaders continuing to play a critical role in determining how to implement the law most beneficially for the citizens of their states. Statements issued by governors in light of the ruling hint at the future direction of potential reforms across states. Read More

As documented in this NASHP chart, 14 governors have released statements supporting the ruling, with comments emphasizing how the ruling improves access and continuity of coverage and lowers uninsured rates. Ten governors struck a more neutral tone, stating that the decision maintained the current status of coverage. Sixteen governors clearly opposed the Court’s ruling, with comments calling for an overhaul or repeal of the Affordable Care Act and suggestions to replace the law with options to give states greater flexibility and employ market-based reforms.

In addition to weighing in on the ruling, several governors used this platform to advocate for related health care priorities. Governors in Alaska, Missouri and Virginia called for the legislature to pass Medicaid expansion; while those in Michigan and New Hampshire drew attention to alternate coverage expansion plans. Governors in New Hampshire, North Carolina, South Carolina, and Wyoming called for a focus on state flexibility and options to assure affordability and access to care for their citizens. Several governors from states operating state-based marketplaces (SBM) (Connecticut, Idaho, Kentucky, Nevada, and Rhode Island) said the decision affirmed that that the SBM was an appropriate marketplace model to benefit the citizens of their states.

The ruling underscores that the ACA was built on a foundation of state innovation and experimentation; similar opportunities await as governors, along with other state leaders, debate future reforms in their states.

NASHP will continue to track state activity around the King v. Burwell decision and support state leaders as they develop and advance reforms. If you have feedback or more you’d like to add to our chart, please email ccousart@nashp.org.

State	Governor (Political Affiliation)	Quote	Health Insurance Marketplace Model*	Medicaid Expansion Status
AK	Walker (I)	“We are pleased so many of our friends, family and neighbors will be able to continue to receive health care. Now it’s important that we continue to work toward Medicaid expansion, so more Alaskans can receive the health coverage they need.” More…	FFM	No
AL	Bentley (R)	“I, as a physician, have always believed, that the Affordable Care Act is deeply flawed and does little to help improve the health of our citizens.” More…	FFM	No
AR	Hutchinson (R)	“We will continue our work…to find innovative solutions for Medicaid and healthcare reform. I am convinced now more than ever that we need to proceed with caution to measure the costs to the taxpayers and the reliability of the outcome as we consider the potential of a state exchange.” More…	SPM	Yes¹
AZ	Ducey (R)	“[The ACA] isn’t the right plan for Arizona or for America, and it should be replaced.” More…	FFM	Yes
CA	Brown (D)	“Because of this ruling, health insurance continues to be accessible to every American, making our entire nation healthier and more prosperous.” More…	SBM	Yes
CT	Malloy (D)	“Today reminds us why we’re so proud to have built the best exchange in the nation…we embraced the Affordable Care Act, celebrated healthcare reform, and stood for progress by helping insure over 250,000 Connecticut residents.” More…	SBM	Yes
DE	Markell (D)	“For the more than 19,000 Delawareans who qualify, the federal subsidies are critical in helping to make health insurance more affordable. And we know that coverage is an important component in connecting Delawareans to care.” More…	SPM	Yes
FL	Scott (R)	“It’s a bad law. It was supposed to reduce health care costs and health care costs have gone up.” More…	FFM	No
IA	Branstad (R)	“The increasing costs of healthcare due to Obamacare red-tape and burdensome regulations have already led to tighter budgets for Iowa families….Obamacare continues to be unaffordable, unsustainable and unpredictable.” More…	FFM	Yes¹
ID	Otter (R)	“Due to the wise and prudent course set by the governor and Legislature to ensure Idaho implemented our own state-run exchange, Idaho would not have been directly impacted by the court’s decision in either direction.” More…	SBM	No
IN	Pence (R)	“ObamaCare must be repealed and states must be given the flexibility to craft market-based solutions focused on lowering the cost of health care rather than growing the size of government.” More…	FFM	Yes¹
KS	Brownback (R)	“Kansans will continue to suffer higher health care costs….We are hopeful that Congress and President Obama’s administration will provide states the needed flexibility in finding Kansas solutions to our health care challenges.” More…	FFM	No
KY	Beshear (D)	“The U.S. Supreme Court’s decision…reaffirms that, from the very start, we did the right thing for the more than 500,000 Kentuckians who have qualified for healthcare coverage through kynect since January 1, 2014.” More…	SBM	Yes
LA	Jindal (R)	“The debate will continue because the law has failed to accomplish its prime objective: Containing health care costs.” More…	FFM	No
MI	Snyder (R)	“Our focus can now center on securing the second waiver for our Healthy Michigan Plan, which has been an outstanding success. ” More…	SPM	Yes¹
MN	Dayton (D)	“We need a period of stability now where we can improve upon the system that’s been established. I really hope the critics will recognize now that this is the system has been enacted. It’s federal law, and we’re going to work to make it better.” More…	SBM	Yes
MO	Nixon (D)	“Today’s ruling…removes all doubt that the ACA is and will remain the law of the land. There are no more excuses for continuing to send our tax dollars to other states and denying 300,000 working Missourians the opportunity to access affordable health care coverage through Medicaid expansion.” More…	FFM	No
MS	Bryant (R)	“Mississippi was right…not to willingly entrench Obamacare by establishing a state-based exchange, and I will continue to resist any efforts that attempt to shove Obamacare deeper into this state.” More…	SBM	No
MT	Bullock (D)	“Forty thousand Montanans can now be sure they will not lose their health insurance or have their taxes increased in order to maintain coverage.” More…	FFM	Yes¹
NC	McCrory (R)	“[W]e must build a North Carolina-based reform plan that focuses on healthier patients at a cost taxpayers can afford. We must give doctors, hospitals and all health care providers the flexibility to provide their patients the highest quality care possible.” More…	FFM	No
ND	Dalrymple (R)	“This is what we anticipated when the Legislature decided to utilize the federal exchange. The Affordable Care Act is law and we expected it to be applied equally in all the states.” More…	FFM	Yes
NE	Ricketts (R)	“Today’s decision…allows Nebraskans to keep the health insurance premium subsidy provided under Obamacare. This decision maintains the status quo and does not appear to have any impact on the functionality of Obama’s healthcare law.” More…	FFM	No
NH	Hassan (D)	“We need to keep building on the new competition in our health insurance marketplace to continue making coverage more affordable and more accessible for all of our people and businesses. [I]t’s crucial that we also maintain our commitment…and eliminate the remaining uncertainty in the market by continuing our business-backed, bipartisan health care expansion plan.” More…	SPM	Yes¹
NJ	Chrstie (R)	“State means state, not the federal government. This decision turns common language on its head. Now leaders must turn our attention to making the case that Obamacare must be replaced.” More…	FFM	Yes
NV	Sandoval (R)	“[W]e have remained confident that the thousands of Nevadans who rely on our Silver State Health Insurance Exchange would not be impacted…. We remain committed to state control of our marketplace and assuring affordable health plans are available to reduce the number of uninsured Nevadans.” More…	SBM	Yes
OH	Kasich (R)	“The law has driven up Ohio’s health insurance costs significantly and I remain convinced congress should repeal and replace it with something that actually reduces costs.” More…	FFM	Yes
OK	Fallin (R)	“The American people need Congress to use its powers to move the country towards constructive, market-oriented solutions that empower families, provide flexibility to states, improve health and reduce the cost of health care.” More…	FFM	No
PA	Wolf (D)	“I am extremely pleased with the Supreme Court’s ruling in King v. Burwell. As a result of this decision, roughly 382,000 Pennsylvanians will keep their much-needed assistance to help them afford health care.” More…	FFM	Yes¹
RI	Raimondo (D)	“Last year, thousands of Rhode Islanders took advantage of almost $70 million in tax credits to gain the coverage they need to live healthy and productive lives. I applaud the Supreme Court for ensuring these benefits won’t be taken away from Americans across the country.” More…	SBM	Yes
SC	Haley (R)	“In South Carolina, we will continue to work around [the ACA] as best we can, finding better ways to make health care more affordable and give patients more choices.” More…	FFM	No
SD	Daugaard (R)	A spokeswoman for Gov. Dennis Daugaard, a Republican, said the state doesn’t have to change its approach to the federal health law since the court upheld the subsidies.	FFM	No
TN	Haslam (R)	“So while philosophically I did not agree with the ruling, in terms of the smoothness of the market and people being able to obtain insurance in a predictable way, it’s good.” More…	FFM	No
TX	Abbott (R)	“Today’s action underscores why it is now more important than ever to ensure we elect a President who will repeal Obamacare and enact real healthcare reforms.” More…	FFM	No
UT	Herbert (R)	“Ultimately, we are a nation of laws and I will continue to work diligently to maximize state flexibility within the legal parameters.” More…	FFM	No
VA	McAuliffe (D)	“This historic decision is a victory for the 286,000 Virginians who will now keep affordable health care that is essential to economic success. It is also a clear sign that now is the time to drop cynical efforts to prevent families from accessing care that will make their lives better.” More…	FFM	No
VT	Shumlin (D)	“This is very good news for the 6.4 million Americans who were in danger of losing their affordable health care coverage….We are making progress to deliver the services Vermonters expect through Vermont Health Connect. We have insured nearly 20,000 Vermonters who previously did not have insurance, and now Vermont has the second lowest rate of uninsured in the nation.” More…	SBM	Yes
WA	Inslee (D)	“I applaud the Supreme Court for upholding this landmark law that is helping so many people here in Washington state and across the nation. The Affordable Care Act has helped more than 730,000 Washingtonians find affordable care, and more than 300,000 of those had been uninsured.” More…	SBM	Yes
WI	Walker (R)	“Today’s ruling means Republicans must redouble their efforts to repeal and replace this destructive and costly law.” More…	FFM	No
WV	Tomblin (D)	Gov. Earl Ray Tomblin’s “appreciates” a U.S. Supreme Court ruling letting 28,000 West Virginians keep receiving federal subsidies for health insurance plans bought from a federal marketplace. More…	SPM	Yes
WY	Mead (R)	“Simply stated, this ruling maintains the status quo. It will still be necessary for Wyoming to develop its own path forward for better health care access and better health care for our citizens. I will continue to work with the Legislature on these important issues.” More… https://www.wvva.com/story/29412364/206	FFM	No

*Health Insurance Marketplace Models
FFM = Federally-Facilitated Marketplace
SPM= State-Partnership Marketplace
SBM= State-Based Marketplace
¹States have expanded Medicaid through an alternative expansion. For more details, please see this StateRefor(u)m chart.

Supreme Court Protects Coverage, Avoids Crisis for State Insurance Markets

June 25, 2015/in Policy Blogs Health Coverage and Access, State Insurance Marketplaces /by NASHP

The following is a statement from NASHP Executive Director Trish Riley regarding the Supreme Court decision on King v. Burwell.

“With their decision today, the Supreme Court has protected coverage for 6.4 million Americans and avoided a crisis for states and their insurance markets, had the insurance subsidies been eliminated. The Court recognized the ACA was built on a state foundation and reaffirms whether a state chooses to establish a state exchange or not, affordable health coverage remains accessible for its residents.
The wait and see period is over and now states can move forward. Leaders in the 34 states that rely on the FFM can examine and improve coordination between their Medicaid and CHIP programs and the FFM to ensure a seamless coverage experience; consider ways to make coverage more affordable in their markets; design new exchange models to offer states more flexible roles; and carefully review opportunities to seek significant waivers in 2017 that will allow for more state experimentation in providing affordable, quality coverage.
The National Academy for State Health Policy (NASHP) looks forward to working with states as they continue their ACA implementation journey, post-King. We will be convening state health policy leaders in early July to discuss next steps and will release a summary of those discussions to inform the broader policy community later this summer.“
In addition to Trish Riley, two of our state health policy leaders are available for media interviews to discuss the case and next steps:

Carrie Banahan, Executive Director, Office of the Kentucky Health Benefits Exchange
Peter Lee, Executive Director of the California Health Benefit Exchange

To schedule an interview please contact Lesa Rair, 202-903-2785 or lrair@nashp.org
The National Academy for State Health Policy (NASHP) is an independent academy of state health policymakers who are dedicated to helping states achieve excellence in health policy and practice. A non-profit and non-partisan organization, NASHP provides a forum for constructive work across branches and agencies of state government on critical health policy issues.
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New Mexico’s State-Based Marketplace: An Emerging Model

June 16, 2015/in Policy New Mexico Reports Eligibility and Enrollment, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by NASHP and Tess Shiras

The Supreme Court’s ruling in King v. Burwell could have a significant impact on states. If the Supreme Court finds for the petitioners in King v. Burwell, states with Federally-Facilitated Marketplaces (FFMs), and possibly State Partnership Marketplaces (SPMs), may have to adopt a new model that qualifies as a State-Based Marketplace (SBM) to maintain access to the advanced premium tax credit (APTC) for their citizens.
Under the assumption that such a ruling would allow APTC to be available in SBM states that use the healthcare.gov technology platform, there are existing federal-state hybrid exchange models that current FFM or SPM states could adopt to protect these subsidies. One proposed model is New Mexico’s exchange, which is a SBM that is proposing to run core exchange functions while using the healthcare.gov technology platform from the Centers for Medicare and Medicaid Services (CMS) for individual enrollments. This proposed model would allow states that declare their intent to establish a SBM to operate most core exchange functions while using the federal platform for individual enrollment and, importantly, qualify as a SBM.

Download the Issue Brief

Maine Takes Steps Towards Becoming First State to Legislate Back-up Plan for King v. Burwell

June 16, 2015/in Policy Maine Blogs Health Coverage and Access, State Insurance Marketplaces /by NASHP

As we get closer to a decision on King v. Burwell, attention is turning to the 34 states without a state-based exchange. To date Maine has come closest to enacting a law, in the event of a decision for the plaintiff, with LD 1344, “An Act to Protect Maine Consumers in the Individual Health Insurance Market and Support Maine’s Economy”. Currently awaiting a final vote in the Senate, the bill allows the state to establish a state-based health insurance exchange should the U.S. Supreme Court strike down the ability for the Federally Facilitated Marketplace (FFM) to continue to provide subsidies to the 75,000 Mainers who rely on it for assistance in paying premium and cost sharing expenses.
The bill, which passed the House with strong bipartisan support authorizes Maine to partner with the federal marketplace and includes an automatic sunset provision to eliminate the law, should the Court rule in favor of the government and allow the FFM to continue to provide subsidies.
While Maine has come the closest to passing legislation that would allow for the creation of a state-based exchange in anticipation of the Supreme Court’s decision, 10 other states considered bills to do so this session and nine sought legislation to prohibit the state from taking such action. Bills to prohibit the creation of a state-based exchange have become law in both Arkansas and Arizona. In Pennsylvania, Governor Wolf has applied to the federal government seeking a contingency plan, should the Supreme Court rule for the plaintiff. Delaware has also recently submitted a plan to develop a state-supported marketplace and preserve marketplace subsidies. A State Refor(u)m chart outlines state legislative activity surrounding exchanges. In an issue brief earlier this year, NASHP identified considerations and policy options for states pending the outcome of King v. Burwell. A decision from the Court is expected later this month.

King v. Burwell Has Been Decided, But There Is Still Work For States To Do

June 16, 2015/in Policy Health Coverage and Access, State Insurance Marketplaces /by NASHP

OLYMPUS DIGITAL CAMERA The Supreme Court has ruled on the case, and affirmed the provision of tax-subsidies through the federally-facilitated marketplace (FFM), a decision potentially effecting more than 6.4 million Americans currently receiving subsidies in the 34 states. NASHP has released materials to help states as they prepare to take the next steps as they continue ACA implementation, in post-King era.
Statements issued by governors in light of the ruling hint at the future direction of potential reforms across states, in a new chart NASHP looks at What Governor’s are Saying About King v. Burwell
In a statement, NASHP Executive Director Trish Riley notes the 34 states that rely on the federal facilitated marketplace (FFM) can now move forward to examine and improve coordination between their Medicaid and CHIP programs, and to ensure a seamless coverage experience; consider ways to make coverage more affordable in their markets; design new exchange models to offer states more flexible roles; and carefully review opportunities to seek significant waivers in 2017 that will allow for more state experimentation in providing affordable, quality coverage.
Pre-Decision Materials:
While no states had legislated a back-up plan, a number of states considered bills for the creation of a state-based exchange. A State Refor(u)m chart outlines state legislative activity surrounding exchanges in the most recent session. See Trish Riley’s latest blog post on this legislation.
In an issue brief earlier this year, NASHP identified considerations and policy options for states pending the outcome of King v. Burwell.
A new brief from NASHP looks at one proposed model, New Mexico’s SBM. This brief provides a detailed examination of New Mexico’s proposed model including an analysis of the applicability of the model to FFM or SPM, a breakdown of exchange responsibilities, and comparison to other existing marketplace models.