State Insurance Marketplaces – Page 6 – The National Academy for State Health Policy

How Governors Addressed Health Care in their 2020 State of the State Addresses

February 13, 2020/in Policy Charts Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Prescription Drug Pricing, Social Determinants of Health, State Insurance Marketplaces, State Rx Legislative Action, Work Requirements /by Sarah Lanford and Anita Cardwell

New Federal Rule Increases Administrative Burdens and Cost to Marketplaces

January 17, 2020/in Policy Blogs, Featured News Home Health Coverage and Access, State Insurance Marketplaces /by Christina Cousart

New regulations imposed by the US Department of Health and Human Services (HHS) require a significant change in how insurers bill consumers for health insurance premiums. The technical change:

Imposes a significant administrative burden on insurers, the health insurance marketplaces, and consumers;
Raises premium prices; and
Risks generating confusion among consumers when they pay their monthly premiums.
Collect no less than $1 per enrollee per month to cover non-Hyde abortion services (if offered);
Create distinct accounts to collect premium payments and use them to reimburse enrollees’ claims for non-Hyde abortion services; and
Alert enrollees that the insurer is separately charging for these services by adding a distinct line item on the enrollee’s monthly bill; sending the enrollee a separate bill for non-Hyde services; and/or by sending the enrollee a notice, shortly after the time of enrollment, that their monthly bill will include a separate charge for these services.

Billing and Premium Payments Changes

This new regulation alters the current enrollee billing and notification requirement, mandating that insurers send an entirely separate bill to enrollees for premium charges associated with non-Hyde abortion services. The invoice for the separate premium that would be used to fund non-Hyde abortion services can be included in the same envelope as the health plan’s monthly premium bill. However, the non-Hyde charges must be listed on a distinct piece of paper with separate explanations so that the enrollee “understands the distinction between the two bills.” If an enrollee has opted to receive electronic communications, the non-Hyde premium charges must be sent through separate emails.

Prior to implementation of this rule, insurers were permitted to collect a single premium payment from enrollees, and then split the payment into the separate accounts required by the prior regulation. The rule changes this process to now require that enrollees submit two distinct premium payments — one for premium charges for non-Hyde services, and another for the remainder of the premium. In order to implement this change, insurers will be required to send clear instructions to enrollees to explain the need to pay the two charges through separate transactions, such as two distinct credit card charges. Enrollees who do not pay their full monthly premium (including the separate charge for non-Hyde services) risk having their coverage terminated by their insurer. Insurers are allowed to offer consumers a grace period (usually 90 days) during which consumers can reconcile missed payments before terminating coverage.

Stakeholder comments submitted when the rule was proposed cited concerns that multiple bills and payments could create confusion for enrollees. In an attempt to mitigate these losses, HHS indicated it will not take enforcement action against insurers that do not terminate enrollee coverage because the consumer did not pay the separate bill, at least not until new regulations are put in place to provide additional guidance on these requirements. The rule also suggest that insurers may leverage allowable “premium disregard thresholds” as one tool to aid consumers who may have missed making a separate payment, for example, the insurer will not terminate coverage as long as 99 percent of the premium is paid during a set amount of time.

Finally, the rule provides insurers with a new option to allow enrollees to opt-out of coverage of non-Hyde services by not paying the second premium. This option would fundamentally change the plan consumers were enrolled in for the year, as well as their premium costs, which is a potentially significant change for an insurer to bear in the middle of a plan year. The regulation grants deference to state law and/or health insurance marketplace certification requirements that prohibit such mid-year changes. This option also may not apply in states that mandate coverage of non-Hyde abortion services on private health insurance plans (CA, IL, ME, NY OR, and WA).

Expected to Cost Marketplaces and Insurers Millions

As stated by commenters and reflected in the final rule, implementation of these changes will require insurers or state-based marketplaces that perform premium billing on behalf of insurance (including MA, RI, and VT) to make “changes to nearly every aspect of the enrollment and billing process.” HHS estimates the rule will impose one-time costs of nearly $4.1 million to each insurer or marketplace that must institute these changes, plus an additional cost of nearly $1.1 million annually to maintain operation of the rule.

In total, insurers and marketplaces are estimated to spend more than $550 million to implement this rule between 2020 and 2022. HHS estimates that these additional costs will result in premium increases to consumers. While premiums have already been set for the 2020 plan year, HHS estimates that these changes will result in a 1 percent increase in premiums per year beginning in plan year 2021.

These estimates do not include additional expenditures that might be made by all health insurance marketplaces, brokers, and other agencies to ensure systems are in compliance with the new regulations and to conduct outreach and education to mitigate confusion among consumers who will now receive multiple monthly bills. HHS estimates that the 12 state-based marketplaces alone will spend a total of $24.6 million from 2020 to 2024 to implement these such changes. In the case of marketplaces that do premium billing, these charges are in addition to those outlined above.

Outlook for States’ Insurance Markets

The billing changes made by this rule are slated to go into effect on June 27, 2020, which gives states and insurers limited time to prepare the systems and outreach materials that will be needed to smoothly implement this change. HHS acknowledges that the rule may result in coverage losses, caused in part by confusion and the additional burden put on consumers to understand and follow through on making separate premium payments. Reductions in enrollment could affect a health plan’s risk mix and lead to additional changes in premiums. HHS also acknowledges that insurers may choose to drop coverage options to avoid the burden of implementing the rule, which would reduce the number of choices available to consumers in the marketplaces.

The National Academy for State Health Policy will continue to track this issue as state regulators coordinate with insurers on implementation of these rules and monitor impacts of these changes on markets.

What States Did in 2019 to Address Health Coverage and Costs

December 16, 2019/in Policy Blogs, Featured News Home Administrative Actions, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Medicaid Expansion, Newly-Enacted Laws, Prescription Drug Pricing, State Insurance Marketplaces, Work Requirements /by Sarah Lanford

Early in 2019, more than 20 governors identified affordable insurance coverage and rising health care costs as critical policy issues that needed to be addressed in their state of the state addresses. Highlighted below are some of the significant steps states took in the past 12 months to expand coverage and tackle health costs, including expanding Medicaid, establishing new coverage programs, transitioning from the federally-facilitated marketplace to state-based exchanges, and continuing efforts to rein in drug prices.

Read the companion blog, How States Addressed Health-Related Social and Economic Factors in 2019

Expanding Coverage

Washington State enacted a first-in-the-nation quasi-public option requiring the state’s Health Care Authority to contract directly with at least one commercial carrier to offer coverage through the state’s health insurance marketplace. This ensures individuals who are eligible for cost-sharing subsidies will be able to choose the public option without losing their advanced premium tax credit. The law requires standard plan design that provides specific benefits and limits consumer cost sharing. Further, the law allows the state to regulate certain health care prices, such as provider and facility reimbursement rates, which will be capped at 160 percent of Medicare rates.

The Colorado legislature passed a similar bill with support from Gov. Jared Polis that requires the state to develop a proposal for an affordable state coverage option. In November, the state finalized its proposal to allow residents who buy individual health insurance to purchase a state public option plan. If approved by the state legislature and the federal government, coverage under the option will begin in January 2022.

California enacted a law to provide government-subsidized health benefits to undocumented immigrants. California had been one of six states plus Washington, DC to use state funds to cover income-eligible children regardless of their immigration status. The new law expands coverage to undocumented, income-eligible young adults through age 25, expanding the availability of state-subsidize health care to more Californians.

Maine implemented the Affordable Care Act’s (ACA) Medicaid expansion two years after voters passed it by ballot referendum because the previous governor refused to implement the policy. As she promised, Gov. Janet Mills enforced the law and sought federal approval to extend Medicaid coverage to about 36,000 Mainers.

Georgia Gov. Brian Kemp announced in his state of the state address that he included $1 million in the budget to craft state flexibility options for Georgia’s Medicaid program. Kemp then worked with the legislature to pass the Patients First Act, authorizing the state to seek federal approval for waivers to implement an alternative Medicaid expansion model and to pursue a range of options affecting individual market coverage. The state released draft versions of those waivers this fall. The state is now seeking approval to operate its own coverage subsidy program that would include a cap on enrollment if costs reach a certain threshold. The initiative would also allow consumers to purchase state-certified, non-qualified health plans that will not be required to meet quality health plan standards, such as the Essential Health Benefit. The state’s 1115 wavier seeks to expand Medicaid to residents earning up to 100 percent of the federal poverty line, and it includes a work requirement.

Marketplace Transitions

There has been increased interest among states that used the federally facilitated marketplace (FFM)to transition to state-based marketplaces (SBM). Nevada was the first to transition from the federal platform to an entirely state-run marketplace. It launched this year in time to enroll individuals into qualified health plans for plan year 2020. In making this shift, Nevada will have more autonomy over operations, can tailor policies for its residents’ unique needs, and expects to save millions of dollars.

New Jersey, Pennsylvania, and Maine are on track to follow in Nevada’s footsteps. In announcing Maine’s plans to create its own marketplace by plan year 2021, Mills noted that states operating their own SBMs have performed better on both enrollment and reducing cost of premiums than those using the FFM. Transitioning to a state-based marketplace allows states flexibility, such as working with health plans to extend the open enrollment period, as well as increasing access to enrollment data and targeting outreach funding.

Increasing Affordability

This year, states took a wide variety of approaches seeking to increase health care affordability for consumers, including the establishing of reinsurance programs, creating spending growth targets, and increasing subsidies through tax credits for middle-class marketplace enrollees. In the absence of federal action, a growing number of states are also helping patients avoid costly surprise medical bills.

Reinsurance programs can lower premiums and stabilize markets by offsetting the costs of more-expensive claims for carriers. During the 2019 legislative session, with support from its governor, Colorado joined 11 other states that currently operate reinsurance programs. Since the program received federal approval, health insurance rates fell an average of 20.2 percent in the state. Officials predict that lower premiums may encourage uninsured Coloradans to purchase coverage and lower the overall uninsured rate in the state.

In Rhode Island, Gov. Gina Raimondo signed an executive order establishing a 3.2 percent growth target for health care spending. The executive order charges the state’s Office of Health Insurance and the Executive Office of Health and Human Services to engage providers, insurers, and community partners in the initiative, and to issue annual reports to track the state’s progress in meeting health spending targets.

Lawmakers in California went a different route and established a state-level individual health insurance mandate similar to the original provision in the ACA that is no longer enforced, joining Massachusetts, New Jersey, Vermont and Washington, DC. They also allocated state funds to extend tax credits to help offset premiums for middle-class Californians who earn between 400 and 600 percent of the federal poverty limit who enroll in a health plan through the state’s marketplace. The mandate penalty is expected to generate about $295 million next year to help fund the subsidies that will make individual coverage more affordable for the middle class.

In Nevada, Gov. Steve Sisolak signed a bill into law to prohibit the practice of surprise balance billing. The law holds patients harmless for surprise balance medical bills, only requiring enrollees to pay applicable cost-sharing amounts. The law creates a binding arbitration process that requires insurers and providers to submit their proposed reimbursement rates to a neutral arbitrator who selects one of the parties’ rates. Nevada joined other states that have taken action to protect consumers from unexpected medical bills this year.

Addressing Prescription Drug Costs

NASHP has been tracking state legislative action on drug costs since 2016. This year, states continued to take steps to rein in drug costs, from passing legislation to create wholesale drug importation programs to regulating pharmacy benefit managers (PBMs) more aggressively.

Following Vermont’s lead, Florida, Colorado and Maine enacted laws to start the process of creating a wholesale importation program to import drugs from Canada at lower prices. While states will need federal approval to implement their programs, the Trump Administration released the Safe Importation Action Plan that lays the foundation for the federal rule-making process. Rules to implement the program are expected to be released by the Administration this week.

States continued efforts to better understand PBM operations and regulate them. At an administrative level, Ohio, Washington, and West Virginia asserted their purchasing power to capture savings for Medicaid through more active oversight of prescription drug benefits. In Nevada, lawmakers gave their Department of Health and Human Services the option to carve pharmacy benefits out of Medicaid managed care contracts so the state could negotiate directly with manufacturers. Carving out the pharmacy benefit gives the department direct control over negotiations with PBMs and ensures that any rebates or discounts from drug manufacturers flow to the state rather than a third party. Maine took a different approach and now requires more health plan oversight of PBMs. By tasking carriers with PBM monitoring responsibilities, Maine is using its Bureau of Insurance regulatory authority to enforce other provisions of its PBM law.

The new PBM law in Maine was just one piece of a comprehensive suite of legislation aimed at controlling drug costs in the state. Three additional new laws include updates to Maine’s existing drug transparency program, the creation of a drug affordability board, and support for the state to pursue a wholesale drug importation program. These laws work in conjunction with each other to create an infrastructure through which the state can gather actionable data and hold all players in the drug supply chain accountable.

While this summary doesn’t capture all of the activity and progress made by states during 2019 to expand coverage, increase affordability, and address costs, it shows the diversity of actions that states have taken. As we look ahead to 2020, we anticipate states will continue to make health coverage and costs a priority. The National Academy for State Health Policy will continue tracking those efforts, sharing promising practices, and supporting states in their health care goals.

Georgia Proposes New Changes to its Individual Market and Medicaid Program in Two Federal Waivers

November 11, 2019/in Policy Georgia Blogs, Featured News Home Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces, Work Requirements /by Anita Cardwell

This spring, Georgia passed the Patients First Act authorizing the state to seek federal approval for a Section 1115 waiver to implement an alternative Medicaid expansion model and an Affordable Care Act (ACA) Section 1332 waiver to pursue a range of options affecting individual market coverage. Last week, the state released draft versions of both waivers, outlined below.

Most of the components of the state’s 1115 waiver proposal are similar to Medicaid expansion models that have been approved in other states. However, the changes Georgia proposes through its 1332 waiver are more notable for their potential implications and the questions they raise about the parameters and administration of the state’s individual market. This is also the first example of a state seeking a broader 1332 waiver based on guidance released by the Centers for Medicare & Medicaid Services last year, which changed the interpretation of the 1332 waiver’s “guardrails.”

Proposed 1332 Waiver

Georgia is seeking to use Section 1332 waiver authority to implement significant changes to coverage available through its individual market. The proposal includes two phases — the first part of the plan would implement a reinsurance program, and the second portion involves transitioning from a federally-facilitated marketplace (FFM) to a more state-controlled, decentralized model — though it would not be the same as an ACA state-based marketplace.

Reinsurance program: Similar to many other states, Georgia is proposing to create a statewide reinsurance program beginning in plan year 2021 with the goal of stabilizing the individual market, reducing premiums, and ensuring an adequate selection of insurance carriers. The program would reimburse carriers at tiered rates according to geographic regions in order to provide larger reimbursements to areas with higher premiums.
Georgia Access Model: Beginning in plan year 2022, the state would implement a number of changes through the proposed Georgia Access Model, including:
- State individual market operational changes: As part of the state’s plan to no longer use the FFM, the state’s Office for Health Strategy and Coordination along with other state agencies would be responsible for determining consumers’ eligibility for coverage, certifying plans offered on the individual market, licensing web brokers, and distributing tax credit dollars and addressing any related appeals.
- State-run subsidy program: The state would develop and administer its own subsidy program, using both federal advance premium tax credits (APTCs) as well as state funds, to help individuals who earn 100 to 400 percent of the federal poverty level (FPL) purchase individual market coverage. The state is also requesting permission to cap consumer enrollment if state costs reach a certain threshold, and if this occurs individuals seeking coverage would be placed on a waiting list.
- Enrollment through web brokers and carriers: The state is proposing to allow consumers to directly enroll in individual market coverage through web brokers and carriers rather than through a centralized state agency model. This would involve giving the web brokers and carriers the responsibility for developing the functions needed to help consumers enroll in coverage, such as plan comparison tools and shopping portals.
- Allowing consumers to purchase alternative coverage options: Although consumers using the Georgia Access Model will still be able to use subsidies to purchase qualified health plans (QHPs), state-certified “non-QHPs” will also be available as a subsidized coverage option. These non-QHPs will not be required to meet QHP standards, including Essential Health Benefit requirements, and consequently would likely be less expensive — although they will be required to maintain pre-existing condition protections. They will also be required to be a major medical health plan and in the individual market’s single risk pool, but they will not be allowed to be medically underwritten.
Implementation timeline: The state is seeking comments on the proposal through Dec. 3, 2019, and plans to submit the waiver application to federal officials by Dec. 20, 2019, after which a federal comment period would be opened.

Proposed Pathways to Coverage – 1115 Waiver

Rather than implement the ACA’s full Medicaid expansion, Georgia is requesting to expand Medicaid only up to 100 percent of the FPL — at the enhanced ACA Medicaid expansion match rate, which has not yet been approved in any other state — along with the following conditions:

Eligible individuals: Individuals ages 19 to 64 who are not currently eligible for Medicaid, which would include adults without dependent children with incomes up to 100 percent of the FPL, and parents, caretakers, or guardians with income between 35 to 100 percent of the FPL.
Work requirement: To be eligible for coverage through the Georgia Pathways to Coverage program, individuals would be required to demonstrate they are working or engaged in other approved activities (e.g., community service, job training) for at least 80 hours per month.
Employer-sponsored insurance (ESI) premium assistance program: If an eligible individual has access to ESI, the individual will be enrolled in that coverage instead of Medicaid and the state will pay the ESI premiums for the individual if it is more cost-effective for the state.
Premiums: Some individuals will be required to pay premiums (tiered based on family income), and these premiums will be deposited in a Member Rewards Account.
- Individuals required to pay premiums: Individuals who are eligible for the Georgia to Pathways Coverage program who have incomes of 50 to 100 percent of the FPL, and individuals enrolled in transitional medical assistance.
- Exempt individuals: Individuals with incomes below 50 percent of the FPL; individuals in the ESI premium assistance program; and individuals who are enrolled in and two months after graduation from certain vocational education training programs of highly sought-after trades.
- Penalties for nonpayment: Enrollees required to pay premiums who fail to pay have a three-month period to retain eligibility before being disenrolled.
Copayments: The same individuals who are subject to premiums will be required to make copayments for certain services that will be assessed retrospectively, but they are not to exceed 5 percent of an individual’s household income when combined with premium payments. Copayments are the same as in the existing state plan, with the addition of a copayment for non-emergency use of the emergency room.
Member Rewards Accounts: Enrollees’ premium payments will be deposited in a Member Rewards Account, which will also be funded with state contributions. Funds in these accounts can be used for copayments or to pay for additional services that are not covered, such as vision or dental care. Individuals can earn points in their accounts by engaging in healthy behaviors.
Benefit package and delivery system: The benefit package will mostly align with those provided through the state plan, with the exception of non-emergency medical transportation. Also, while the Early and Periodic Screening, Diagnostic and Treatment benefit for 19- and 20-year-old individuals is part of the state plan benefit package, the proposal requests to waive vision and dental services for these enrollees. For individuals for whom the state is covering the cost of ESI, wraparound benefits are not covered. The program will use a managed care delivery system exclusively.
Eligibility effective date: The state is requesting to waive retroactive eligibility, and to have eligibility begin the month following the determination of eligibility and the payment of any premium required.
Implementation timeline: The state is seeking comments on the proposal through Dec. 3, 2019, and is planning to submit the waiver to federal officials on or before June 30, 2020 for a federal comment period. However, if approved, implementation of the program would not begin before July 7, 2021.

Although the timing for implementation of the two waivers differs, the state comment period for both waivers closes on Dec. 3, 2019. For more information and to view the waiver documents, explore the state’s informational page. The National Academy for State Health Policy (NASHP) will be tracking Georgia’s plans as they evolve and will report on other states’ emerging proposals.

For more information about states’ implementation of the ACA’s Medicaid expansion, explore NASHP’s interactive map, Where States Stand on Medicaid Expansion, and for information about states’ marketplace models, view NASHP’s map, Where States Stand on Exchanges.

Q&A: How Maryland Uses Multiple Policy Levers to Improve Health Coverage, Affordability, and Access

October 14, 2019/in Policy Maryland Blogs, Featured News Home Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Health IT/Data, Health System Costs, Medicaid Expansion, State Insurance Marketplaces /by Christina Cousart

Maryland has a long history of enacting statewide health reforms and 2019 was no exception with the passage of several significant reforms, including the Maryland Easy Enrollment Health Insurance Program (MEEHP), which passed with bipartisan support and was signed by Gov. Larry Hogan in June. Maryland is also implementing a new value-based plan design for health insurance marketplace plans and is continuing the state’s reinsurance program. Collectively, these reforms are helping advance Maryland’s objectives to improve affordability and attain near universal coverage.

About Maryland’s Easy Enrollment Health Insurance Program

During tax filing season, the state income tax department will ask consumers if they want to learn if they qualify for free or low-cost health insurance. If consumers indicate positively, the consumers’ data is sent to the Maryland Health Connection to determine if they are eligible for Medicaid, the Children’s Health Insurance Program (CHIP), or federal tax credits to purchase insurance through the marketplace. Uninsured individuals are granted a limited special enrollment period to enroll in coverage through the marketplace.

NASHP spoke with Michele Eberle, executive director of Maryland’s health insurance marketplace – Maryland Health Connection – to learn about the implementation of these programs, and how Maryland’s reforms are providing greater stability to its insurance market.

Maryland implemented a reinsurance program beginning in plan year 2019, why?

After the federal reinsurance program ended [after plan year 2016], premiums in the state’s individual market spiked. Maryland has only two insurance carriers in our individual market, and we worried there was a risk of either losing those carriers or pricing people out of coverage. We wanted to be aggressive in addressing the issue of affordability. We also recognized a unique opportunity in that Congress planned to delay implementation of the Health Insurance Tax [HIT – an annual fee assessed by the federal government on health insurers]. We argued that we would assess our insurers, in lieu of this fee to the federal government, and use the money to finance a reinsurance program. Our 2.75 percent assessment gave us nearly $365 million, combined with federal funding drawn from a 1332 waiver, we secured nearly $1 billion over a five-year period for a reinsurance program. [For more information read State Reinsurance Premiums Lower Premiums and Stabilize Markets.]

Our goal was to reduce premiums by 30 percent from what they would have been without the reinsurance program. And, for the first time in 20 years, we saw our premiums decrease in 2019 on average by 13 percent. The program has been so successful, the legislature this year agreed to maintain a 1 percent assessment on our insurers to finance the program even once the federal HIT is implemented [ plan year 2020].

What led Maryland to propose and enact the MEEHP?

This concept originally started as a traditional individual mandate [a requirement that all individuals purchase health insurance]. But there was mixed support for a mandate and operational challenges to implementing one in our state.

The policy is a testament to the work and commitment of our many stakeholders and legislature. Our goal is to achieve health care access for all, without people feeling that they are forced into a program. We also want to offer consumers affordable and value-based coverage. We developed MEEHP because it addresses these issues, which is a win-win for all.

How will the MEEHP work?

For the 2020 plan year, the marketplace will use data collected from state tax filings to complete a preliminary assessment of whether a person is eligible for Medicaid, CHIP, or a federal tax credit. The person will then be provided a list of resources to help them enroll in the coverage program for which they are eligible. In 2021, we plan to roll out an automatic enrollment feature (upon request) if the person qualifies for Medicaid or CHIP. If the person does not qualify for Medicaid or CHIP, they can enroll in marketplace coverage during a 35-day special enrollment period based on the date the marketplace received their information from the Office of the Comptroller )

At the marketplace, we are working very closely with the [state] Comptroller to implement this program, including transferring information between their department and our system. We now know the Comptroller’s office timelines and what they will need to have this ready for the upcoming tax season. Very early on, the marketplace and the Comptroller’s office began collaborating and that partnership is essential to ensuring we could meet fast-approaching deadlines.

Our current focus has primarily been on modifying our IT systems to operationalize the program. But we are also prioritizing working with stakeholders and other partners on how to message about the new program.

We are especially excited that this initiative gives us more robust information about Maryland’s uninsured population. It will help us target our outreach and inform our efforts to boost enrollment. We are trying to think of ways to make it easy for consumers to follow up and enroll in coverage.

How will Maryland’s new, value-based plans serve consumers?

As noted previously, the reinsurance program has led to a tremendous reduction in individual market premiums. However, while premiums have been going down, deductibles have been rising, leading to higher out-of-pocket health care spending by our consumers. We were concerned that consumers wouldn’t see the value of their coverage — if premiums and deductibles are too high, they will question whether it is worth purchasing coverage.

Under our value-based plan program, each carrier must offer at least one plan with a capped deductible for two metal levels in which it offers coverage ($1,000 for gold plans, $2,500 for silver). In addition, a bronze plan must cover at least three physician visits (primary care or specialists) prior to the deductible and the gold value plan must offer generic drugs before deductible.

We believe these requirements will help ensure that consumers can get value from their plans. Looking ahead, we will continue to refine our value-plan requirements. For example, we are looking at whether generic prescriptions should be covered pre-deductible, or with a separate deductible. We are also looking over how to improve coverage for diabetic populations.

What has been the key strategy to advancing these reforms so quickly in Maryland?

Maryland’s administration and legislature have a history of committing themselves to the improved health of Marylanders. For instance, even before passage of the Affordable Care Act, Maryland had enacted its own small group market reforms, including benefit requirements and a community rating standard. We are fortunate to have a lot of engagement from stakeholders and the administration on advancing further reforms.

Part of what drives innovation here is our global budget initiative, an all-payer model regulating hospital costs. The global budget underlies all our health systems and payers, so that anything that affects one part of our health care system reverberates throughout. The state does whatever it can to maintain this program, including actions to maintain our insurance markets, reduce our uninsured rate, and keep our uncompensated care costs down.

Which stakeholders have been especially helpful throughout your work?

Both of our health insurance carriers are always at the table and I appreciate the relationship we have built with them since establishment of the marketplace seven years ago. The marketplace and the carriers work together, proactively, to address concerns. We have a plan management stakeholder committee that includes all carriers and consumer advocates. They are one of the first groups we engage on any new initiative for the marketplace. We have discussions on how new policies will impact our insurers. I meet regularly with the CEOs of our health plans and discuss how we can work in partnership to affect overall health in our state. There were some challenges early on in our relationship, but the insurers have seen some benefits in working with us. For example, Kaiser Permanente’s market share has grown from 2 percent to 46 percent in our health insurance marketplace. Both of our insurers have seen significant growth overall.

We also have two groups that are focused specifically on consumer issues. What is important for us is to be as transparent and inclusive as possible. We know these issues effect populations statewide.

What advice would you offer to other states looking to enact similar reforms?

Establishing and building relationships with your stakeholders — consumer advocates, legislature, carrier community — is essential. It is important to approach reforms with a holistic view of what is going on with your markets and health systems. The insurance marketplace is one part of this wheel, but to really make changes on affordability and cost, we need everyone heading in the same direction. For example, I recognize the importance of our reinsurance program, but also acknowledge that other reforms will be necessary if we are going to have a long-term impact on health care costs.

State Insurance Reforms Tackle Price Transparency, Rising Costs, and the Uninsured

October 8, 2019/in Policy California, Connecticut, Nevada Blogs, Featured News Home Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Health System Costs, State Insurance Marketplaces /by Christina Cousart

September was a busy time for state insurance regulators as they worked to finalize rate filings and prepare for the upcoming health insurance open enrollment season. While initial filings indicate nominal increases to individual market premiums for the 2020 plan year, insurance costs are escalating for individuals and families who receive coverage through their employers.

Beyond monitoring rates, state regulators continue to take action to ensure that all consumers across their markets have access to affordable, high-value coverage. Below are a few notable updates from states:

California enacts bills to address cost transparency. During the last month of its legislative session, California enacted two new laws that require insurers to provide enhanced reporting on health costs and quality.

AB 731 (Health Care Coverage: Rate Review) requires insurers, including large group health plans, to submit data to the state on medical use trends by geographic region and enhances requirements for plans to report data on spending compared to Medicare rates. The law will go into effect by July of 2021.
AB 929 (California Health Benefit Exchange: Data Collection) mandates that insurers provide data to the health insurance marketplace so that it can evaluate progress toward lowering costs, improving quality, and reducing disparities in the state. The law also requires that the marketplace make data on costs, quality, and health disparities public.

Connecticut seeks to “redefine the health care dynamic” through state employee plans. The state comptroller recently issued a request for proposals for insurers to administer state health benefits. The request for proposal carves out a role for the state to act as an active participant in negotiations between insurers and providers on reimbursement rates, including access to full details about negotiated payments.

Nevada releases detailed report on its uninsured. Reports estimate that nearly 400,000 Nevadans are currently uninsured. Among the uninsured, nearly 22 percent are young adults, 60 percent are Latino, and 63 percent are employed. Nevada’s recently implemented state-based marketplace will use this detailed data to target outreach efforts for the upcoming open enrollment period.

The National Academy for State Health Policy will continue to track and report on these and other insurance initiatives as they unfold in the coming months.

State-based Marketplace Leaders Share their Success and Growth with Federal Leaders

September 23, 2019/in Policy Blogs Eligibility and Enrollment, Health Coverage and Access, Health IT/Data, State Insurance Marketplaces /by Trish Riley and Christina Cousart

State-based marketplace (SBM) leaders convened in Washington, DC last week to share experiences and ideas and meet with key Congressional staff in advance of this year’s open enrollment period.

SBMs, which exercise total control over their health insurance marketplaces in contrast to states that use the federal marketplace, are making considerable progress in reaching and serving the uninsured. However, confusion fostered by unclear federal policies — such as the recent public charge rule and the looming decision in Texas v Azar that could strike down the Affordable Care Act – has created a cloud of uncertainty that challenges all states.

View a slideshow highlighting the advantages of state-based marketplace here.
Explore a map detailing each state’s marketplace model.

Today, 13 states operate SBMs, including Nevada that transitioned to this model for the 2020 open enrollment season. Additionally, four states (ME, NJ, NM, and PA) have announced plans to transition to the SBM model, three of which are currently operating as hybrid SBM models that use the federal platform (SBM-FPs) during this enrollment season.

Officials from the newly transitioning states – New Jersey and Pennsylvania – were welcomed at the meetings. They explained that a desire for stable insurance markets, state sovereignty over their marketplaces, and the potential for financial savings drove enactment of their new laws to transition to the SBM model.

Pennsylvania Democrat Gov. Tom Wolf’s proposal to establish an SBM and a reinsurance program received unanimous support from the state’s Republican-controlled legislature. In New Jersey, the decision to launch an SBM came on the heels of earlier efforts to restore the individual mandate requiring coverage and a successful federal waiver application to begin a reinsurance program.

By “owning” their marketplaces through the SBM model, state officials indicated they believe they will more efficiently and effectively serve their constituencies through implementation of state-focused policies and tailored outreach that were not possible when they used the federally facilitated marketplace (FFM).

Data shared at the meetings underscored the greater success that SBM states have had in serving their populations. (View a slideshow about SBM advantages here.) Unlike states that use the FFM, SBM states have the flexibility to address the health insurance needs of local populations and, as a result, have:

Maintained steady enrollment steady;
Been more successful in lowering their states’ uninsured rates; and
Helped more unsubsidized consumers find coverage.

While SBM states have held down premium cost growth better than FFM states, SBM leaders expressed urgency to do more to make coverage affordable, especially for middle-income consumers. This slide highlights a number of strategies SBM states are pursuing.

Five states are operating reinsurance programs – that subsidize coverage of high-cost enrollees – in partnership with the federal government and five more states will join their ranks in the 2020 plan year. The results officials presented made clear that reinsurance programs do lead to significant premium reductions and provides a tangible initiative for state insurance departments to hold insurers accountable through quantifiable premium reductions. But, state officials were quick to point out, state-run reinsurance programs are time-limited or are simply unaffordable for many states. The need to restore and make permanent a federally funded reinsurance program remains a priority even as states pursue other strategies to address affordability.

The message from SBM leaders who attended the Washington, DC meeting was clear – SBMs are succeeding, sustainable, and growing in number because they are on the ground, fine-tuning their operations, and growing their capacity to address local needs.

Multiple Factors Appear to Be Contributing to Children’s Rising Uninsured Rates

September 16, 2019/in Policy Blogs CHIP, CHIP, Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Maternal, Child, and Adolescent Health, Medicaid Expansion, State Insurance Marketplaces, Work Requirements /by Maureen Hensley-Quinn

US Census Bureau data released this past week revealed 8.5 percent (27.5 million people) did not have health coverage at any point during 2018 – an increase from 7.9 percent (25.6 million people) in 2017. The latest census data also affirmed fears raised after reports of declining child enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) that there was a rise in the overall uninsured rate for children – at 5.5 percent in 2018 – for the second year in a row.

Children’s uninsured rates have steadily decreased from 2008 when it was 9.7 percent to an all-time low in 2016 of 4.7 percent. However, the downward trend began to reverse in 2017 when the rate of uninsured children rose to 5 percent nationally and it has increased again in 2018. The resounding questions posed by state officials responsible for covering children in Medicaid and CHIP and other stakeholders are:

Why is children’s enrollment in public coverage programs declining and the uninsured rate increasing?
What is prompting an almost decade-long trend of increasing coverage for children to reverse?
According to the state officials who met and discussed children’s insurance enrollment at the 32nd annual National Academy for State Health Policy’s (NASHP) annual conference last month, there are no simple answers to these critical questions. They suggest that multiple factors, outlined below, are contributing to the decline.

Eligibility, Enrollment, and Retention Policies, Practices, and Systems
State officials explained that at the first indication of decreases in child enrollment in public programs, they looked inward to find a possible eligibility or enrollment system issue or policy problem to address. Although no one reported a major issue, many officials acknowledge that these policies and systems require continual updating and improving. Many officials want to further streamline the enrollment process for families by utilizing technology and existing data more fully, requiring less frequent renewals, and improving communication of what can be complex information for parents. Frustrating to many, these goals are not new and some are explicitly required by the Affordable Care Act (ACA), but still need attention. As states assess their systems and policies, there is a wealth of resources available to help them better target their investments.

This data suggests a strong economy does not guarantee access to health insurance. The 2018 data indicates that the percentage of people with private coverage (employer-sponsored, purchased, or Tricare) did not statistically change between 2017 and 2018. Therefore, even if the economy is helping families secure employment or increased income, it does not appear to guarantee access to health insurance.
The Strong Economy
It makes sense that during this time of job growth and low unemployment there would be a decreased need for public coverage programs. However, the data indicates that in 2018 the highest percentage of uninsured children (7.8 percent) were in families with incomes below 100 percent of the federal poverty level (FPL), which represents an increase over 2017. Also notable is the 0.7 percent increase between 2017 and 2018, of uninsured of children in families with incomes above 400 percent of FPL. This data suggests that a strong economy does not guarantee access to health insurance. Further, the 2018 data indicates that the percent of people with private coverage (employer-sponsored, purchased, or Tricare) did not statistically change between 2017 and 2018. Therefore, even if the economy is helping families secure employment or increased income, it does not appear to guarantee access to health insurance.

Changes to National Immigration Policies
State officials also suggested that changes to federal immigration policies have an effect on the decline in children’s enrollment in public programs and the increase in overall uninsured rates. According to a 2018 Urban Institute survey, the rule allowing the Department of Homeland Security to consider immigrants’ use of Medicaid when determining if they are or could become public charges has had a chilling effect on enrollment even before the rule became final. Although children’s use of Medicaid and CHIP is explicitly excluded from the final public charge rule, it is a complicated rule and is likely unclear to families who must determine how use of public coverage could affect their potential citizenship status. The data confirms that in 2018 naturalized citizens were 2.2 percent more likely to be uninsured. The data also indicates that in 2018, 8.7 percent of Hispanic individuals were uninsured, which is double the rate of other races or ethnicities in the report. All of which supports the speculation that immigration policy changes have had an impact on the rising rate of uninsurance.

Lack of Outreach and Marketing Funds
Outreach and marketing often take a backseat to other administrative and operational budget demands, particularly because state resources are already stretched thin. Instead, many state children’s coverage programs maintain active partnerships with community-based organizations and seek other low- or no-cost ways to get the word out about the availability of coverage. However, more and more state officials would like the opportunity to engage families to help them identify what messages resonate and the best ways to deliver them, such as social media or more traditional advertisements. State Medicaid and CHIP programs were benefiting from the federal navigator program that supported individualized health coverage application assistance, but in recent years, federal investment in that program has steadily declined.

Federal Policy Changes Affecting Affordability and Undermining the ACA
Finally, some state officials acknowledge that federal policies that supported the ACA have changed and may have impacted uninsured rates. Such policies include the elimination of the cost-sharing reductions and the federal reinsurance program, as well as others that have resulted in higher health insurance premiums and as a consequence lower enrollment. It is suspected there could be a relationship between parents’ loss of coverage and the decline in children’s enrollment. The ACA requires parents seeking coverage through health insurance marketplaces to enroll their eligible children in Medicaid or CHIP. If parents, who are no longer subject to the federal insurance mandate, are deterred by cost from seeking to enroll themselves in coverage, they may be missing the prompt to enroll their children during ACA’s open enrollment period and it could be a factor in the climbing child uninsured rate as well.

Without a clear cause and with multiple contributing factors for the declining children’s enrollment in public programs and the rising uninsured rate, states are challenged to identify how best to invest their limited resources to the address this issue, though many officials are deeply engaged in addressing this problem. NASHP will continue to work with states to understand better the emerging enrollment and uninsured data and to provide resources on tested and effective enrollment and renewal policies and practices to support state efforts to make sure eligible families have health coverage.

State Officials Fear Final Public Charge Rule Could Deter Health Coverage Enrollment

September 10, 2019/in Policy Blogs CHIP, CHIP, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Healthy Child Development, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health, State Insurance Marketplaces /by Maureen Hensley-Quinn and Anita Cardwell

The Department of Homeland Security (DHS) recently finalized a rule that significantly changes immigration policies related to “public charge” determinations. Under long-established US immigration policies, individuals who are deemed likely to become a “public charge” and require extensive government support can be denied an adjustment of their immigration status (e.g., issued a green card) or entry into the country.

State officials across the country who administer health coverage programs are concerned about the rule’s chilling effect – that it will deter many immigrants from applying for coverage or even dropping out of programs they are eligible for because they fear their participation could impact their immigration status, even when it may not.

The Department of Homeland Security’s final rule defining “public charge” applies to most people seeking admission or adjustment of status (e.g., a green card). Notably, it does not apply to:

Refugees and asylum-seeking;
Survivors of trafficking;
Special immigrant juveniles;
Other specified groups; and
People who already have green cards, with narrow exceptions.

Source: Greenberg, M. Public Charge presentation, Aug. 21, 2019

As originally proposed by DHS, the final rule significantly expands the list of non-cash public benefit programs that DHS can consider in its public charge determinations, including those providing health care coverage, food, and housing assistance that address many of the social determinants of health. Specifically, public charge determination processes will now consider immigrants’ use of:

Most forms of Medicaid;
The Supplemental Nutrition Assistance Program (SNAP); and
Several federal housing assistance programs.

The proposed rule had included the Medicare low-income subsidy program that provides assistance to pay for the prescription Part D coverage program, but the final rule excluded it. DHS also requested public comments on whether to include the Children’s Health Insurance Program (CHIP) on the list of benefits for public charge determinations, but the final rule also excluded CHIP. Additionally, the final rule excluded the following from determining whether an immigrant met the public charge definition:

Medicaid use by children and youth under age 21 and pregnant women up to 60 days postpartum;
Emergency Medicaid; and
Medicaid services provided through the Individuals with Disabilities Education Act (IDEA) and schools.

The rule stipulates that individuals can be considered a public charge if they are “more likely than not” to receive any of the identified public benefits for more than 12 months over a 36-month period, and it does not distinguish by benefit type. Receipt of two types of benefits in one month is considered as two months of benefit usage. As a result, families that receive support from more than one program would reach the threshold sooner.

The policies laid out in the rule are complicated and allow for DHS agent discretion, which further challenges state officials who want to provide accurate information to residents about whether accessing public health coverage will ultimately cost them citizenship. The rule identifies “heavily weighted” negative and positive factors to guide DHS agents’ consideration in determining an immigrant’s likelihood of being or becoming a public charge.

An example of heavily weighted negative factor is the receipt of Medicaid coverage for more than 12 months during a 36-month period. A heavily weighted positive factor is employment that provides household income of at least 250 percent of the federal poverty level. The rule requires that DHS consider the totality of the immigrant’s circumstances, and the rule’s preamble notes, “depending on the alien’s specific circumstances, a heavily weighted negative factor can be outweighed by a positive heavily weighted factor,” but the rule is not prescriptive about how that will be determined, resulting in some ambiguity.

The rule’s “totality of circumstances” test includes benefit usage, but also takes into account an individual’s age, health, financial status, and education level. For example, having a medical condition that could require significant treatment or institutional care, or not having the financial capability to cover these care costs, is considered a heavily weighted negative factor.

Although tax credits provided through health insurance marketplace are not listed explicitly on the benefit programs to be considered in public charge determinations, they are a factor that is taken into account. Specifically, while private health insurance coverage is considered a heavily weighted positive factor, an individual who receives subsidized marketplace coverage would not receive the same favorable weighting.

Some state officials told the National Academy for State Health Policy (NASHP) there was already evidence of a chilling effect from the proposed rule. According to a 2018 Urban Institute survey of nonelderly adults who are foreign-born or live with one or more foreign-born family members, approximately 14 percent reported they did not participate in a noncash program because they feared it would jeopardize their future green card status. Now that the public charge rule is final, many state officials expect that more immigrants – regardless whether they are directly impacted by the rule or not – will drop coverage because of this chilling effect. For example, the final rule excludes consideration of children’s enrollment in Medicaid in public charge determinations, but their foreign-born parents may not choose to enroll them for fear it may affect their pursuit of a green card.

The rule’s “totality of circumstances” test and the allowance that DHS agents will weigh different circumstances in determining whether an individual is or will become a public charge creates a challenge in messaging how applying for public health coverage could impact an immigrants future status. State officials representing Medicaid, CHIP, and state-based marketplaces acknowledge they are not immigration experts and are reluctant to encourage individuals to retain or apply for public coverage given the implication it could have on their citizenship status.

Officials in some states are engaging community-based immigration organizations to provide immigrants with individualized guidance and advice about whether to apply for public coverage. While this strategy will be helpful, states anticipate there may be many individuals whose fear will keep them from seeking assistance. State officials are concerned about the anticipated coverage lapses and expect there will be increased costs for safety net care, which at this time is hard to estimate.

Although lawsuits against the rule have been filed by nearly 20 states as well as two California counties and several advocacy groups to delay its implementation, as of early September the rule appears poised to go into effect Oct. 15, 2019.

How Washington State Is Reducing Costs and Improving Coverage Value – A Q&A with its Health Benefit Exchange CEO

August 5, 2019/in Policy Washington Blogs Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Safety Net Providers and Rural Health, State Insurance Marketplaces /by Christina Cousart

Washington State made history recently with passage of Chapter 364 – a new law that is poised to revolutionize the state’s individual insurance market. The law takes a multi-pronged approach to its market redesign by:

Creating a quasi-public option product for Washington’s individual market;
Requiring standard plan design for plans sold on its exchange; and
Developing a plan to implement and fund subsidies for individuals earning less than 500 percent of the federal poverty level (FPL).

Washington’s quasi-public option is the first-in-the-nation requirement that a state agency – Washington’s Health Care Authority (HCA) – contracts directly with at least one private insurance carrier to offer individual market coverage on the exchange. Through these contracts, the state will require health plans to meet a series of goals and requirements including:

Reimbursements capped at 160 percent of Medicare rates;*
Standard plan design (see details below);
Population health improvement;
Alignment with state value-based purchasing models; and
Incorporation of recommendations from Washington’s Bree Collaborative, a multi-stakeholder group tasked with improving health care quality, outcomes and affordability, and the health technology assessment program.

The carrier that contracts to sell these plans must make the plans available in at least one county in the state, and must offer at least one bronze, one silver, and one gold value plan. The intent is that the quasi-public plans will cost less and be higher-value to entice consumers to purchase these plans.

“Standard plan design” institutes requirements that insurers must meet, including a standard set of benefits and rate of cost sharing for the plans. The primary aim of standard plan design is to enhance a consumer’s experience by enabling them to comparison shop based on provider networks, premiums, and quality rather than based on cost sharing and deductibles. Washington joins many other states that have implemented standard benefit design for their exchange plans, including California, Connecticut, Massachusetts, Maryland, New York, and Washington, DC.

The law also requires a new standard plan design for plans sold on the exchange. The requirement lays out many ambitious goals to achieve through standardized requirements, such as:

Reduce deductibles;
Make more services available without needing to meet the deductible;
Maximize subsidies;
Limit adverse premium impacts;
Reduce barriers to maintain and improve health; and
Encourage choice based on value.

Washington’s exchange is tasked with developing the specifics of the standard plan design, and has already convened a multi-stakeholder workgroup to inform that process. Beginning in 2021, any insurer that sells plans on the exchange must offer at least one standard silver and one standard gold plan. While insurers may sell non-standardized plans in addition to standard plans, no non-standard silver plan may be of lower value than the standard silver plan that is offered.

Pam MacEwan

NASHP recently spoke with Washington Health Benefit Exchange Chief Executive Officer Pam MacEwan to learn more about what lies ahead in Washington.

What brought policymakers together to develop this law?

PM: A lot of what we see in health care is that there are challenges with reaching consensus on what the problems are. In this case, our premium increases [on the individual market] had been in the double digits. It was overwhelming our consumers who could not afford increases of up to 30 percent. Our legislators began hearing from their constituents. Our medical associations, hospitals, consumer groups were all starting to come together on this issue. The stories and data were compelling. It was clear that costs were unaffordable and that Washington was going to start losing any ground we had gained on reducing the uninsured.

We had explored options to lower premiums in the past, including reinsurance. While many stakeholders were on board with the concept of reinsurance [payments issued to insurers who have enrollment high-cost individuals] it was a challenge to come to agreement on how to finance the program. The policies passed this year do not require state funding and are expected to accomplish similar goals.

What did you hope to accomplish through the various components of this law?

PM: Our main drive was to do something that would have an effect on health care prices and affordability. There are three components that are important in the law 1) standardization of health plans sold on the exchange; 2) active purchasing of a state-procured health plan [the quasi-public option]; and 3) targeting elimination of the “subsidy cliff” by studying how we can further subsidize coverage for individuals earning up to 500 percent FPL.

Through our standard health plans we aim to address high deductibles that seem to be rising out-of-control. Consumers are spending a lot on their care, but perceive little value from their coverage. We see that consumers are confused about their health plans and do not always understand what is covered. Through the model we envision, consumers will have clear access to certain services before they hit their deductible, and there will be greater predictability of cost sharing. It is possible that this may not lead to reduced premiums, but we believe that consumers will perceive greater value from their health plans if they know they can access certain services before reaching their deductibles, or if they can obtain their generic prescriptions without a copay.

For the public option, we will be working with our Health Care Authority to develop plans that have a higher overall value, that use value-based purchasing, and that use evidence-based standards for care. Coupled with the reimbursement cap, we estimate premiums for these plans will be 5 to 10 percent lower than other plans, while also providing greater value for consumers.

Finally, the study on how to further subsidize coverage is an important piece of the law. It may be a challenge to get funding, but the information will be necessary for us to come to a consensus on how to address affordability concerns especially for those at the “subsidy cliff”, meaning individuals earning about 100 percent FPL who do not qualify for federal tax credits.

How were policymakers able to negotiate inclusion of a reimbursement cap as part of this law?

PM: Our providers were anxious about how the payment piece would work out. There are real concerns about pegging reimbursements to a federal benchmark, it sets up a perceived slippery slope of payments potentially decreasing. Under this bill, negotiations started to set the rate at 100 percent of Medicare payments. This gradually increased until we reached agreement at 160 percent. For reference, we estimate that reimbursements for our exchange plans currently average at about 174 percent of Medicare.

Data was especially important. Data from our all-payer claims database (APCD) gave us an idea of what hospital payments across our state were, not just in the exchange but in other markets, including our state employee plans. This gave us a rough idea of what we wanted to shoot for.

How does the law address concerns about reimbursements to high-cost, high-needs areas, like rural communities?

The law includes some added protections for our rural communities, giving rural hospitals a payment bump.** We have also seen a benefit to those communities from the law we passed last year that requires insurers who offer plans to our state employees or teachers to also offer plans on the exchange. Coverage in rural areas is an issue, but that law pulled insurers into our rural communities. We are heading in the right direction. Our goal is not to harm rural providers.

What will be your process to develop the standard plan design envisioned by this law?

PM: We did a lot of work toward developing this last year. We convened a carrier workgroup to advise us on technical aspects like copayments, consumer behaviors, and cost-sharing considerations. We convened other stakeholders to focus more on the consumer issues, including medical providers and hospitals. We plan to work in close partnership with our insurance commissioner. Because they do final certification of health plans, we need to put forth policies that they will be able to quickly approve. We also benefit from learning from our peers — states like California and Massachusetts who have led on this issue.

The procurement process for the public option is uncharted territory for us. This is something that has not been done before and we want to be sure that our insurers and providers will be on board. We do believe we have insurers who are interested; we will be sure to engage our insurers throughout the process. We will be working in close partnership with the HCA, which brings a depth of knowledge from their experience contracting for Medicaid and the public employee health plan.

I am confident we will be able to meet the timelines to implement this all for the 2021 plan year but, as with anything new, there are always things you do not anticipate. We will keep up conversations and get the right people at the table to advise us along the way.

What advice would you offer other states exploring similar policies?

PM: Start early. You will need to work through the research and build consensus among your stakeholders to get something like this passed. You also need good leadership. We benefited from a strong chair of our House Committee on Health, Eileen Cody. She very much put her shoulder to the wheel to drive this forward.

Also, other states are further ahead on some of these policies. We have created relationships that help us build on best practices. There is a lot to learn from each other.

*The cap may be waived if a carrier is unable to meet network access standards required by the insurance commissioner or if a carrier can reduce premiums by 10 percent from the previous year.

**The law sets a threshold that payments to rural hospitals and critical access providers may not be less than 101 percent of allowable costs as defined by the Centers for Medicare & Medicaid Services. Payments to primary care providers may not be less than 135 percent of Medicare rates.