Health Exchange Navigator

 
 
Health Insurance Exchange Sections of PPACA 

 Consumer Operated and Oriented    Plan (CO–OP) program

 American Health Benefit Exchanges & SHOPs

 

 Video: HHS Stakeholder Conference

 Waivers for State Innovation

 CMS HIE Data Base (HIAD)

 HHS Guidelines

 

 Offering Plans in More Than One State

 Essential Benefits – 2011 DOL Study

 

 Multi-state Plans

 CMS Eligibility Rules - Proposed    
 COOP Proposed Rule 7/18/2011  Tax Credits to Federal Exchanges?    
   IRS Proposed Reg on Tax Credits    
       
 Quick PPACA HIE Links:      
 Qualified Health Plans Defined      Sec. 1301  State Flexibility                         Sec. 1321  Indiv/Sm Grp Risks   Sec. 1342  Tax Cr Disregarded    Sec. 1415
 Essential Benefits                             Sec. 1302  Federal Assistance                  Sec. 1322  Risk Adjustments      Sec. 1343  Study of Geo FPL        Sec.1416
 Special Rukes                                    Sec 1303  Flex for Non-M'caid                 Sec. 1331  Refund Tax Credits   Sec. 1401  Sm Bus. Tax Credits   Sec. 1421
 Related Definitions                          Sec. 1304  Innovation Waivers                Sec. 1332  HIE Eligilibity Etc.     Sec. 1411  
 Affordable Choices                         Sec. 1311 Multiple State HIEs                  Sec. 1333  Prem & Costsharing  Sec 1412  
 Consumer Choice                             Sec. 1312  Multi-State                                Sec. 1334  Easy Enrollin HIE      Sec. 1413  
 Financial Ingetrity                            Sec. 1313  Transitional Reins                    Sec. 1341  Disclosures                Sec. 1414  
 
 
Interactive State Map with updates on Exchanges (Current to December 2011) 
 
 
State Health Exchange Websites & Legislation: (See Attached PPt at Bottom of Page)
 

 Massachusetts

 https://www.mahealthconnector.org/portal/site/connector/

Georgia 

 Executive Order   HIE Website

 Utah

  http://www.exchange.utah.gov/

Ohio

 Executive Order

 California

AB1602   SB900

 Montana

 

 Washington

 S5445

 Colorado

 SB200

 North Dakota

 

 Connecticut    

 SB921   HIX Law  Conn Website

 West Virginia

 SB408

 Hawaii

 SB1348

 Maryland

 SB182   Update 10-21-11

 Vermont

 H202     VT Single payer  Act128 Final

 Oregon

 SB99  Nevada  SB440
 North Carolina  NC Ins Info   NC BCBS  Arkansas  Governor's Advisory Committee
 Mississippi  Exchange Development Documents  MS Exchange History  Pennsylvania  Progress Update
 
 
 
State by State Exchange Status:
 
 State Run Exchanges - Pre PPACA  MA, UT  In Committee/House of Origin  NJ, PA
 Exchanges Established - Post PPACA  CA, CO, CT, HI, MD,
 NV, OR, VT, WA, WV
Dead for 2011
Session Adjourned
AK, AL, AR, AZ, DE, FL, GA,  IA, ID, IN, KS, KY, LA, MN, MO, MS, MT, NC, NE, NH, NY*, OK, RI, SC, SD, TN, TX
 Passed Both Houses /Vetoed By Gov.  NM

 No legislation Intro'd

 MI, OH, WI
 Exchange Analysis/Planning Law Passed  IL, ME, ND, VA, WY    
* NYS expected to return in September to take up HIE legislation
 
Exchange Legislation Status - Updated 8/17/2011
 

Exchange Legislation Status
(All bills would establish state exchange, with exception of IL, ME, NE,  VA and WY, which call for studies/recommendations)
Bold text =Passage by House or Senate; Signing or veto by Governor

 

Legislatures in states shaded in gray have adjourned for 2011

 

 

 

 

 

 

 

State

Bill Number

Status

Approximate Legislative Adjournment

Status of Exchange Bill(s)
(Link to legislation that has passed)

 

AK

SB70

 Referred to Finance Committee (3.23.11).

ADJOURNED FOR 2011, 4/17/2011

Dead for 2011 (legislature adjourned)

 

AL

HB 401

Pending Health Committee Action in House of origin (3.31.11).

ADJOURNED FOR 2011, 6/09/2011

Dead for 2011 (legislature adjourned)

 

AR1

SB880

Referred to Senate Committee on Public Health, Welfare & Labor (3.7.11).

ADJOURNED FOR 2011, 4/27/2011

Dead for 2011 (legislature adjourned)

 

AR2

HB2138

Engrossed in House 3.21.11.  Sent to Interim Joint Study Committee on Insurance & Commerce (3.31.11).

ADJOURNED FOR 2011, 4/27/2011

Dead for 2011 (legislature adjourned)

 

AZ1

HB2666

Passed Banking and Insurance Committee (2.9.11).  House Second Reading (2.10.11)

ADJOURNED FOR 2011, 4/20/2011

Dead for 2011 (legislature adjourned)

 

AZ2

SB1524

Referred to Committees on Banking & Insurance and Rules (2.2.11).

ADJOURNED FOR 2011, 4/20/2011

Dead for 2011 (legislature adjourned)

 

CA

Legislation establishing CA Health Benefits Exchange signed into law in October 2010.

9/9/2011

AB1602,

 

SB900

 

CO

SB200

Passed Senate (4.27.11). Amended version passed House (5.4.11).  House-passed version passed by Senate and sent to Governor (5.5.11).  Signed into law (6.1.11).

ADJOURNED FOR 2011, 5/11/2011

SB200

 

CT

SB921

Referred to House and Senate Committees on Finance, Revenue and Bonding (3.29.11).  Passed as amended, 23-13 (5.31.11). Passed House 108-30 (6.7.11).  Sent to Governor for signature.  Became Public Law (6.8.11)

6/8/2011

SB921

 

DE

N/A

6/30/2011

No exchange legislation introduced this session (legislature adjourned)

 

FL

N/A

ADJOURNED FOR 2011, 5/7/2011

No exchange legislation introduced this session (legislature adjourned)

 

GA

HB476

House Committee favorable reported (3.10.11). House withdrawn, recommitted to the Rules Committee (3.16.11).

ADJOURNED FOR 2011, 4/14/2011

Dead for 2011 (legislature adjourned)

 

HI

SB1348

Passed Senate as amended. (3.8.11). Passed House as amended (4.12.11).  Conference committee report passed House and Senate and sent to Governor (5.3.11).

ADJOURNED FOR 2011, 5/5/2011

SB1348

 

IA1

SF235

Introduced, referred to Commerce (2.16.11). Subcommittee (2.17.11).

ADJOURNED FOR 2011,
6/29/2011

Dead for 2011 (legislature adjourned)

 

IA2

SF480

Passed Senate (3.21.11). Referred to House Comm. on Human Resources (3.22.11). In Subcommittee (3.24.11).

 

ID

N/A

ADJOURNED FOR 2011, 4/8/2011

No exchange legislation introduced this session (legislature adjourned)

 

IL

HB1577

Passed House 108-8 (3.30.11).   Passed Senate (5.29.11).  Study committee report and legislative recommendations due by 12.31.11.

ADJOURNED FOR 2011, 5/30/2011

Exchange implementation analysis/plan required by 2011 law

 

IN

SB580

Referred to Committee on Health & Provider Services (1.20.11).

ADJOURNED FOR 2011, 4/29/2011

Dead for 2011 (legislature adjourned)

 

KS

N/A

ADJOURNED FOR 2011, 5/13/2011

No exchange legislation introduced this session (legislature adjourned)

 

KY

N/A

ADJOURNED FOR 2011, 3/9/2011

No exchange legislation introduced this session (legislature adjourned)

 

LA

N/A

ADJOURNED FOR 2011, 6/23/2011

No exchange legislation introduced this session (legislature adjourned)

 

MA

N/A

12/31/2011

Already operating state-run exchange (pre-PPACA)

 

MD

SB182

Passed Senate, 34-11 (3.28.11); Passed House, 106-29 (4.6.11).  Signed into law (4.12.11).

ADJOURNED FOR 2011, 4/11/2011

SB182

 

ME1

HP 1098
(LD 1497)

Referred to the Committee on Insurance and Financial Services.

ADJOURNED FOR 2011, 6/29/2011

Dead for 2011 (legislature adjourned)

 

ME2

HP 1165
(LD 1582)

Engrossed in House (6.7.11). Engrossed in Senate (6.7.11).  Finally passed in House (6.8.11).  Placed on Special Study Table Pending final passage in Senate (6.8.11).  Recommendations due to legislature and governor by 9.1.11 (PLANNING LAW ONLY)

Exchange implementation analysis/plan required by 2011 law

 

MI

N/A

12/31/2011

No exchange legislation introduced thus far

 

MN1

HF497

Referred to Health & Human Services Reform Committee (2.14.11).

ADJOURNED FOR 2011, 5/23/2011

Dead for 2011 (legislature adjourned)

 

MN2

SF917/HF1204

Referred to Commerce and Consumer Protection Committee (3.21.11).

Dead for 2011 (legislature adjourned)

 

MO

HB609

 Voted and reported do pass by Rules Comm. (4.4.11).

ADJOURNED FOR 2011, 5/13/2011

Dead for 2011 (legislature adjourned)

 

MS

H1220

Passed House 82-36 (2.7.11); Passed Senate as amended 49-0 (3.2.11).  Died in conference (3.28.11).

ADJOURNED FOR 2011, 4/7/2011

Dead for 2011 (legislature adjourned)

 

MT

HB124

Business & Labor Committee Hearing (2.1.11); Missed deadline for general bill transmittal (2.24.11).

ADJOURNED FOR 2011, 4/28/11

Dead for 2011 (legislature adjourned)

 

NC

HB115

Appropriations Comm. reported favorable Com. substitute (3.30.11). Re-referred to Comm. on Insurance (3.30.11).  Passed House, 83-34 (5.25.11.).

ADJOURNED FOR 2011, 6/19/2011

Dead for 2011 (legislature adjourned)

 

ND

HB1126

Passed House, 91-3 (2.22.11).  Amended and passed by Senate 36-10 (4.6.11).  Conference committee report passed by House 90-0 (4.22.11).  Conference committee report passed by Senate 31-15 (4.25.11).  Signed by Governor (5.9.11).

ADJOURNED FOR 2011, 4/28/11

Exchange implementation analysis/plan required by 2011 law

 

NE

LB240

Referred to Banking, Commerce & Insurance Committee (1.13.11). Notice of hearing for 2.14.11. (PLANNING LAW ONLY)

ADJOURNED FOR 2011, 5/20/2011

Dead for 2011 (legislature adjourned)

 

NH

SB163

Rereferred in Senate Commerce Committee (3.9.11).

ADJOURNED FOR 2011, 6/30/2011 (may return in September to take up vetoes)

Dead for 2011 (legislature adjourned)

 

NJ1

A3561

 Introduced, referred to Assembly Health and Senior Services Committee (12.6.10).  Identical to bill S1288.

1/12/2012

In committee in house of origin

 

NJ2

A1930

Reported from Assembly Committee as a substitute; 2nd reading (12.6.10). Referred to Assembly Health and Senior Services Committee (2.8.11).  Identical to S2553.

In committee in house of origin

 

NM

SB38

Passed Senate, 36-3 (3.2.11); Passed House, 34-31 (3.19.11).  Vetoed by Governor (4.8.11)

ADJOURNED FOR 2011, 3/19/2011

Passed both houses, vetoed by governor.  Dead for 2011 (legislature adjourned).

 

NV

SB440

Rerefered to Committee on Finance. (4.7.11).  Passed Senate, 23-0 (5.30.11).  Passed House, as amended, 38-0 (6.4.11).   Returned to Senate for concurrence.  Senate concurred and engrossed (6.6.11).  Signed into law by Governor (6.16.11).

ADJOURNED FOR 2011, 6/7/2011

SB440

 

NY2

A8514/
S5849

Introduced (6.23.11).  Passed Assembly (6.23.11).

REG. SESSION ADJOURNED FOR 2011,
6/24/2011

Passed in house of origin/Pending in other house. (A8514).  Regular session adjourned but legislature expected back in September 2011.

 

OH

N/A

12/31/2011

No exchange legislation introduced thus far

 

OK1

SB971

Introduced (4.27.22).  Referred to Joint Committee on Appropriations and Budget (5.2.11)

ADJOURNED FOR 2011, 5/27/2011

Dead for 2011 (legislature adjourned)

 

OK2

HB2130

House engrossed, 51-34 (3.21.11). 1st & 2nd reading in Senate - referred to Retirement & Insurance Committee (3.23.11).  Interim study committee named to develop recommendations on exchange establishment.

ADJOURNED FOR 2011, 5/27/2011

Dead for 2011 (legislature adjourned)

 

OR

S99

Public hearings held (2.17-2.24-3.3-3.10). Passed Senate 24-5 (4.25.11).  Passed House Committee on Health Care (6.1.11).  Passed House, 42-18 (6.6.11).   Signed into law by Governor (6.17.11)

6/30/2011

SB99

 

PA

H627

Referred to Insurance Committee (2.14.11).

12/31/2011

In committee in house of origin

 

RI

S87

Senate passed as amended (4.5.11). House Health, Education & Welfare Comm. Hearing schedule (4.13.11).

ADJOURNED FOR 2011, 6/30/2011

Dead for 2011 (legislature adjourned)

 

SC

H. 3738

Referred to Committee on Ways & Means (2.24.11).

6/2/2011

Dead for 2011 (legislature adjourned)

 

SD

N/A

ADJOURNED FOR 2011, 3/28/2011

No exchange legislation introduced (legislature adjourned)

 

TN

N/A

 

ADJOURNED FOR 2011, 5/21/2011

No exchange legislation introduced this session (legislature adjourned)

 

TX1

SB1586

Introduced (3.11.11).  Referred to Finance Committee (3.23.11).

REG. SESSION ADJOURNED FOR 2011, 5/30/2011

Dead for 2011 (legislature adjourned)

 

TX2

H636

Considered in public hearing; committee sustitute considered; testimony taken; left pending in committee (3.1.11).

 

UT

N/A

ADJOURNED FOR 2011, 3/10/2011

Already operating state-run exchange (pre-PPACA)

 

VA

HB2434

Passed House, 95-Y 3-N (2.3.11); Passed Senate, 37-Y 1-N (2.17.11); Governor's recommendation adopted (4.6.11). Task force report due by October 1, 2011.

ADJOURNED FOR 2011, 2/27/2011

Exchange implementation analysis/plan required by 2011 law

 

VT

H202

Passed House with amendments, sent to Senate (3.24.11).  Amended version passed Senate (4.29.11).  Conference committee report adopted 21-9 in Senate (5.3.11).  Report adopted 94-49 in House.  Sent to Governor (5.5.11).  Signed into law (5.26.11).

ADJOURNED FOR 2011, 5/6/2011

H202

 

WA

S5445

Passed Senate, 27-22 (3.2.11). Passed House as amended, 75-22.  Senate passed House version.  Sent to Governor (4.18.11).  Signed into law (5.11.11)

ADJOURNED FOR 2011, 4/24/2011.

S5445

 

WI

N/A

12/31/2011

No exchange legislation introduced thus far

 

WV

SB408

Passed Senate (2.28.11); Passed House, 63-35 (3.12.11). Signed into law (4.4.11).

ADJOURNED FOR 2011, 3/12/2011

SB408

 

WY

HB50

Passed House and Senate (3.3.11).  Signed into law (3.10.11).  Task force report due by December 1, 2011.

ADJOURNED FOR 2011, 3/3/2011

Exchange implementation analysis/plan required by 2011 law

 

 

 

 

 

 

 

 
 Consultant Observations:
 
 
 
There is immediate confusion when an “Exchange” is discussed.  Exchange can mean a “Health Information Exchange” or a “Health
Insurance Exchange.”  The two exchanges are dramatically different, but both are referred to as an “HIE”.  There are many private and
government variations, legal structures, and types of HIEs. 

 A.    Health Information Exchanges

           1.      Private Health Information Exchanges

 Private Health Information Exchanges (HInfoE) are web-based portals providing consumer health and health care information.  Private

HInfoEs (e.g. www.webMD.com) provide individuals and company health plans with medical and clinical education, treatment options, care
costs, provider quality metrics, repositories for personal medical records, and much more.  Others provide medical information and online
clinical care (e.g. www.mdlivecare.com).  

 

2.      Government Health Information Exchanges

 

Government Health Information Exchanges typically transmit healthcare-related data among facilities, health information organizations, and government agencies according to government (state or federal) standards.  The purpose of government HInfoEs is to improve healthcare delivery, information gathering, and transparency.   Georgia has a separate website for provider cost and quality information.  (e.g. http://georgiahealthinfo.gov/)  There are state coordination efforts for integrating multiple government HInfoEs. Georgia participates in a federal cooperative coordination effort. (e.g.http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&mode=2)

 

Government HInfoEs are an integral component of the health information technology (HIT) infrastructure under development in the United States and the associated National Health Information Network (NHIN). 

 

B.     Health Insurance Exchanges

         1.      Private Health Insurance Exchanges

 Private Health Insurance Exchanges (HInsE) are web-based portals focusing on consumer guidance and information for the private

purchase of health insurance.  Private market HInsEs (e.g. www.ehealthinsurance.com) serve as marketing sites for brokers/agents
selling commissioned products. Private HInsEs provide product descriptions and premium estimates.  Purchases can be made online or by
follow up meetings with an agent.  Both individual and small group products are sold through private HInsEs.

 Private sites may also provide information and guidance for those eligible for government insurance options.

(e.g. http://www.healthplanone.com/healthinsurance/georgia/). Some private sites exclusively market government insurance programs and
provide legal assistance for enrollment and eligibility. (http://www.usgovernmentbenefits.org/hd/index.php?t=medicaid+georgia+eligibility )

         2.      Government Health Insurance Exchanges

 Government HInsE’s can be used to identify individuals eligible for government programs such as Medicaid, High Risk Pool coverage,and Children’s Health Insurance Plans. (e.g. http://www.usgovernmentbenefits.org/hd/index.php?t=medicaid+georgia+eligibility)

 Government HInsE’s can be used to mandate private insurance, mandate coverage, provide premium subsidies, control plan designs, set premium levels (or require approval of rate increases), shift funds among carriers through risk adjusters, and establish state (e.g. Massachusetts

& Utah https://www.mahealthconnector.org/portal/site/connector/ ,  http://www.exchange.utah.gov/) or a nationwide insurance program (e.g. PPACA).
 
Deloitte HIE Observations 7-18-2011 
 
States will operate two exchanges: one for individual purchasers, and a second for small businesses (the Small Business Health Options Program [SHOP]). States may opt to govern the exchanges by one board, composed of knowledgeable health industry representatives; the voting majority cannot be made up of individuals licensed to sell health insurance. Otherwise, the two must be governed by separate boards and the state needs to ensure the SHOP will coordinate and share relevant information with the exchange. The day-to-day operations of the two may be integrated. In certain cases, an exchange may operate in two or more states, and a state is allowed to operate regional exchanges if it chooses.

Basic exchange functions

  • Enrollment and eligibility: an exchange must use a single streamlined application to determine eligibility and to collect information necessary for enrollment for: (1) QHPs, (2) premium tax credits, (3) cost-sharing reductions, and (4) Medicaid, the Children's Health Insurance Program (CHIP), or the Basic Health Plan (BHP). It must also manage the open enrollment periods for individuals (ex. Oct 15-December 7 is open enrollment) and a rolling enrollment process for the SHOP program.
  • Consumer support website: exchanges must operate websites that make it easy for consumers to compare between QHPs in terms of coverage, costs, and services.
  • Navigator program development and operational oversight: exchanges must award federal grants to support consumer assistance in selecting and using health insurance programs.
  • Payment of premiums: exchanges may (1) take no part in payment of premiums, (2) create an electronic “pass through” without directly retaining any payments, or (3) establish a process to collect premiums from enrollees and pay the QHP issuers.
  • Federal compliance: consistent with ACA, states will have responsibility for quality and performance reporting to HHS, and insurance premium increases of more than ten percent will be subject to review.

State responsibility for risk mitigation in implementing exchanges:
ACA established three risk-mitigation programs to offset market uncertainty and risk selection to maintain the viability of exchanges: (1) temporary reinsurance and (2) risk corridor programs, and (3) a permanent risk adjustment program. In the 103-page companion rule to the requirements for the health exchanges, the Centers for Medicare & Medicaid Services (CMS) outlined requirements for these programs intended to stabilize premiums and spread risk in the initial phases of exchange implementation.

Employer participation:
Employer size: until 2016, states can set eligibility thresholds at up to 50 or 100 employees. In 2017, states may allow employers with more than 100 employees to use SHOP.
Tax credits for certain small employers: starting in 2014, SHOP eligible employers are eligible for a tax credit of up to 50 percent of their premium payments if: (1) they have 25 or fewer employees, (2) their employees have an average annual wage of less than $50,000, (3) they offer all full-time employees coverage, and (4) they pay at least 50 percent of the employee premium.

Health plan participation:
QHPs: the exchange must certify a health plan is a QHP using criteria it develops to assure that the plans meet criteria for quality and affordability.

Yet to be determined with guidance forthcoming:

  • Specifics of federal reporting requirements by exchanges (e.g. quality and administrative performance, financial integrity)
  • Procedures for SHOP eligibility determinations, premium tax credits, cost-sharing reductions, benefit design standards for QHPs, including essential health benefits and calculations of actuarial value
  • Procedures for exemption from the individual mandate

Key dates:

  • September 28, 2011: proposed rules’ comment period ends
  • January 1, 2013: states must receive approval or conditional approval to implement their exchanges, or notify CMS it intends for the federal government to operate the exchange (existing exchanges as well as new exchanges)
  • January 1, 2014: exchanges begin operation
 Deloitte CO-OP Observations
7/18/2011

On July 17, 2011 the U.S. Department of Health and Human Services (HHS) published a proposed rule to set standards for establishing the Consumer Oriented and Operated Plan (CO-OP) program as required by the ACA, Section 1322. Highlights:

  • A CO-OP is a private, nonprofit organization that will offer qualified health plans (QHPs) through the health insurance exchanges beginning on January 1, 2014; CO-OPs will be subject to the same market rules as other health insurers.
  • CO-OP members must elect the board of directors, a majority of whom must be enrolled in the CO-OP health plan.
  • CO-OP profits must be used to lower premiums, improve health benefits and quality of care, expand enrollment, or otherwise contribute to the stability of coverage for members.

HHS will offer $3.8 billion to states for start-up costs (to be repaid in five years), loans to enable financially viable CO-OPs to meet state insurance solvency, and reserve requirements (to be repaid in 15 years with interest) and require at least one CO-OP in every state.

Ċ
Ron Bachman,
Jul 25, 2011, 11:33 AM
Ċ
Ron Bachman,
Jul 13, 2011, 5:10 PM
ĉ
Ron Bachman,
Jul 26, 2011, 6:06 AM
Ċ
Ron Bachman,
Jun 26, 2011, 10:08 AM
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