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State Action Round-Up on Affordable Care Act Implementation

  • Tracy Garber

    Senior Analyst, Manatt Health Solutions

  • Sara Collins
    Sara R. Collins

    Senior Scholar, Vice President, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund

  • Tracy Garber

    Senior Analyst, Manatt Health Solutions

  • Sara Collins
    Sara R. Collins

    Senior Scholar, Vice President, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund

In just six months, the major health insurance provisions of the Affordable Care Act will go into effect. To keep you up-to-date on implementation, today we are launching a series of posts that will provide an overview of action on the new state health insurance marketplaces, or exchanges, and expansion in eligibility for the Medicaid program. The Commonwealth Fund will publish new posts in the series as states decide whether to participate in Medicaid expansion and as the state insurance marketplaces take shape across the country.

Insurance Marketplace Updates

Beginning on October 1, 2013, Americans who do not have affordable health benefits through a job will be able to go to a new health insurance marketplace in their state and enroll in a private health plan. Adults with annual incomes up to 400 percent of poverty ($45,960 for an individual and $94,200 for a family of four) will be eligible for premium tax credits to help reduce the cost of coverage. In most states, companies with 50 or fewer employees will also be able to select plans through their state’s small-business marketplaces.

Currently, 16 states and the District of Columbia intend to operate a state-based marketplace, while the remaining 34 states will have a federally facilitated marketplace. Seven of these 34 states will conduct plan management activities and/or consumer assistance and outreach functions in a state–federal partnership model. Another seven of the 34 will conduct plan management activities only, and one, Utah, will operate the small-business marketplace while the federal government operates the individual marketplace.

Here is a list of recent state and federal activity.

Action on state-based marketplaces:

  • In Minnesota, a call center to help people enroll will open on September 3, 2013. Over 600 applications have been sent in for the initial 35 jobs.
    • Minnesota also released a bulletin with guidance on services that consumer assistance partners are allowed to provide:
  • Colorado announced 58 organizations as part of its consumer assistance network to help people enroll in the state marketplace and awarded $17 million to the organizations.
  • Based on plans submitted by May 15, a silver plan for an individual in Colorado would have a premium ranging from $232 to $837.
  • California's insurance commissioner recommended excluding Anthem Blue Cross from the state’s small-business marketplace, citing three rate hikes in the past seven months that he deems excessive.
    • Aetna will not offer individual plans in California in 2014, nor is it one of 13 carriers that have been approved to sell in the California marketplace (subscription required).
    • UnitedHealth Group will also not offer individual coverage in California next year. UnitedHealth is the country’s largest insurer.
    • California has included acupuncture as an essential benefit, leading some acupuncturists to expect an increase in patients.
  • Insurers have submitted proposed rates to Connecticut; they are currently under review.
  • According to Politico Pro, two insurers have applied to sell on Vermont’s marketplace: Blue Cross Blue Shield of Vermont and MVP Health Plan (subscription required).
  • Washington’s exchange issued a request for proposals for in-person assister outreach partners. Total awards will not exceed $750,000 and proposals are due by August 19, 2013.
  • Oregon state regulators cut insurers proposed premium rates
  • Rhode Island released its final 2014 premium rates. Almost all are down from the proposed rates submitted earlier.

Action on federally facilitated and partnership marketplaces:

  • So far in Mississippione insurer has applied to sell through the marketplace (6/13/2013).
    • In 36 of Mississippi’s 82 counties, no insurer has yet applied to offer coverage through the marketplace.
  • Delaware began receiving applications for insurers to sell through its marketplace on May 30; it will send its recommendations for certification to the Centers for Medicare and Medicaid Services by July 31.
  •  In Iowa, six insurers have applied to offer plans through the marketplace. They are: Coventry Health Care of Iowa, Inc.; CoOportunity Health; Avera Health Plans; Gunderson Health Plan, Inc.; Sanford Health; and Health Alliance Midwest, Inc.

Medicaid Expansion Updates

The Affordable Care Act set a new income eligibility floor for Medicaid, expanding the program to cover all legal U.S. residents beginning in 2014 with incomes up to 138 percent of the federal poverty level ($15,856 for an individual and $32,499 for a family of four).
In June 2012 the Supreme Court ruled that states’ participation in the Medicaid expansion was optional. A state may choose not to participate, foregoing the influx of new federal funds, but still maintain its traditional Medicaid program.

As of July 3, 23 states and the District of Columbia have indicated that they intend to expand Medicaid as it was written in the law; three states are pursuing or expressed an interest in a variation on the expansion; 19 states have indicated they will not participate; and five states remain undecided.

These updates highlight recent state-level action.

  • Iowa’s governor signed legislation on June 20, 2013 that expands Medicaid. Under the “Iowa Health and Wellness Plan,” the state intends to use some of the federal funds to pay premiums for people to get coverage through the exchanges. The federal government has not yet officially approved Iowa’s plan, which is similar to the Arkansas plan.
  • Arkansas made available a draft waiver request for private coverage of its Medicaid expansion population.
  • New Jersey legislature passed SB2644, a Medicaid expansion bill. The bill now goes to the governor to sign. 
  • Maine's House of Representatives passed a bill (97–51) that would expand Medicaid for three years. The Senate passed the same bill (23–12). Both houses fell a few votes shy of the number needed to prevent an anticipated veto from the governor.
    • The governor vetoed the bill on June 17, 2013. 
    • House Democrats in Maine tried to override the governor’s veto of the expansion bill that passed the legislature, but fell short by three votes. This means Maine will most likely not participate in the expansion, at least in 2014.
  • Michigan’s House of Representatives passed a bill on June 13, 2013 that would expand Medicaid but impose cost-sharing requirements for those enrolled for more than 48 months.
    • The legislature adjourned on June 20, 2013 before the Senate voted on the Medicaid expansion. The legislature meets year-round so the governor is still optimistic about passing expansion. The governor has said he will not call a special session during the summer break to address Medicaid expansion.
  • The Arizona legislature passed a state budget including the state’s Medicaid expansion on June 13, 2013 and the governor signed the expansion into law.
  • Medicaid expansion officially passed through the California legislature and was signed into law by the governor. 
  • Montana's governor may call a special session for Medicaid expansion.
  • Five Democratic legislators in Pennsylvania sent a letter to the governor urging him to reconsider participating in Medicaid expansion  (subscription required).
    • Pennsylvania’s Senate passed a bill that included a Medicaid expansion provision. The House removed the expansion provision from the bill and sent it back to the Senate, which can either reinsert the provision or wait until the legislature meets in the fall. 
  • Mississippi’s governor called a special session on June 27, 2013, to address the reauthorization of Medicaid in the state. The legislature renewed the current Medicaid program but did not vote on expansion.

Latest Federal Rules and Regulations on Affordable Care Act Implementation

Sources for this blog post include: Politico Pro, CQ Healthbeat, KidsWell Weekly Update, California Healthline, RWJ News Digest, Kaiser Daily Health Policy Report, and other news sources.

Publication Details



T. Garber and S. R. Collins, State Action Round-Up on Affordable Care Act Implementation, The Commonwealth Fund Blog, July 2013.