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Update: 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 about five months, the major health insurance provisions of the Affordable Care Act will go into effect. This is the third post in a series that offers an overview of action on the new state health insurance marketplaces, or exchanges, and expansion in eligibility for the Medicaid program.

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 the federal poverty level ($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

  • An audit of California’s marketplace, Covered California, found it is on track for open enrollment to begin this fall. 
  • California's exchange has approved six insurers to sell plans on the small business marketplace. They are Blue Shield of California, Chinese Community Health Plan, HealthNet, Kaiser Permanente, Sharp Health Plan, and Western Health Advantage. 
  • California may spend more than $300 million to support enrollment outreach and education. About $174 million will come from federal funds and about $130 will come from the California Endowment. 
    • Covered California announced $3 million in grant funds for education outreach
    • Covered California, in partnership with the private Sierra Health Foundation, has granted $1.5 million to three organizations to promote consumer outreach. The recipients are: California Family Resource Association, Healthy Community Forum for the Greater Sacramento Region, and Women’s Health Specialists. 
  • Four insurers have submitted plans for approval to be sold in Connecticut’s individual marketplace. After reviewing new data suggesting enrollees will be healthier than originally thought, HealthyCT, a new plan, recently resubmitted its proposal with lower rates, with the average single plan costing $271 per month. These rates are not yet final and are still under review. The three other insurers that will submit plans are: Aetna, Anthem Blue Cross Blue Shield (BCBS), and ConnectiCare. HealthyCT, Anthem BCBS, and United Healthcare have submitted plans for review to be sold in the small-group exchange.
    • ConnectiCare originally submitted plans to be sold in the small-group exchange as well, but has since withdrawn the submission, although it may sell in the small-group exchange in the future. 
  • Washington, D.C., awarded a contract to MAXIMUS to run a call center for its marketplace.
  • Three insurers, Aetna, CareFirst, Kaiser, and United, have been approved to sell plan on D.C.’s individual marketplace. The average silver plan premium for a 40-year-old ranges from $247–$312 per month. 
    • Following United HealthCare and Aetna, Kaiser is the third insurer to drop premium rates for small-business plans sold through D.C.’s marketplace
  • Maryland released approved 2014 rates for its individual marketplace. According to the press release, some rates have dropped by as much as one-third. Nine insurers have been approved to sell on the exchange: Aetna, All Savers, BlueChoice, Care First of Maryland, Inc., Coventry Health and Life Insurance, Coventry Health Care of Delaware, Evergreen, Group Hospitalization and Medical Services, and Kaiser Foundation Health Plan of the Mid-Atlantic.
  • Massachusetts awarded $1.14 million in navigator grants to 11 organizations. 
  • In Detroit, Michigan, city officials are considering moving pre-Medicare retirees into the marketplace to save money.
  • In Nevadafour insurers, Health Plan of Nevada, Anthem, Saint Mary's, and Nevada Health CO-OP, have submitted plans to be sold through the marketplace. Proposed rates, which are currently under review, vary by geographic region, as in other states.
  • Organizations in Oregon have until August 9 to apply for $750,000 in grants to educate small businesses about the exchange and enrollment. 
  • Vermont’s governor plans to have a financing plan for Green Mountain Care, a single-payer system, in front of the state legislature by January 2015. 
  • Four insurers have been approved to sell plan's on Washington's individual marketplace. They are: Bridgespan, Group Health Cooperative, Lifewise, and Premera BlueCross. 

Action on federally facilitated and partnership marketplaces:

  • The online broker eHealthInsurance will be allowed to enroll individuals in federally facilitated marketplaces.
  • In Alabama, BCBS and UnitedHealthcare have applied to sell plans on the federally facilitated exchange in all counties in the state. Humana has applied to sell plans in 50 of the 67 counties. 
  • Delaware has contracted with four community organizations, Brandywine Women’s Health Associates, Christiana Care, Delmarva Foundation, and Westside Family Healthcare, to support outreach and enrollment activities
  • In Florida, 11 insurers have applied to sell plans in the individual marketplace and five have applied to sell plans in the small-business marketplace. Cigna and Florida Blue are two of the plans applying to sell in the individual marketplace.
  • See a list of awards granted to 44 in-person counselor programs in Illinois
  • Sarah Kliff explains how an average premium price quoted by Indiana for plans sold through the marketplace in 2014 may not be illustrative of what consumers can expect to pay
  • Anthem BCBS and Maine Community Health Options (CO-OP) have been approved by Maine to sell plans on the state’s marketplace. Anthem recently formed a partnership with the Maine Health Network (a network of hospitals and providers) that was approved by the insurance department. 
    • Maine Community Health Options has applied to sell seven plans on the individual marketplace and five on the small-business exchange. Anthem has applied to sell 20 on the individual marketplace; information about plans to be sold on the small-business exchange has not been released. 
  • Humana became the first company to offer individual plans in 36 counties in Mississippi though the federally facilitated marketplace. 
  • Unitedhealthcare, Cigna, and Assurant Health have declined to sell plans in Missouri’s federally facilitated marketplace in 2014. 
  • North Carolina has approved three insurers, Blue Cross and Blue Shield of North Carolina, Coventry Health Care of the Carolinas, and FirstCarolinaCare, to sell in the federally facilitated marketplace. BCBS of North Carolina has also applied to sell in the small-business exchange. 
  • South Dakota has approved three insurers, Avera Health Plans, Sanford Health Plan, and DAKOTACARE, to sell plans in the individual marketplace and federally facilitated small-business marketplace
  • The New York Times reports on what community organizations in Texas are doing to educate Texans about the federally facilitated marketplace. 

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, forgoing the influx of new federal funds, but still maintain its traditional Medicaid program.

As of August 2, 2013, 22 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; 21 states have indicated they will not participate; and four states remain undecided.

These updates highlight recent state-level action.

  • Idaho Health and Welfare office is trying to prepare for a Medicaid expansion should one pass through the legislature, talking with private insurers about plans that they might offer a Medicaid-eligible population. 
  • The governor of Illinois signed the Medicaid expansion bill into law
  • The Iowa Health and Wellness Plan, which expands Medicaid and uses some federal funds to pay for premiums for some people in the state exchange, will be submitted for official approval by the federal government by August 20. 
  • An op-ed by Louisiana’s governor lays out his opposition to Medicaid expansion. 
  • In Michigan, a Senate workgroup builds on the Medicaid expansion legislation passed by the House, adding additional reforms to the expansion. 
  • New Hampshire is awaiting recommendations from a commission, due in October, on whether to expand Medicaid
    • The commission is also looking into moving some newly eligible people to the marketplace.

Latest Federal Rules, Notices, and Guidance on Affordable Care Act Implementation


Publication Details



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