What Is Your State Doing to Affect Access to Adequate Health Insurance?
Select a state on the map and an action above to learn what the individual insurance market stabilization strategies states may be pursuing.
Notes: Section 1332 of the ACA authorizes states to apply to waive specified provisions of the health law to facilitate state-specific programs for improving coverage. If a state's "innovation waiver" program is forecast to reduce federal spending, the state is entitled to have these savings passed through to it for purposes of implementing the program. The states identified in this table have secured, or are seeking, approval for innovation waivers that use these federal "pass-through" funds to partially finance the state's reinsurance program.
*Program funding and projected premium effects data are estimates and come from the states' Section 1332 waiver applications.
**For states with an approved waiver for which pass-through funding levels have been announced by the federal government, the federal share of program funding equals the federal pass-through funding for the year identified, as calculated by the federal government, divided by the total program funding, as estimated in the state's waiver application. For these states, the state share of funding equals the difference of total program funding and federal funding. For states with a pending waiver application, or with an approved application for which pass-through funding levels have not yet been announced, the respective funding shares are derived from information provided in the state's waiver application.
***State reinsurance programs typically are designed following one of two broad models. A "condition-specific" reinsurance program covers some or all of an insurer's claims costs that have been incurred by enrollees diagnosed with one more specified high-cost health conditions. An "attachment point" reinsurance program covers some or all of an insurer's claims costs that exceed a specified threshold, or attachment point, regardless of the type of claim.
Note: The ACA requires most individuals to maintain "minimum essential" health coverage or pay a tax penalty (the individual mandate). Recent changes in federal law, effective in 2019, reduce this tax penalty to $0, but do not repeal the underlying requirement to maintain coverage. This graphic identifies states that require residents to maintain adequate health coverage -- whether or not the state imposes a penalty on individuals who fail to do so -- notwithstanding the elimination of the federal tax penalty.
Note: The ACA provides federal subsidies to reduce the cost of individual market health insurance for eligible individuals. Premium tax credits are available to otherwise eligible individuals with household income between 100% and 400% of the federal poverty level (FPL) who enroll in coverage through an ACA marketplace, and cost-sharing subsidies are available to such individuals with incomes between 100% and 250% FPL who enroll in a silver tier plan. This table identifies states that make available separate, state-funded subsidies to defray the cost of ACA-compliant individual market health coverage: for example, an additional premium subsidy for individuals receiving federal premium tax credits, or a subsidy for individual market consumers whose incomes render them ineligible for federal coverage assistance.
Notes: Short-term policies are not subject to the federal consumer protections of the ACA. Under federal regulations finalized in August 2018, short-term policies may provide coverage for a period of 364 days and may be renewed, at the discretion of the insurance company, for up to 36 months. This table identifies states that, by limiting the maximum duration of short-term coverage to less than 364 days, or by applying state law consumer protections to such coverage, impose limitations on the sale of short-term plans than are more strict than those mandated under the default federal approach.
*The states identified entirely prohibit short-term coverage or bar short-term insurers from discriminating on the basis of an applicant's health status.
**A state is identified as having limited the initial contract duration of underwritten short-term coverage to less than 364 days if a short-term plan lasting longer than the specified duration would become subject to one or more of the following state consumer protections: guaranteed issue, guaranteed renewability, or required coverage of essential health benefits. Such states typically impose limitations on the renewal of short-term policies, but, in most cases, do not prohibit insurers from issuing multiple new short-term policies consecutively.
***A state is identified as having limited the total length of time a consumer may be enrolled in underwritten short-term coverage to less than 364 days if it prohibits the issuance of multiple short-term policies consecutively, closing a loophole that otherwise may permit continuous enrollment in such plans.
†Connecticut makes consecutive short-term policies subject to certain preexisting condition coverage requirements.
††Hawaii also prohibits the issuance of a short-term policy to an individual who was eligible to purchase coverage through the ACA marketplace during an open or special enrollment period in the previous calendar year.
†††California prohibits the issuance of any health insurance policy with a duration of less than 12 months.
‡Virginia prohibits the issuance of a short-term policy during the annual open enrollment period; Washington also prohibits the issuance of a short-term policy during the annual open enrollment period, for coverage beginning in the upcoming year.
‡‡Delaware prohibits insurers from (1) issuing the same short-term policy to an enrollee for successive back-to-back terms; and (2) from issuing a different short-term policy to the same individual more than once in any given year.
Notes: The Trump administration reduced the annual open enrollment period (OEP) for the ACA marketplaces from 90 days to 45 days, beginning with the OEP for 2018 coverage. Eligible individuals who sought to enroll in marketplace coverage for 2018 in states that used HealthCare.gov had to do so between November 1 and December 15, 2017. By contrast, the states that operated their own ACA marketplace enrollment websites could choose to provide a longer OEP. The 45-day (November 1 - December 15) enrollment window remained the federal default for the 2019, 2020, and 2021 OEPs. For the 2022 OEP and beyond, the Biden administration established a 75-day enrollment window, running from November 1 through January 15, for the states that use HealthCare.gov. Under the Biden administration policy, state marketplaces that operate their own enrollment websites can opt for a different enrollment window, provided it ends no earlier than December 15.
The map identifies the states that adopted an OEP that was longer than the federal default and specifies the dates of states’ OEPs, to the extent they varied from the OEP applicable to HealthCare.gov. While, as a formal matter, some states effectuated their enrollment extensions by establishing a broadly available special enrollment period (SEP) beginning on the day following the end of the federal default open enrollment window, the map identifies all states that, as a matter of practice, have offered a continuous, broadly available enrollment period for next-year coverage that is longer than 45 days.
*For the 2020, 2021, and 2022 enrollment periods, the map includes state decisions, in response to the COVID-19 pandemic, to reopen the marketplace to enrollment by the uninsured. The end dates specified for these enrollment windows indicate the last day by which a consumer could sign up for coverage that would take effect in the current year.
**In response to the COVID-19 pandemic, the federal government exercised its authority to reopen HealthCare.gov for 2021 coverage. (Since the state uses the federal marketplace, it lacks authority to make this decision itself.)
Note: This graphic identifies states that have adopted certain specific actions intended to promote a competitive ACA marketplace. In particular, only those states that: (1) have merged their individual and small-group markets; (2) require that all individual market coverage be sold through the ACA marketplace; or (3) leverage insurers’ participation in state public health insurance programs, such as Medicaid, or state insurance markets to encourage or require participation in the ACA marketplace. Other factors and state actions not identified here also may affect the competitiveness of a state's ACA marketplace.
Note: States may adopt a program, such as a "public option" or "Medicaid buy-in," which offers individual market consumers the option of enrolling in coverage that is sponsored and/or administered by the state. Under Section 1331 of the ACA, states may also establish a Basic Health Program (BHP) for individuals with incomes up to 200% of the federal poverty level who would otherwise be eligible for individual market coverage. The BHP, which is funded by a combination of state and federal dollars, must provide coverage that is at least as comprehensive and affordable as subsidized ACA marketplace coverage. This table identifies states that have established a public option, Medicaid buy-in, or other similar program, or that operate a BHP. The table does not include state actions related to the ACA's Medicaid expansion.
Note: The ACA requires all individual market health plans to cover broadly similar benefits, adhere to overall limits on cost-sharing, and fall within standard actuarial value tiers. This table identifies states that also require participating individual market insurers to offer plans that incorporate standardized cost-sharing parameters, such as uniform deductibles and co-payments for certain services.
Note: Transitional policies are those that were issued following the ACA’s enactment in 2010 but before 2014. These policies, also known as “grandmothered plans,” are required to meet some, but not all, of the ACA’s individual market consumer protections. In states where transitional policies are allowed, insurers may choose whether to continue to offer such policies. In some states, transitional policies may no longer exist in the individual market, even though permitted under state law.
*Table reflects state decisions as of December 31, 2018; such decisions govern transitional policies renewed on or before October 1, 2019. State decisions regarding transitional policies renewed after October 1, 2019 are not reflected in this table.
Note: *The table identifies states that have established rules exempting certain health coverage products from federal and state insurance regulation. These rules tend to encourage market segmentation and a deterioration of the ACA-compliant risk pool, thereby making comprehensive individual market coverage less affordable and accessible. States may have taken other actions that are likely to decrease access to affordable and adequate individual market coverage that are not identified in this table. For example, this table does not include state actions that may encourage the sale of, or broaden access to the following forms of coverage, which are not fully compliant with federal rules governing the individual market: short-term, limited duration insurance; association health plans that meet the definition of a large-group plan under federal law; transitional, or "grandmothered" health plans; or coverage arrangements offered by a health care sharing ministry.
J. Giovannelli, K. Lucia, and S. Corlette, "To Understand How Consumers Are Faring in the Individual Health Insurance Markets, Watch the States," To the Point (blog), Commonwealth Fund, July 18, 2018.
Justin Giovannelli, Associate Research Professor, Center on Health Insurance Reforms, Health Policy Institute, McCourt School of Public Policy, Georgetown University[email protected]