Obamacare in Wisconsin

Health Insurance Marketplace in Wisconsin

If you live in Wisconsin, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014.

Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Wisconsin has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Wisconsin’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Consumer Operated and Oriented Plan Program

Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets.  CO-OP in Wisconsin:

Common Ground Healthcare Cooperative

 Who can help you (the Navigators)

Get local help

Partners for Community Development, Inc.

Partners for Community Development will facilitate the enrollment of the uninsured with emphasis on reaching out to Hispanic and Hmong families and other hard-to-reach eligible consumers in Door, Kewaunee, Manitowoc, Ozaukee, and Sheboygan Counties in Wisconsin. It will focus outreach and enrollment efforts in its service area on hard-to-reach consumers and families with limited English proficiency.

Northwest Wisconsin Concentrated Employment Program, Inc.

The Northwest Wisconsin Concentrated Employment Program will help lead a Navigator project in their region to promote accessibility to health insurance Marketplace and the health care system in Wisconsin. The cooperative agreement will be used to provide Marketplace Navigator services at 21 Wisconsin Job Centers without reach provided at libraries, Senior Centers and college campuses by existing staff that have experience working with diverse populations.

Legal Action of Wisconsin, Inc./SeniorLAW

SeniorLAW is a community and consumer-focused nonprofit located in Milwaukee that provides a variety of services to individuals age 60 or over, mostly related to health insurance and public benefits. This group will conduct outreach to the 60-64 population in Wisconsin, using community education, client contacts and agency relationships that SeniorLAW has established throughout Southeastern Wisconsin.

National Council of Urban Indian Health

National Council of Urban Indian Health is the only national, membership-based organization dedicated to outreach and education on behalf of Urban Indian Health. It provides training, technical assistance, outreach, and education to Urban Indian Health Programs.

National Healthy Start Association

The National Healthy Start Association is a non-profit organization that works to improve birth outcomes and health disparities across the country through the federal Healthy Start programs. They will reach out to the uninsured population and provide education and assistance services for Marketplace enrollment.

R&B Receivables Management Corporation DBA R&B Solutions
Anticipated grant amount: $104,520
R&B Receivables Management Corporation currently works to connect uninsured and underinsured individuals with coverage options to help them afford health care. They will expand their services to connect with a broader range of underserved populations, and leverage their experience screening people for eligibility for medical assistance programs to connect people with coverage.

Who you can contact for more help

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know  with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in Wisconsin

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Wisconsin

On November 16, 2012, Governor Scott Walker (R) notified federal officials that Wisconsin would default to a federally-facilitated health insurance exchange.1 After initial efforts to develop a state-based health insurance exchange, Governor Walker announced in July 2012, he would not take any action to implement federal health reform until after the November elections.2

In 2011, Walker had issued an executive order to create the Office of Free Market Health Care to develop a plan for a Wisconsin health benefit exchange; however, almost a year later he closed the Office.3,4 Exchange establishment legislation failed to pass at the end of the 2012 legislative session. Prior to closing, the Office of Free Market Health Care had been seeking subcontractor assistance with the state’s marketing and outreach strategy and had completed actuarial and economic analyses to determine next steps in designing an exchange.5

Under former-Governor Jim Doyle (D), Wisconsin’s Department of Health Services had investigated the information technology necessary for a state-run exchange and based on insight from over 40 healthcare stakeholders, created an exchange prototype to simulate eligibility determinations and the consumer enrollment process. The prototype was launched in December 2010, with much of the functionality required of an exchange website.

On April 5, 2012, Governor Walker signed into law SB 92, a bill prohibiting plans in a state exchange from offering abortion coverage, except in cases of rape, incest, or to avert severe physical impairment or death of the pregnant woman.6

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since Wisconsin has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, United- Choice Plus, POS.

Exchange Funding

The Wisconsin Department of Health Services received a federal Exchange Planning grant of $1 million in September 2010 and a federal Early Innovator grant of $37.7 million in February. Wisconsin planned to use the Early Innovator grant to refine their exchange prototype into a single portal through which residents could access subsidized and non-subsidized health care and other state-based programs.7 In January 2012, the Governor announced the state would be returning the Early Innovator grant funding.8

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Wisconsin will not participate in Medicaid expansion.

Next Steps

The federal government will assume full responsibility for running a health insurance exchange in Wisconsin beginning in 2014.


1. Scott Walker Office of the Governor. Letter to Secretary Sebelius. November 16, 2012.http://www.walker.wi.gov/Documents/11.16.12%20Letter%20to%20Secretary%20Sebelius.pdf
2. Governor Scott Walker. Governor Walker’s Reaction to the US Supreme Court Ruling on ObamaCare, June 28, 2012. http://www.wisgov.state.wi.us/Default.aspx?Page=8533b724-db36-4bce-9b24-3b408bfe3206.
3. Wisconsin Executive Order #10. January 27, 2011. http://www.wisgov.state.wi.us/journal_media_detail.asp?locid=177&prid=5649
4. Wisconsin Executive Order #57:http://docs.legis.wisconsin.gov/code/executive_orders/2011_scott_walker/2012-57
5. Office of Free Market Health Care. Office of Free Market Health Care Releases Report on Impacts of Patient Protection and Affordable Care Act (PPACA), August, 24,2011.http://www.iiaw.com/index.php?module=cms&folder=16&cmd=cmsproxy&filename=files/0824freemarket.pdf
6. SB 92. 2012 Legislative session. Enacted April 5, 2012.http://docs.legis.wisconsin.gov/2011/related/acts/218
7. Early Innovator Grant Awards. HHS announcement. February 16, 2011.http://www.healthcare.gov/news/factsheets/exchanges02162011a.html (Accessed August 23, 2011)
8. Office of the Governor Press Release. “Governor Walker Turns Down Obamacare Funding.” January 18, 2012. http://165.189.60.210/Default.aspx?Page=84c6be7e-6bf7-47bb-949a-7330dd644579

Also of interest

Provided by the Henry J. Kaiser Family Foundation

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Obamacare in West Virginia

Health Insurance Marketplace in West Virginia

If you live in West Virginia, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014.

Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

West Virginia will expand its Medicaid program in 2014 to cover households with incomes up to 133% of the federal poverty level. That works out to about $15,800 a year for 1 person or $32,500 for a family of 4. You can find out whether you qualify for Medicaid in West Virginia 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Who can help you (the Navigators)

Get local help

Advanced Patient Advocacy, LLC

For nearly 14 years, Advanced Patient Advocacy has partnered with health care providers and state and local governments in 21 states to provide services to communities to help educate and enroll uninsured consumers. Advanced Patient Advocacy will work with medical centers to identify uninsured individuals and provide education and assistance to help them make informed decisions about enrollment in the Marketplaces.

West Virginia Parent Training and Information, Inc.

West Virginia Parent Training and Information, Inc. will provide public education about health insurance options, and facilitate enrollment in the new health insurance marketplaces. The effort will include outreach to people with disabilities, people with limited English proficiency and/or limited literacy, people of low socioeconomic status, and people in rural areas.

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know  with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in West Virginia

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in West Virginia

On February 15, 2013, Governor Earl Ray Tomblin (D) submitted a blueprint to Secretary Sebelius for West Virginia to establish a state-partnership exchange with plan management responsibilities.1 In the previous year, Governor Tomblin had signed SB 408 into law to establish the West Virginia Health Benefits Exchange and the state had begun exploring implementation options for a state-based exchange.2 However, concerns over the sustainability of a state-run exchange led the Governor to pursue a partnership exchange instead.

Prior to the decision to pursue a partnership exchange, the Health Policy Division, within the Office of the Insurance Commissioner (OIC), led the exchange planning initiative. In January 2012, the OIC released a business plan which documented an approach to implementing the Exchange.3 In addition, the OIC held a series of public engagement meetings throughout the state and met regularly with stakeholder groups to focus on exchange implementation issues related to carriers, consumers, producers, and providers.

Contracting with Plans: In April, 2013 the West Virginia Offices of the Insurance Commissioner (OIC) released a Qualified Health Plan Submission Guide to provide guidance to health insurance issuers regarding the certification standards for individual and SHOP Qualified Health Plans (QHPs) offered through the Exchange. OIC expects issuers to submit QHPs April 1 – May 31 of 2013, and will review submissions and recommend QHPs to the Department of Health and Human Services (HHS) April 1 – July 31 of 2013. OIC expects issuers to enter into certification agreements with HHS in August 2013.

Rates may vary based on tobacco use, family composition, age, and geography. West Virginia will use eleven geographic rating areas. Issuers must submit rate information to the Exchange on an annual basis, and the OIC will review rates for compliance with rating standards.4

Acting as a clearinghouse, OIC will accept plans that meet federal and state certification criteria. The State has partnered with the West Virginia School of Osteopathic Medicine to develop a strategy to maximize and report on provider quality in the Exchange, such as through measurement and reporting, purchasing, and engaging consumers through better information.

Risk Adjustment, Reinsurance, and Risk Corridors: In 2011, the West Virginia legislature passed HB 2745 to develop an all-payer claims database and the state expects to begin collecting data in 2013.5 This database will provide the baseline information to create a risk adjustment program, as well as to provide outcome quality data and enable analyses of exchange policy initiatives. Governor Tomblin noted in his letter of intent to establish a state-partnership exchange that West Virginia does not intend to operate a reinsurance program in 2014.6

Consumer Assistance and Outreach: The federal government will administer the state’s Navigator program, while the West Virginia OIC will oversee an In-Person-Assister (IPA) program.1 CMS has allocated $600,000 for the Navigator program in West Virginia.7 Navigator entity applications were due on June 7, 2013 and grantees will be notified by the federal government on August 15.8

The state selected an In-Person Technical Assistance contractor in July 2013 to help select IPA entities that will operate around the state.9 IPAs will focus on assisting vulnerable and underserved populations in the individual private and public markets. They will likely receive training in the small group market as well, to assist individuals that do not have an agent-consumer relationship. The state plans to have IPAs meet the same training, privacy and security, and conflict of interest standards as outlined in federal guidance on Navigators. The state currently estimates a need of 270 IPAs during open enrollment, and approximately 30 IPAs during non-peak periods. IPA entities will be selected in June and trained and certified in August of 2013. Outreach efforts will be conducted in August-September 2013. West Virginia will rely on the federal government for mass marketing and branding of the marketplace. The IPA vendor may perform some marketing at the local level.10

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since West Virginia did not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Highmark (Blue Cross Blue Shield of West Virginia)- Super Blue Plus 2000 PPO.

Exchange Funding

The West Virginia Office of the Insurance Commissioner received a federal Exchange Planning grant of $1 million in September 2010 and a federal Level One Establishment grant of $9.7 million in August 2011. The Establishment grant will be used to study consumer quality and effectiveness, complete economic modeling, and investigate risk adjustment strategies and policy integration with state agencies.In July 2013, West Virginia received a second Level One Establishment grant for $10.2 million to support the IPA program and plan management activities.11 The state requested and received a No Cost Extension for the Establishment grant, in part due to the delay of the release of an RFP for an actuarial assessment and economic model of the Exchange.12

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

West Virginia will participate in Medicaid expansion.

Next Steps

On March 5, 2013, West Virginia received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-partnership exchange.13 Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time and complying with future guidance and regulations.

Additional information about the West Virginia Exchange can be found at: http://healthbenefitexchangewv.com

Footnotes

  1. State of West Virginia, Offices of the Insurance Commissioner, Health Policy Division. “Blueprint Section 4: Plan Management.”← Return to text
  2. SB 408/HB 3018 (Chapter 100). West Virginia Health Benefit Exchange Act.← Return to text
  3. West Virginia, Offices of the Insurance Commissioner, Health Benefits Exchange. “Business Plan, Version 1.2.” January 19, 2012.← Return to text
  4. West Virginia Offices of the Insurance Commissioner. Qualified Health Plan Submission Guide. Aparil 2013.← Return to text
  5. HB 2745. West Virginia 2011 Legislation.← Return to text
  6. Letter from Governor Tomblin to Secretary Sebelius. February 15, 2013.← Return to text
  7. WV Health Benefit Exchange. Stakeholder Meeting Summary. May 16, 2013.← Return to text
  8. WV Health Benefit Exchange. Stakeholder Meeting Summary. May 28, 2013.← Return to text
  9. WV Health Benefit Exchange. Stakeholder Meeting Summary. July 9, 2013.← Return to text
  10. WV Health Benefit Exchange. Stakeholder Meeting Summary. May 16, 2013.← Return to text
  11. West Virginia Health Insurance Marketplace Grants Awards List.← Return to text
  12. West Virginia Establishment Grant Quarterly Report, 4/1/12-6/30/2012.← Return to text
  13. Letter from Secretary Sebelius to Governor Tomblin. March 5, 2013.← Return to text

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in Washington

Health Insurance Marketplace in Washington

If you live in Washington, the Washington Healthplanfinder is the Health Insurance Marketplace to serve you. Instead of HealthCare.gov, you’ll use the Washington Healthplanfinder website to apply for coverage, compare plans, and enroll. Visit the Washington Healthplanfinder now to apply.

Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are a number of different tiers of plans available on the Washington Health Insurance Exchange. Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Washington health insurers don’t have to offer every tier of plan, but within the Washington health insurance exchange, all health insurance companies must offer at least one silver plan and one gold plan to consumers.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Washington will expand its Medicaid program in 2014 to cover households with incomes up to 133% of the federal poverty level. That works out to about $15,800 a year for 1 person or $32,500 for a family of 4. You can find out whether you qualify for Medicaid in Washington 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Who can help you?

Get local help

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in Washington

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Washington

On May 11, 2011, Governor Christine Gregoire (D) signed SB 5445 into law establishing the Washington Health Benefit Exchange (HBE).1 Additional Exchange legislation signed by the Governor in March 2012, removed limitations on the Board’s governing authority over the Exchange (HB 2319).2 In October 2012, the state announced that the online marketplace would be called Washington Healthplanfinder.

Structure: The legislation defines Washington’s Exchange as a quasi-governmental organization, specifically a “self-sustaining public-private partnership separate and distinct from the state.”

Governance: The Exchange is governed by an 11-member board, including two non-voting, ex officio members (or their designees): the Insurance Commissioner and the Administrator of the Health Care Authority. The Governor will appoint eight voting board members from lists of nominees created by the two largest caucuses in the House and Senate. The legislation specifies that appointees must include at least one employee benefits specialist, one health economist or actuary, one representative of small business, and one health consumer advocate. The remaining voting members should possess related expertise in areas such as individual or small employer health care coverage, health benefit plan administration, or health care finance. The Governor will appoint a ninth member to the Board who will serve as chair and vote only when needed in case of a tie. Voting board members cannot be legislators or employees of the state or its political subdivisions. The Governor cannot appoint members whose participation in Board decisions would benefit their own financial interests or those they represent. Members developing these conflicts of interest should resign or be removed from the Board.

Current appointed Board members are:

  • Margaret Stanley (Chair), formerly with Puget Sound Health Alliance and Regence Blue Shield
  • Steve Appel, farmer and formerly with Washington Farm Bureau
  • Bill Baldwin, The Partners Group
  • Don Conant, Valley Nut and Bolt and School of Business at St. Martin’s University
  • Doug Conrad, University of Washington School of Public Health
  • Melanie Curtice, Stoel Rives LLP
  • Ben Danielson, MD, Odessa Brown Children’s Clinic
  • Phil Dyer, Kibble & Prentice/USI and former state legislator
  • Teresa Mosqueda, Washington State Labor Council and Healthy Washington Coalition

The Board held their first meeting in early January and assumed governing authority over the Exchange on March 15, 2012. A few months later the Board hired a CEO.

Exchange legislation specifies the Board should establish advisory committees to represent the views of the health care industry and other stakeholders, and may also establish technical advisory committees or seek advice of technical experts. In addition, it requires the Exchange to consult with the American Indian Health Commission. In May 2012, the Board selected 17 Advisory Committee members to provide expertise and experience on various issues. Members include carriers, brokers, small employers, consumer advocates, a Tribal representative, and providers.3

The Washington Health Care Authority assisted the Board in establishing HBE and was responsible for providing staff, resources, managing grants and other funds appropriated by the Legislature.  While HBE is now an independent organization, it continues to work closely with the Health Care Authority and other state agency partners, including the Office of the Insurance Commissioner (OIC) and the Department of Social and Health Services (DSHS). The Exchange Board, the Insurance Commissioner, and the Washington Health Care Authority are all responsible for continuing to move Exchange implementation forward on an aggressive timetable. The Exchange Board has a policy decision timeline outlining when key decisions should be made.4

Contracting with Plans: In early 2012, the Exchange formed a Plan Management Workgroup which includes representatives of the health insurance industry to provide input on how to offer individual and small group plans in the Exchange. In June 2012, the Board approved 19 criteria (all of which were specified in the ACA) to be the framework for health insurers’ participation in the Exchange.5 The OIC is responsible for reviewing nine criteria while the HBE will review the remaining ten. In February 2013, HBE released guidance that further details requirements for QHP participation in Healthplanfinder.6

The Exchange intends to allow all qualified health plans (QHPs) meeting the minimum standards to participate in the Exchange in 2014. HB 2319 created new insurance market rules for plans sold inside and outside Healthplanfinder. If an insurer offers a bronze plan in the individual or small group markets outside the Exchange, it must also offer plans in the silver and gold levels for that same market. Catastrophic plans may only be sold inside of the Exchange. Issuers may participate in Healthplanfinder’s individual market, SHOP market, or both and are not required to participate in the same markets inside and outside of the Exchange. Issuers must offer at least one QHP at the silver level and one QHP at the gold level in order to participate in Healthplanfinder. Issuers are also required to offer a child-only plan at the same level of coverage as any QHP offered through Healthplanfinder. The OIC requires issuers to offer contracts to all Indian Health centers in their service area, and issuers must notify HBE of all such contracts.

Nine issuers filed with the OIC to provide a total of 57 proposed QHPs on the individual market, including four catastrophic plans.7 No platinum level plans were proposed for either market. OIC will review the plans to ensure their compliance with the ACA’s essential health benefits requirement and other state and regulatory requirements.  HBE intends to conduct final certification of QHPs for 2014 during Board meetings in July and August of 2013. HBE will certify QHPs annually and issuers will offer QHPs for a term of one year. QHP issuers must also sign a participation agreement with HBE in order to participate in Healthplanfinder. A draft participation agreement was released in May 2013 and issuers are expected to submit signed participation agreements to HBE by mid-July.6

HB 2319 required that by the end of 2012, the Board establish a rating system for qualified health plans to assist consumers in evaluating plan choices.  In September 2012, the Board approved nine consumer rating factors and the use of specific corresponding data sources including the Consumer Assessment of Healthcare Providers and Systems (CAHPS) data for enrollee satisfaction and Healthcare Effectiveness Data and Information Set (HEDIS) data for provider reimbursement and promotion of primary care.8 QHP issuers must also document implementation of quality improvement strategies outlined by the Affordable Care Act (ACA), and submitted strategies will be posted online for consumers to review.

Issuers must ensure that each QHP’s network is sufficient in the number and type of providers, including mental health and substance abuse specialists. The network must also satisfy the essential community providers standard outlined by the ACA and comply with the provisions set forth by the Public Health Service Act and Washington Administrative Code 284-43-200. QHP issuers may only contract with hospitals with more than 50 beds if the hospital has a patient safety evaluation system in place. The OIC will monitor compliance of network adequacy requirements and HBE will decertify QHPs of issuers that do not adhere to the standards. Issuers must also submit health care provider data to HBE for a network directory.

Rates will differ based on QHP service area, which will be determined by county. Consumers will be able to locate their service area and view premium rates by entering their zip code into Healthplanfinder. The OIC requires QHP issuers to provide justification for premium increases and will post justifications online for the public.

HBE will aggregate subscriber premiums and send the aggregated payments to the appropriate issuer. Subscribers enrolled in the individual market will also be allowed to pay premiums directly to the issuer.

Dental and Vision Benefits: A Technical Advisory Committee (TAC) for dental plans began meeting in June 2012 to provide professional perspective on dental issues and make recommendations to the Board. Due to existing state law requiring dental benefits to be offered and priced separately in the Exchange, Washington has had to evaluate how to best operationalize its offerings of dental benefits in the Exchange, while also adhering to existing federal requirements around pediatric dental as an essential health benefit required as part of all Exchange plans.9 10 The Dental TAC also held multiple meetings to develop Qualified Dental Plan (QDP) certification standards.11 In March 2013, HBE issued final guidance for participation of stand-alone pediatric dental plans in Healthplanfinder. Six issuers intend to offer dental plans. The Board expects to perform final certification of QDPs at their July and August meetings.12

Risk adjustment, Reinsurance, and Risk corridors (RRR): In a presentation to the Exchange Board in September 2012, the Office of the Insurance Commissioner’s Workgroup on RRR expressed a preference for state operated risk adjustment programs.13 The OIC will monitor issuer compliance with the risk adjustment program; if the OIC determines that an issuer is not in compliance with program requirements, HBE will decertify all of the issuer’s QHPs.

Consumer Assistance and Outreach: In January 2013, the Board approved a proposal establishing a Navigator program comprised of Lead Organizations, organized by county service area or target population, that will contract with HBE to build, train, fund, and monitor networks of in-person assisters (IPAs) and Navigators.14  IPAs and Navigators will perform the same services, including providing enrollment assistance, conducting community outreach, and maintaining ongoing relationships with consumers. HBE allocated $6 million of an Establishment grant for IPA Lead Organization contracts. IPAs will be phased out of the Navigator program in 2015. In March 2013, HBE issued a Request for Proposals for IPA Lead Organizations and applications were due April 22.  HBE received 19 proposals and grant awardees will be announced in late May.15  An RFP for tribal assister services was released on April 5, 2013; responses are due by June 28.16

In March 2013, HBE selected a vendor to implement and operate a customer support center. The center will be open from 7:30am through 8:00pm and will be staffed by 60 full-time Customer Service Representatives. Customer Service Representatives will be hired and trained this summer and must pass a final exam and be certified by a supervisor before taking customer calls. A translation service will be available to provide interpretation for approximately 175 languages and all representatives will be trained on how to rout calls to other agencies. The center will open September 1.17

HBE is planning a marketing campaign that will be executed in four phases, starting with a soft launch in August and September 2013 to build Healthplanfinder brand awareness. HBE will utilize earned media, social media, and paid media as well as outreach to grassroots organizations and small businesses to spread awareness.18 HBE is also producing an eight-part “Countdown to Coverage” webinar series to educate consumers on the Affordable Care Act, how Healthplanfinder works, and the coverage options that will be available in 2014. In April 2013, HBE launched the Washington Healthplanfinder website, including a cost-estimate calculator.

HBE has created a logo that identifies QHPs as certified. Issuers are encouraged to use the logo to brand QHP marketing materials and may not modify the logo or use another logo to represent Healthplanfinder or QHP certification. QHP issuers are expected to create marketing and enrollment materials prior to October 1, 2013; however, HBE must approve the use of the logo on all materials.6

Small Business Health Options Program (SHOP) Exchange: A SHOP TAC and an Agents and Brokers TAC were established in July 2012 to provide recommendations to the Board and began meeting a few months later. The TACs have been discussing the role of agents and brokers in the small group business (SHOP) exchange as well as the individual Exchange, compensation models, and agent and broker concerns around how the Exchange will impact their business. HBE expects producers to play a prominent role in the SHOP; however, their role is still being defined. Employers may offer a single health plan or a choice of health plans at a single metal level to employees and employer premium contribution must be at least 50% for employees. HBE requires 100% employee participation for employer groups with three or fewer employees and employee participation of 75% for employer groups with more than three employees. HBE will collect and aggregate employer premium payments.6

While seven carriers initially submitted letters of intent to participate in the SHOP, most have since withdrawn due to concerns about operational readiness and risk. One carrier has indicated it will participate; however, it serves only five counties.19 In May 2013, the Board voted to launch the SHOP on October 1, 2013, despite the limited carrier participation.20

Information Technology (IT): Development of the Exchange’s IT infrastructure has been led by the Washington Health Care Authority. IT plans include designing a system with a single point of entry for state health insurance programs that uses shared eligibility services for tax credits through the Exchange and Medicaid/CHIP, similar enrollment functions and some shared administrative functions. The Washington Health Care Authority secured a subcontractor in February 2012 to build an IT system integrator which would determine eligibility for Medicaid, CHIP, and the Exchange.21 The first seven deliverables have been built including functionalities for plan management, SHOP Employer functionality, SHOP employee enrollment, Individual eligibility and enrollment, financial management, and administrative functionality.22 23 The Exchange system will interface with the Medicaid systems (Provider One and ACES) to determine eligibility. Integration of the systems is underway and expected to be fully functional for the open enrollment period.24 The state has received approval from the Centers for Medicare and Medicaid Services (CMS) for enhanced funding to upgrade Medicaid eligibility and enrollment systems.

In June 2012, the Exchange Board approved a requirement that the Exchange IT system design and build include the capability of the Exchange to aggregate premiums.

In February 2013, Washington was one of two states selected by the Center for Consumer Information and Insurance Oversight (CCIIO) for a first wave of information technology system testing conducted by the federal government. Testing began in April and is intended to assess the infrastructure behind Healthplanfinder as well as its ability to integrate with federal data systems.25

Financing: The Exchange Board is required to develop a methodology by the end of 2012 to ensure the Exchange is self-sustaining after 2014. HB 2319 gives the Board explicit authority to assess a surcharge on premiums. The Exchange is required to be self-sustaining without direct state tax subsidies, or else operations can be suspended. The Exchange Operations Committee evaluated options for Exchange financing including, requiring an assessment on qualified health plans based on either total membership or Exchange membership, imposing a new tax on hospital revenue, and/or charging a user fee for Exchange members or employers.26 After multiple meetings discussing self-sustainability around revenue models, the Board’s draft recommendation to the legislature was a 0.5% premium tax effective January 1, 2014 on all premiums and prepayment for health care services received. Then beginning January 1, 2015, the premium assessment would rise to 1.0%.27 Legislation to establish a financing mechanism for HBE (ESHB 1947) is currently being considered by the House and Senate. The bill reflects the Board’s recommendation.28

Basic Health Program (BHP) Option: Washington has considered establishing an optional bridge program available through the Affordable Care Act (ACA) which allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139 and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through an Exchange. The state released a proposal in June 2012 to operationalize a BHP, but awaits final approval from the federal government.29 Washington already operates the Washington Basic Health program, a state-sponsored program that provides low-income residents below 200% FPL with health care coverage through private health plans; however, this program would have to be modified to meet federal criteria for a BHP.30 The Washington Health Care Authority was required to submit a report to the Legislature on whether to proceed with implementation of a federal Basic Health Plan Option by the end of 2012.

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The state recommended the EHB benchmark be Blue Shield- Regence Innova Plan PPO.31 In addition, the Children’s Health Insurance Program (CHIP) will serve as the pediatric dental supplement, and the Federal Employee Vision Plan (FEDVIP) as the pediatric vision supplement. The Insurance Commissioner is required to submit annually to the Legislature a list of state-mandated benefits, the costs of which will be borne by the state.

 Exchange Funding

The Washington Health Care Authority has received two federal grants: the Exchange Planning grant of almost $1 million and the Level One Establishment grant of approximately $23 million to be used for operational planning and to develop an information technology system for critical Exchange functions related to eligibility, enrollment and information exchange.32 In May 2012, the state was awarded a $127.8 million Level Two Establishment grant to fund Exchange development through December 2014.33

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Washington is participating in Medicaid expansion.

 Next Steps

On December 7, 2012, Washington received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange.34 Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time and complying with future guidance and regulations.

Additional information about the Washington Health Benefit Exchange can be found at: http://wahbexchange.org/

Footnotes
  1. SB 5445, Washington’s 2011 Health Benefit Exchange act.← Return to text
  2. HB 2319. An Act furthering state implementation of the health benefit exchange. 2012 Regular Session.← Return to text
  3. See Advisory Committee Members.← Return to text
  4. Health Benefit Exchange Board Policy Decisions Timeline November 2012.← Return to text
  5. Washington State Health Benefits Exchange. May 16, 2012.← Return to text
  6. Washington Health Benefit Exchange. Guidance for Participation in the Washington Health Benefit Exchange. February 1, 2013.← Return to text
  7. Washington Health Benefit Exchange. Board Meeting: QHP Certification Update. May 15, 2013.← Return to text
  8. Consumer Rating System. Health Benefit Exchange Board Meeting. September 19, 2012.← Return to text
  9. Health Benefit Exchange Policy Committee Meeting Minutes. September 17, 2012.← Return to text
  10. Pediatric Dental handout. September 2012.← Return to text
  11. Draft- Working Document- Qualified Dental Plan (QDP) Criteria Attributes.← Return to text
  12. Washington Health Benefit Exchange. Final Guidance for Participation of Dental Plans. March 7, 2013.← Return to text
  13. Office of the Insurance Commissioner. Reinsurance and Risk Adjustment Workgroup. Exchange Board Presentation. September 19, 2012.← Return to text
  14. Washington Health Benefit Exchange: Proposed Navigator Program. January 2013.← Return to text
  15. Washington Health Benefit Exchange. Navigator Program Technical Advisory Committee Meeting Notes. April 25, 2013.← Return to text
  16. Request for Proposal Number HBE 13-003 for Washington Health Benefit Exchange Tribal Assister Services. April 5, 2013.← Return to text
  17. Washington Health Benefit Exchange. Customer Support Center Update. May 15, 2013.← Return to text
  18. Washington Health Benefit Exchange Board Meeting. Marketing Update. January 9, 2013.← Return to text
  19. Washington Health Benefit Exchange. SHOP Implementation Options 2014. May 15, 2013.← Return to text
  20. Washington Healthplanfinder Sees Competitive Health Plan Options for Consumers.” May 16, 2013.← Return to text
  21. RFP Health Benefits Exchange Systems Integrator Services. October 28, 2011.← Return to text
  22. IT Project Operations Committee Update. June 12, 2012.← Return to text
  23. Washington HCA. RFP K521 for HBE Systems Integrator Services. October 28, 2011.← Return to text
  24. Washington Health Benefit Exchange Board Meeting. Eligibility Services/ACES Remediation Project Update. April 17, 2013.← Return to text
  25. Washington Healthplanfinder Newsletter. February 2013.← Return to text
  26. Washington HBE Operations Committee. Self-sustainability discussion. August 7, 2012.← Return to text
  27. Report to the Washington State Legislature: Financing of the WHBE. December 1, 2012.← Return to text
  28. HB 1947 Concerning the operating expenses of the Washington health benefit exchange.← Return to text
  29. Washington State Proposal for a Federal Basic Health Option. June 18, 2012. Washington State Health Care Authority.← Return to text
  30. See Washington Basic Health Program ← Return to text
  31. Essential Health Benefits Benchmark Plan Selection- Revised. February 13, 2012. Milliman.← Return to text
  32. Washington Level One Establishment Grant Application. Funding Opportunity #IE-HBE-11-004. May 1, 2011-April 30, 2012.← Return to text
  33. Level II Establishment Grant Application. Washington State Health Benefit Exchange.← Return to text
  34. Letter from HHS to Governor Gregoire. December 7, 2012.← Return to text

Also of interest

Obamacare in Virginia

Health Insurance Marketplace in Virgina

If you live in Virginia, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014.

Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

 Expanded Medicaid

Virginia has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Virginia’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Who can help you (the Navigators)

Get local help

Virginia Poverty Law Center, Inc.

The Virginia Poverty Law Center (VPLC) is a non-profit organization that serves Virginia’s legal aid system by providing advocacy, training, and litigation support on civil justice issues that affect low-income Virginians based in Richmond. It provides training and technical assistance to the legal aid community and others and works on health care issues with a wide range of statewide organization and partners. It will be working with a statewide consortium of nine well-established legal services programs in the commonwealth.

Advanced Patient Advocacy, LLC

For nearly 14 years, Advanced Patient Advocacy has partnered with health care providers and state and local governments in 21 states to provide services to communities to help educate and enroll uninsured consumers. Advanced Patient Advocacy will work with medical centers to identify uninsured individuals and provide education and assistance to help them make informed decisions about enrollment in the Marketplaces.

Who you can contact for more help

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know  with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in Virginia

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

 The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Virginia

On December 14, 2012, Governor Bob McDonnell (R) informed federal officials that Virginia would not continue to plan for a state-based health insurance exchange.1

Prior to the decision, Governor McDonnell had signed HB 2434 into law declaring the state’s intent to establish a state-based health insurance exchange.2 The legislation was based on a recommendation by the Virginia Health Reform Initiative Advisory Council, housed within the Virginia Department of Health and Human Resources.3 HB 2434 required the Governor to submit recommendations regarding establishment of an exchange in Virginia for consideration during the 2012 session of the General Assembly and prohibited qualified health insurance plans offered through the exchange from covering abortions, except in cases of rape, incest, or life endangerment of the pregnant woman.

On November 25, 2011, the Advisory Council’s exchange recommendations were submitted to the General Assembly by the Governor.4 The Council voted in favor of establishing a state-based exchange as a quasi-governmental agency with a governing board.5 However, Governor McDonnell opposed passing the additional legislation needed for the establishment of a state-based exchange until after the Supreme Court ruled on the Affordable Care Act (ACA) in late June 2012.6 Numerous bills to establish a state-run health insurance exchange were introduced in the Virginia Legislature in 2012; however, all were tabled for the next legislative session.7 In the absence of establishment legislation, the Advisory Council temporarily suspended its meetings.

Contracting with Plans: On February 14, 2013, Governor McDonnell sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO) announcing the state’s intent to perform plan management activities despite not having entered into a state-federal partnership exchange.8 On March 21, 2013 Governor McDonnell approved legislation authorizing the State Corporation Commission (SCC) to perform plan management functions, including collecting and analyzing information on plan rates, benefits, and cost-sharing and ensuring continued plan compliance. The SCC was also granted the authority to manage consumer complaints, provide technical assistance, and decertify issuers. The legislation authorizes the Virginia Department of Health to assist in plan management functions.9 Premium rates will vary based on family composition, age, tobacco use, and geographic area.10 Virginia will have 12 geographic rating areas, determined by the federal default mechanism.11

Consumer Assistance and Outreach: In April 2013, Governor McDonnell signed into law HB 2246 and SB 1261 to prohibit navigators from performing activities that would require an insurance agent license. Navigators must be selected in accordance with federal law and may not act as intermediaries between employers and insurers offering QHPs or dental plans through the Exchange. The SCC will monitor Navigator activities and submit findings to the Governor and the Senate and House Commerce and Labor Committees in November of 2014 and 2015.12

Information Technology (IT): Virginia is focusing on a significant Medicaid IT system upgrade and has received approval from the Centers for Medicare and Medicaid Services (CMS) for an enhanced federal match. In May 2012, the state released a Request for Proposals soliciting subcontractors to streamline eligibility and enrollment for all existing social service benefits, including Medicaid, TANF, and food stamps. State officials envision eventual interoperability between the upgraded system and an exchange.

Essential Health Benefits (EHB): The ACA requires that all individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. Drawing input from multiple stakeholders and various analyses, the Advisory Council recommended in June 2012 that a subcommittee be established to consider Anthem, the state’s small-group PPO as the state’s benchmark plan. The subcommittee recommended Anthem as the EHB benchmark plan and the Children’s Health Insurance Program (CHIP) dental benefit plan (Smiles for Children) as the pediatric dental supplemental plan.13

 Exchange Funding

In September 2010, the Virginia State Department of Medical Assistance Services received a federal Exchange Planning grant of $1 million. The state planned to submit a Level One Establishment grant application in June 2012; however, the Governor announced in a letter to the Legislature in July, he decided not to submit the application.14 In February 2013, Virginia received a $4.3 million Level One Establishment grant to support plan management functions, including hiring IT consultants and engaging stakeholders. In July 2013, Virginia received a second Level One Establishment grant for $1.2 million to fund the actuarial analysis needed to support the certification, decertification, and recertification of QHPs and stand-alone dental plans.15

Virginia, along with nine other states, received technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance exchanges, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.16

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Virgina legislature passed a Medicaid expansion measure but the governor has not included expansion in his budget.

Next Steps

On March 29, 2013, Virginia received approval from CCIIO to perform plan management activities. The federal government will retain control over all other Exchange functions.17

More information about the Advisory Council’s health insurance exchange activities can be found at: http://www.hhr.virginia.gov/Initiatives/HealthReform/index.cfm

Footnotes
  1. Governor McDonnell Letter to Secretary Sebelius. December 14, 2012.← Return to text
  2. HB2434. Virginia’s 2011 Health Benefit Exchange Act.← Return to text
  3. Report of the Virginia Health Reform Initiative Advisory Council. December 20, 2010.← Return to text
  4. Report Pursuant to House Bill 2434: Virginia Health Reform Initiative (VHRI) Advisory Council recommendations for a Health Benefit Exchange. Report of the Secretary of Health and Human Resources. November 25, 2011.← Return to text
  5. The Virginia Health Reform Initiative. Presentation to House Appropriations Committee. November 16, 2011.← Return to text
  6. Martz, Michael. ‘McDonnell: If health insurance mandate stands, Va. should run exchange.’ Richmond Times-Dispatch. December 9, 2011.← Return to text
  7. See: http://lis.virginia.gov/← Return to text
  8. Letter from Governor McDonnell to Gary Cohen. February 14, 2013.← Return to text
  9. SB 922 Health insurance; SCC< et al., to perform plan management functions, review of premium rates.← Return to text
  10. State Corporation Commission, Bureau of Insurance. Rules Governing Riling of Rates for Individual and Group Accident and Sickness Insurance. July 1, 2013.← Return to text
  11. Virginia Geographic Rating Areas Including State Specific Geographic Divisions. CCIIO.← Return to text
  12. HB 2246  and SB 1261← Return to text
  13. Dise, Monty. EHB Subcommittee Report to the Virginia Health Reform Initiative Advisory Council. June 13, 2012.← Return to text
  14. Salasky, Prue. “Gov. McDonnell tells GA members no special session necessary on health care.” Dailypress. July 10, 2012.← Return to text
  15. Virginia Affordable Insurance Exchange Grants Awards List.← Return to text
  16. Robert Wood Johnson Foundation. ‘RWJF Seeks Coverage of 95 Percent of All Americans by 2020.’ May 6, 2011.← Return to text
  17. Letter from Gary Cohen to Governor McDonnell. March 29, 2013.← Return to text

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in Vermont

Marketplace in Vermont

If you live in Vermont, Vermont Health Connect is the Health Insurance Marketplace to serve you. Instead of HealthCare.gov, you’ll use the Vermont Health Connect website to apply for coverage, compare plans, and enroll. Visit Vermont Health Connect now to apply. Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic. Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below: NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan. Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you. Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services. Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you. Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently. Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Vermont will expand its Medicaid program in 2014 to cover households with incomes up to 133% of the federal poverty level. That works out to about $15,800 a year for 1 person or $32,500 for a family of 4. You can find out whether you qualify for Medicaid in Vermont 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in Vermont

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Vermont

On May 26, 2011, Governor Peter Shumlin (D) signed into law HB 202, a far-reaching health reform law that puts the state on a path toward establishing a single-payer health care system.1 As an interim step, the law created the Vermont Health Benefit Exchange to meet the requirements of federal health reform. The state plans to put into place the components of federal health reform, including the exchange, and in 2017 apply for a federal Waiver for State Innovation to transition to Green Mountain Care, the new public-private single-payer system that will provide coverage for all state residents. In May 2012, the Governor signed additional health system reform legislation further defining the role and duties of the Green Mountain Care Board and the Exchange (HB 559).2 The Vermont Health Insurance Exchange was branded as Vermont Health Connect. Structure: HB 202 defines Vermont’s Exchange as a state-operated division within the Department of Vermont Health Access and headed by a Deputy Commissioner. Governance: The Exchange will be administered by the Department of Vermont Health Access in consultation with a 22-member Medicaid and Exchange Advisory Committee. The Commissioner of Vermont Health Access will serve on the Advisory Committee and appoint members including, a representative of health insurers; five beneficiaries of Medicaid or Medicaid-funded programs; five individuals or representatives of small businesses eligible for or enrolled in the Exchange; five advocates for consumer organizations; and five health care professionals. The Vermont Exchange will be overseen by the Green Mountain Care Board, which is charged with moving the state through several stages of health care system change, ultimately leading to the establishment of a single-payer system. The Green Mountain Care Board consists of a chair and four members appointed by the Governor. Members cannot be affiliated with entities supervised or regulated by the Board, except for health care practitioners; participate in issues in which there is a financial interest; discuss future employment or appear before the Board of other state agencies on behalf of a person subject to supervision or regulation by the Board for a year after leaving the Board. The Chair and all members of the Board are state employees. Current appointed Board members are:

  • Anya Rader Wallack (Chair)
  • Al Gobeille
  • Karen Hein, M.D.
  • Con Hogan
  • Allan Ramsay, M.D.

The Green Mountain Care Board began work on October 1, 2011 and in December, a Deputy Commissioner of the Exchange was hired. As required by the Vermont Health Reform Law of 2011, the Board and Governor Shumlin’s administration submitted reports to the House Committee on Health Care and the Senate Committee on Health and Welfare in January 2012.3 In July 2012, the Department of Vermont Health Access merged the existing Exchange Advisory Group with the Medicaid Advisory Board so as to create the Medicaid and Exchange Advisory Committee and maintain compliance with HB 202. The new Advisory Group includes representatives from consumer advocacy organizations, legislators, providers, brokers, and insurance associations. Contracting with Plans: Vermont Health Connect will selectively contract with carriers according to criteria developed by the Commissioner of the Department of Vermont Health Access and will offer qualified health plans (QHPs) from at least two private carriers, plus two multi-state plans. There are few carriers in Vermont’s non-group and small group markets; therefore, the state is working to ensure adequate participation. Carriers will be required to offer at least silver and gold level plans and bronze plans will be allowed to be sold in the Exchange.4 Carriers will also be required to offer six standard plans designs and will have the option of offering non-standard “choice” plans within set parameters. The state released a Request for Proposals in November 2012 for qualified health plans and stand-alone dental plans to be sold in the Exchange; the state selected QHPs and premium rates will be available to the public in July 2013.5 In July 2013, the Green Mountain Care Board announced the approved rates for the two insurers, BlueCross BlueShield of Vermont and MVP Health Care, that will participate in Vermont Health Connect, which were 4-5% lower than the initial rate filings.6 Earlier in May 2013, the Commissioner of the Vermont Department of Financial Regulation announced that the Vermont Health CO-OP had failed to meet the state’s insurance standards and had been denied a license to sell insurance in the state. Recommendations for quality requirements were developed for the state in August 2012 by subcontractors, including that the state continue using a higher standard to evaluate quality and wellness data for QHPs using Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) standards as well as additional state requirements for consumer protections.7 This would be a higher standard than required by the Affordable Care Act. Dental and Vision Benefits: The Green Mountain Care Board considered dental options assessed by the Department of Vermont Health Access and voted not to mandate the inclusion of adult dental coverage through the Exchange for 2014. Consumer Assistance and Outreach: Vermont Health Connect contracted for the development of a comprehensive outreach and education plan.8 As of July 2013, Vermont Health Connect had launched its outreach campaign with a YouTube channel, Facebook page, Twitter account, new printed educational materials, as well as radio and television ads. It had also scheduled a number of forums and is developing partnerships with community organizations, providers, and businesses.9 On April 10, 2013, Vermont Health Connect released a Notice of Application for Navigator Organizations that will manage individual Navigators.10 To ensure sufficient distribution of Navigator Organizations throughout the state, grants are divided into three tiers: Tier 1 organizations will receive up to $40,000 and will target a specific geographic area or population; Tier 2 organizations will received grants of $40,000-$100,000 and will target a specific geographic are or population; Tier 3 organizations will receive grants up to $200,000, will have statewide reach, and will coordinate with other Navigator Organizations as well as state and local partners. On May 21, 2013, Vermont Health Connect announced it had awarded $2 million to 18 Navigator Organizations throughout the state. Four organizations receiving grant awards will serve as statewide coordinating Navigator Organization with two focusing on individuals and families and two serving small businesses.11 Navigators must complete 24 hours of training and pass a certification exam. The In-person training for Navigators was offered in early July. Vermont Health Connect contracted with the vendor supporting the existing Medicaid Support Center to expand the call center to include Exchange customers and to improve the quality of the service. The Support Center staff will be increased to 70 and the hours will be extended to include weekend hours. The Support Center will include dedicated lines for enrollment assisters and carriers and will be able to accept credit/debit payments. Training of Support Center staff will begin in July and the call center will go live in September.12 Small Business Health Options Program (SHOP) Exchange: HB 559 opens Vermont’s SHOP Exchange to small businesses with 50 or fewer employees in 2014, 100 or fewer employees by 2016, and to all employers by 2017. The state is working with subcontractors to finalize various aspects of the SHOP Exchange including, administrative requirements for the small businesses, broker management, premium billing and collection, and eligibility verification. In January 2012, the Green Mountain Care Board concluded that the individual and small group markets should be merged in 2014. Additionally, the Board recommended that insurance plans for small groups and individuals should only be sold through the Exchange so as to increase Exchange sustainability and promote payment reforms. Based on these recommendations, HB 559 merges the individual and small group health insurance markets into one market and requires plans to be sold only through the Exchange. The law allows for brokers to assist with enrollment through the Exchange. Small business employers will have the option of choosing between two different models for their employees. One option is to give the full choice of insurers and plans to their employees; the other is to give employees the choice of metal level from one insurer’s offerings.13 Information Technology (IT): Vermont intends to use a single, streamlined process for determining eligibility for the Exchange, Medicaid, CHIP, and other public programs. The state’s new system, Vermont Integrated Eligibility and Workflow Solution (VIEWS ), will integrate required components first and then incorporate other benefit programs in the future. The Department of Vermont Health Access has solicited various subcontractors to develop and implement the proposed system.14 The state plans to begin system testing July 1, 2013 and intends to be ready for open enrollment in October 2013. Vermont is also participating as part of a consortium of New England states in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use. The state is actively exploring opportunities to leverage Oregon’s Oracle-based Exchange architecture. Financing: The Board has solicited a subcontractor to develop a plan for financial sustainability. The Exchange Board must recommend two financing plans to the Legislature by January 15, 2013. One plan will recommend financing amounts and mechanisms that must be in place by January 1, 2014 and the second will address the financing of Green Mountain Care. On January 24, 2013, Governor Shumlin submitted the financing plan to the state legislature.15 The plan proposes to fund Vermont Health Connect operations for fiscal years 2014-2016 through reinvestment of ACA savings and increasing the health care claims assessment by one percent. In 2017, the state will move to a single payer system with a separate financing mechanism. Essential Health Benefits (EHB): The Affordable Care Act requires that all individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The Green Mountain Care Board held two public hearings on essential health benefits, the benchmark plan, and plan design and is considering potential market disruptions and how plan design could cause selection problems. The state solicited subcontractors to examine plan designs in the state’s individual and small group markets. The state recommended the Vermont Health Plan- BlueCare, HMO to serve as the benchmark plan. In addition, the Children’s Health Insurance Program (CHIP) will serve as the pediatric dental supplement and the Federal Employee Vision Plan (FEDVIP) will be the pediatric vision supplement.

 Exchange Funding

In September 2010, the Vermont Agency of Human Services received the federal Exchange Planning grant of $1 million. In addition, Vermont is a member of the consortium of New England states that received a federal Early Innovator Grant of $44 million to develop, share, and leverage insurance exchange technology. The multi-state consortium also includes Connecticut, Rhode Island, Maine, and Massachusetts with the University of Massachusetts Medical School as the grant holder. The state has received three Level One Establishment grants: $18 million in November 2011 to further plan and develop the Exchange; $2.2 million in January 2013 to implement and operate an In-person Assister program; and $42.7 million in July 2013 to support the implementation of an integrated eligibility system, consumer support center functionality, and individual and SHOP premium processing. In August 2012, Vermont received a $104.2 million Level Two Establishment grant to fund Exchange development and operations through December 2014.16

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA. As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum. However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that. Vermont is participating in Medicaid expansion.

 Next Steps

On January 3, 2013, Vermont received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange.17 Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time, complying with future guidance and regulations, and receiving legislative approval for a self-sustainability financing plan. The state must also develop a contingency plan by February 1, 2013 if the state is unable to meet timelines and milestones, particularly relating to implementation of the IT infrastructure. For more information on Vermont’s Health Benefit Exchange planning, visit: http://healthconnect.vermont.gov/

Footnotes
  1. Act 48 (HB 202). An Act Related to Universal and Unified Health System in Vermont. Signed May 26, 2011. ← Return to text
  2. House Bill 559. Introduced 2012 session. ← Return to text
  3. Act 48 Integration Report: The Exchange. Submitted by the Agency of Administration, January 17, 2012← Return to text
  4. Vermont Exchange Advisory Group Meeting minutes. May 14, 2012. http://dvha.vermont.gov/administration/hbe-advisory-group-minutes-05-14-12.pdf and Overview H.559. Exchange Advisory Meeting. May 14, 2012. http://dvha.vermont.gov/administration/hbe-h559-overview.pdf← Return to text
  5. Department of Vermont Health Access. RFP Selection of Qualified Health Plans. November 1, 2012. http://www.vermontbusinessregistry.com/bidAttachments/9464/Vermont%20QHP%20RFP%200341011313.pdf← Return to text
  6. Green Mountain Care Board press release, July 8, 2013. http://gmcboard.vermont.gov/sites/gmcboard/files/Exchange_rate_decision%20release_revised.pdf← Return to text
  7. Roadmap for Implementing Quality Requirements: Recommendations for Vermont’s Health Benefit Exchange. August 3, 2012. http://dvha.vermont.gov/administration/qualityimplereportfinal.pdf← Return to text
  8. Vermont Health Benefit Exchange Outreach and Education Plan, prepared by GMMB http://healthconnect.vermont.gov/sites/hcexchange/files/For%20Websitevermont-health-connect-outreach-and-education-plan.pdf← Return to text
  9. Medicaid and Exchange Advisory Board presentation, Outreach and Education Update http://healthconnect.vermont.gov/sites/hcexchange/files/MEAB%20O%20and%20E%2003July2013%20%282%29.pdf← Return to text
  10. Vermont Navigator Organization Grants, Notice of Application, April 10, 2013 http://www.vermontbusinessregistry.com/bidAttachments/9802/VT%20Navigator%20Organization%20Application.pdf← Return to text
  11. Vermont Heatlh Connect Selects 18 Navigator Organizations, press release May 21, 2013 http://healthconnect.vermont.gov/sites/hcexchange/files/Press_Release_Navigator_Organization_Grant%205_21_13.pdf← Return to text
  12.  Customer Support Update, presentation to Medicaid and Exchange Advisory Board, May 6, 2013 http://healthconnect.vermont.gov/sites/hcexchange/files/CSC%20Slides%20for%20MEAB_02May2013v3.pdf← Return to text
  13. The Vermont Health Benefit Exchange: An Update for Small Business Owners. November 28, 2012. http://dvha.vermont.gov/administration/exchange-update-small-biz-11.28.12-final.pdf← Return to text
  14. Planning Review: Vermont Health Benefit Exchange. May 10-11, 2012. http://dvha.vermont.gov/administration/hbe-powerpoint-presentation-for-vermonts-planning-review-with-hhs-05-2012.pdf← Return to text
  15. Health Care Reform Financing Plan, January 24, 2013 http://hcr.vermont.gov/sites/hcr/files/2013/Health%20Care%20Reform%20Financing%20Plan%202014%20and%202017_FINAL.pdf← Return to text
  16. Vermont Affordable Insurance Exchange Grants Awards List. http://www.cms.gov/cciio/Resources/Marketplace-Grants/vt.html← Return to text
  17. Letter from HHS to Governor Shumlin, January 3, 2013. http://www.cciio.cms.gov/resources/files/vt-blueprint-exchange-letter-01-03-2013.pdf← Return to text

Obamacare in Utah

Health Insurance Marketplace in Utah

If you live in Utah, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014. For small businesses and their employees: In Utah, your Small Business Health Options Program (SHOP) is Avenue H. Instead of HealthCare.gov, you’ll use the Avenue H website to apply for coverage, compare plans, and enroll. Visit Avenue H now to apply.

Spanish language speakers can contact cuidadodesalud.gov.`

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the Arkansas insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Consumer Operated and Oriented Plan Program

Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets.  CO-OP in Tennessee:

Aarches Community Health Care

Expanded Medicaid

Utah has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Utah’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Utah Dithers on Medicaid Expansion

Utah is one of the few states still dithering on whether or not to expand Medicaid to cover people making up to 138 percent of the Federal Poverty Level (FPL), despite the Federal Government’s offer of paying 100 percent of the expansion cost until 2017, and 90 percent of all costs after 2020. (The Feds currently pay 70% of Medicaid costs.) What’s the rationale for not expanding Medicaid in Utah? (Apart from the economic boost it will give the state.) As one government insider told me, it boils down to this: “We don’t trust the federal government.” But this isn’t to say that Utah will not be expanding coverage. While Governor Herbert — and it’s his choice to make — is not considering a full expansion, he is still deciding between three options: do nothing; cover up to 100 percent of the FPL, leaving the rest to shop for federal subsidies on the Federal Marketplace; or partially expand Medicaid to 100 percent, and use Medicaid dollars to subsidize private insurance for those between 101 and 138 percent of FPL. This same government insider opined that option three, a privatization of Medicaid dollars, is the likeliest. This is partially due to the Medicaid Expansion task force being led by Chairman Rep. Jim Dunnigan, R-Taylorsville, who happens to be an insurance broker. His argument is that Medicaid restricts a person’s choice of doctors, while putting those at 100 to 138 percent of FPL into private plans on the Healthcare Marketplace with Medicaid-derived subsidies would benefit both patients and providers with more choices and higher reimbursements. This same government insider said this third option — contingent upon the Feds allowing this flexibility with Medicaid dollars — could be implemented by July 1st.

While I’m a firm supporter of Medicaid expansion, I’m willing to admit option three has some merit, as long as the state subsidies on the Health Marketplace are equal to or greater than what the Federal government provides. The important thing is to make sure everyone is covered. And to do this, the public has to keep the pressure on the governor. Most everyone who has weighed in — the AFL/CIO, League of Women’s Voters, even the Utah Hospital Association — support Medicaid expansion. (The LDS church is strangely silent on the issue.) To support Medicaid extension, write an email to Governor Herbert: http://act.betterutah.org/letter/medicaid_expansion/

medicaidchart

Who can help you (the Navigators)

Get local help

Utah Health Policy Project

The Utah Health Policy Project is a nonprofit organization dedicated to lasting solutions to the crisis of the uninsured and rising health care costs. The Utah Health Policy Project will lead the Take Care Utah Navigator Hub that will connect nonprofit community-based organizations with resources on health coverage options.

Utah AIDS Foundation

Utah AIDS Foundation (UAF) is the oldest and largest AIDS service organization in Utah, with over 27 years of experience providing effective, culturally-sensitive services to people living with HIV and populations at high risk for HIV in Utah. UAF will hire two full-time staff to serve as Navigators to educate target communities about Exchanges and to help individuals determine eligibility, understand their options, select, and complete all necessary steps to enroll in a Qualified Health Plan.

National Council of Urban Indian Health

National Council of Urban Indian Health is the only national, membership-based organization dedicated to outreach and education on behalf of Urban Indian Health. It provides training, technical assistance, outreach, and education to Urban Indian Health Programs.

Who you can contact for more help

Utahhealthmatters.com is a very informative site (see above post on Medicaid expansion) and easy to contact with a quick turnaround for responses.

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know  with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in Utah

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Utah

After making health system reform one of the state’s top policy priorities, Utah’s former Governor Jon Huntsman (R) signed legislation in 2008 (HB 133) and 2009 (HB 188) which directed the Office of Consumer Health Services to create the Utah Health Exchange.1 Current Governor Gary Herbert (R) signed into law additional legislation amending provisions related to health system reform in 2010 (HB 294) and 2011 (HB 128); the latter reauthorized the Health System Reform Task Force to evaluate options for bringing the state’s already existing exchange into compliance with the Affordable Care Act (ACA).2 Additional health system reform legislation was introduced in February 2012 (HB 144).3 The Utah Exchange allows small employers to participate in a defined contribution arrangement and compare, select, and enroll in commercial health insurance online. In 2012, the Utah Exchange was renamed to Avenue H.

In early 2012, Governor Herbert stated Utah was in negotiations with the federal Department of Health and Human Services (HHS) regarding the extent to which the state would have to modify its existing health insurance exchange to meet new federal requirements under the Affordable Care Act (ACA). Although the state received conditional approval from HHS in January 2013 for a fully state-run exchange, Governor Herbert subsequently proposed that the state continue running Avenue H as the state’s SHOP exchange for small employers  while the federal government operate a federally-facilitated individual exchange in the state.4  HHS granted approval for this proposal in May 2013.5

In March 2011, Governor Herbert also signed HB 354 into law which bans abortion coverage in any private plan sold in the state, including the Exchange, except in cases of life endangerment or severe impairment of the pregnant woman, rape, incest, or fetal abnormality effective January 1, 2012.6

The following describes the structure and governance of Avenue H, the state’s SHOP exchange.

Structure: Avenue H is administered by the Office of Consumer Health Services, which is housed within the Governor’s Office of Economic Development.

Governance: The Office of Consumer Health Services runs Avenue H, and is responsible for ensuring performance and resolving policy issues. State law requires Avenue H to operate with input from two distinct boards: an Exchange Advisory Board and a Defined Contribution Risk Adjuster Board. HB 294 requires Avenue H to create an Advisory Board to counsel staff on the operation of the Exchange and transparency issues. An Exchange Advisory Board met monthly until June 2011, at which time it was replaced by an Executive Steering Committee. Consumer advocates have raised concerns over the lack of consumer representation on the Executive Steering Committee.7

Current Executive Steering Committee members are:

  • Greg Bell (Co-Chair), Lt. Governor
  • Greg Poulsen (Co-Chair), Intermountain Healthcare
  • Richard Broadbent, Utah Association of Health Underwriters
  • Marc Bennett, HealthInsight
  • Rich McKeown, Salt Lake Chamber’s Health Committee & Leavitt Partners
  • Gordon Crabtree, University of Utah
  • Pam Gold, United HealthCare
  • Pat Richards, SelectHealth
  • Jennifer Cannaday, Regence BlueCross/BlueShield
  • Howard Headlee, Utah Bankers Association
  • David Patton, Department of Health
  • Mark VanOrden, Department of Technology Services
  • Spencer Eccles, Governor’s Office of Economic Development
  • Colleen Mellor, Strategic Employee Benefit Services
  • Todd Kiser, Department of Insurance
  • Greg Matis, SelectHealth
  • Vaughn Holbrook, Regence Blue Cross Blue Shield
  • Ernie Sweat, Fringe Benefit Analysts
  • Patty Conner, Avenue H, Office of Consumer Health Services
  • Norm Thurston, Office of Consumer Health Services

Responsibility for managing the risk sharing mechanisms for Avenue H’s defined contribution market lies with the Utah Defined Contribution Risk Adjuster Board which meets monthly and is composed of up to nine members.8 The Governor appoints between five and seven members, including: three to five members who possess actuarial experience and represent insurers that participate in the defined contribution market in Utah and one to two of whom represent insurers that have a small percentage of lives in the defined contribution market; a representative of an individual employee or employer; and a representative of the Office of Consumer Health Services. The Director of the Public Employees’ Benefit and Insurance Program appoints one member with actuarial experience to represent that program. The Insurance Commissioner (or designee) is the final member and can only vote in the event of a tie.

Current Risk Adjuster Board members are:

  • Jim Pinkerton (Chair), Regence Blue Cross Blue Shield of Utah
  • John Borer, Public Employees’ Benefit and Insurance Program
  • Dave Jackson, First West Benefit Solutions
  • Jim Murray, SelectHealth
  • Kim Miller, United Health Care
  • Norman Thurston, Office of Consumer Health Services
  • Tomasz Serbinowski, Utah Insurance Department

Contracting with Plans: Per Utah’s agreement with HHS, the state will maintain oversight of Qualified Health Plans (QHPs) participating in the state’s individual exchange operated by HHS, as well as those participating in Avenue H. On March 28, 2013, the Utah Insurance Department (UID) issued a bulletin providing information on the filing requirements for plans issued or renewing on or after January 1, 2014, as well as the timeline for the QHP approval process.9

Avenue H acts as a market clearinghouse and accepts all insurers meeting minimum standards. HB 128 gives the Insurance Department authority to conduct rate reviews to verify that insurers price plans similarly within and outside of the Exchange. There are currently over 140 plans offered through Avenue H with varying prices, copays and deductible levels. Brokers play an integral role in assisting small employers with selecting plans.

Consumer Assistance and Outreach: By May 2013, 344 employer groups were enrolled in Avenue H with over 8,000 covered lives.10 To increase enrollment, the state is undertaking initiatives to enhance the consumer experience, including improving the user interface and providing education and decision support to consumers.

As part of its agreement to operate Avenue H as the SHOP exchange, the state must run a SHOP-specific Navigator program and fund a minimum of two Navigators.  The state has the option of limiting the role of the SHOP-specific Navigators to consumer outreach and education functions only. HHS will finance and run a Navigator program in the individual exchange.

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The Health System Reform Task Force collected public comments on EHB and in mid-August 2012 voted to recommend the Public Employee Health Plan’s Utah Basic Plus as the benchmark.11 The Utah Insurance Department issued a final rule, effective October 25, 2012, designating this plan as the state’s EHB benchmark plan.12

Information Technology (IT): The state already has in place the technology backbone necessary to support Avenue H. Now that the state will not be operating the individual exchange, it will need to develop an interface between the state’s public programs and the federal exchange. Prior to the recent developments, in July 2012, subcontractors completed two reports on exchange design and functionality.13

Financing: Avenue H began with an initial appropriation of $600,000 and ongoing funding is through annual appropriation and monthly fees assessed on every subscriber. Avenue H also receives support from the Governor’s Office of Economic Development for the Exchange’s staff members.

Exchange Funding

In September 2010, the Governor’s Office of Economic Development was awarded a $1 million federal Exchange Planning grant.

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Utah is considering Medicaid expansion but is more likely to pursue an alternative expansion model.

Next Steps

On May 10, 2013, Utah received approval to operate Avenue H as the state’s SHOP exchange and to perform plan management functions in the federally-facilitated individual exchange.14 The federal government will perform all other functions for the individual exchange.

For more information about Utah’s existing health insurance exchange, Avenue H, visit: http://www.avenueh.com/

Footnotes
  1. House Bill 133. Health System Reform. 2008 General Session.  House Bill 188. Health System Reform- Insurance Market. 2009 General Session.← Return to text
  2. House Bill 294. Health System Reform Amendments. 2010 General Session. House Bill 128. Health Reform Amendments. 2011 General Session.← Return to text
  3. House Bill 144. Health System Reform Amendments. 2012 General Session. Introduced February 3, 2012.← Return to text
  4. HHS letter to Governor Herbert, January 3, 2013.← Return to text
  5. HHS letter to Governor Herbert, May 10, 2013.← Return to text
  6. House Bill 354. Insurance Amendments Relating to Abortion. 2011 General Session. Enrolled Copy.← Return to text
  7. Utah Health System Reform Task Force Meeting Minutes. October 19, 2011. See also: Utah Health Policy Project.← Return to text
  8. Utah Code: Title 31A, Chapter 42, Section 201. Defined Contribution Risk Adjuster Act.  Utah Defined Contribution Risk Adjuster Plan of Operation. As of October 26, 2010.← Return to text
  9. Utah Insurance Department, Bulletin 2013-4 Health Benefit Plan Market Transition, March 28, 2103.← Return to text
  10. Avenue H May 2013 Dashboard.← Return to text
  11. Essential Health Benefits Recommendation. Health System Reform Taskforce. August 16, 2012.← Return to text
  12. Utah Insurance Department, R590, Utah Essential Health Benefits Package final rule.← Return to text
  13. Final Report for Solicitation PR11072. Utah Health Exchange Planning Grant. July 12, 2011. PlanSource.  Seamless Interface with Public Program Eligibility. Utah Health Exchange- Phase 1 Activity. July 12, 2011.← Return to text
  14. HHS letter to Governor Herbert, May 10, 2013.← Return to text

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in Texas

Health Insurance Marketplace in Texas

If you live in Texas, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014.

Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Texas has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Texas’ current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Who can help you (the Navigators)

Get local help

United Way of Metropolitan Tarrant County

United Way of Metropolitan Tarrant County has served the people in the Fort Worth and Arlington area of Texas for over 90 years. In collaboration with 17 organizations, United Way of Metropolitan Tarrant County will work across the state to promote enrollment in the Marketplace.

Migrant Health Promotion, Inc.

Migrant Health Promotion improves health in farmworker and border communities in Florida, Michigan, Ohio, Washington, and South Texas. This project will focus on enrolling and educating migrant populations in the Rio Grande Valley of Texas.

National Hispanic Council on Aging

National Hispanic Council on Aging (NHCOA) works closely with its Hispanic Aging Network composed of 39 community-based organizations across the continental U.S., the District of Columbia, and Puerto Rico. The NHCOA will deploy Navigators in Dade County, Florida, and Dallas County, Texas, to enroll the uninsured Hispanic population in these two counties with a focus on members of this population that are socially isolated due to cultural and linguistic differences.

Change Happens

Change Happens is a non-profit located in Houston, Texas, with experience in conducting community engagement through education, outreach, and developing dynamic relationships with community members. The goal of the project is to provide trained Navigators with expertise in eligibility and enrollment rules and procedures to conduct public education and
outreach activities that result in 98,891 uninsured individuals enrolled in affordable health insurance.

United Way of El Paso County

United Way of El Paso County has served residents of El Paso, Texas for over 90 years. Through the Enroll El Paso project this grant will provide training to people to work with the community and provide education and assistance with Marketplace enrollment.

Southern United Neighborhoods

Southern United Neighborhoods is a public charity that uses research and training to combat poverty. Southern United Neighborhoods Navigators will provide expertise in eligibility, enrollment and program specifications of Affordable Insurance Exchanges in Arkansas, Louisiana and Texas; implement comprehensive outreach and public education to over 835,000 low to moderate income residents who are likely to be eligible for enrollment in a QHP; and coordinate with community groups, employers, faith-based groups and state agencies to integrate outreach efforts.

East Texas Behavioral Healthcare Network (ETBHN)

The East Texas Behavioral Health Network (ETBHN) will serve the uninsured, underinsured, and self-employed population in 75 counties in Texas. This program will assist this population with understanding new healthcare programs, taking advantage of consumer protections, and navigating the health insurance system in order to find the most affordable coverage that meets their needs.

National Urban League

The National Urban League Navigators plan to conduct outreach and enrollment predominantly in areas that have low-income, medically underserved, urban residents in Texas.

Who you can contact for more help

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know  with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in Texas

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

 The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Texas

On July 9, 2012, Governor Rick Perry (R) announced that Texas would not establish an exchange.1 Prior to this announcement, the Department of Insurance and the Health and Human Services Commission had partnered to explore exchange implementation plans.2 Using federal grant funding they identified subcontractors to assist with the exchange planning process, to collect stakeholder feedback, and to investigate the state’s policy options. In addition, Texas held a public exchange planning symposium and solicited public comments in early 2011.3

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. In August 2012, the Texas Department of Insurance held a public forum to discuss stakeholder feedback on the possible EHB benchmark plans.4 Texas did not put forward a recommendation and the state’s benchmark EHB plan will default to the largest small-group plan in the state, Blue Cross Blue Shield of Texas- BestChoice PPO.

Exchange Funding

The Texas Department of Insurance received a federal Exchange Planning grant of $1 million in 2010, though the state has since returned $900,000 of this grant to the federal government.5

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Texas is not participating in Medicaid expansion.

Next Steps

The federal government will assume full responsibility for running a health insurance exchange in Texas beginning in 2014.


1. Press Release from Governor Rick Perry. “Gov. Perry: Texas Will Not Expand Medicaid or Implement Health Benefit Exchange.” July 9, 2012. http://governor.state.tx.us/news/press-release/17408/
2.Ramshaw E. “Perry Rejects ‘Obamacare,’ But State Agency Pushes On.” The Texas Tribune. June 20, 2011.http://www.texastribune.org/texas-health-resources/health-reform-and-texas/perry-rejects-obamacare-but-state-agency-pushes-on/
3. “Federal Healthcare Reform- Exchange Planning Symposium. Background Information and Requested Stakeholder Input.” February 14, 2011. http://www.tdi.texas.gov/health/documents/background.pdf  (Access August 15, 2011)
4. Texas Department of Insurance. “Essential Health Benefits.” (Accessed September 5, 2012).http://www.tdi.texas.gov/health/documents/ehbsummary.pdf
5. Tan, Thanh. “Health Leaders Say They’re Ready for Federal Reforms.” The Texas Tribune. February 27, 2012.http://www.texastribune.org/texas-state-agencies/health-and-human-services-commission/will-texas-implement-federal-health-care-reforms/

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in Tennessee

Health Insurance Marketplace in Tennessee

If you live in Tennessee, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014.

Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Tennessee has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Tennessee’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Consumer Operated and Oriented Plan Program

Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets.  CO-OP in Tennessee:

Community Health Alliance Mutual Insurance Company

Who can help you (the Navigators)

Get local help

Structured Employment Economic Development Corporation

Seedco, a national organization, helping low-income households and communities move toward economic prosperity since 1987, will act as lead agency for a consortium of partners in each state and oversee all aspects of the proposed program, providing technical assistance, financial oversight, compliance protocols, and partner facilitation. Seedco and its partners will support the activities of Navigators in Georgia and Tennessee, many of whom will be roving.

Tennessee Primary Care Association

The Tennessee Primary Care Association (TPCA) is a community-focused non-profit that aims to improve access to primary health care through leadership, advocacy and support of community health centers. TPCA will leverage health centers’ existing relationships to conduct outreach and enrollment efforts, and reach beyond its member CHC efforts to fill gaps in geographic coverage in the 13 counties not served by community health centers.

Who you can contact for more help

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know  with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in Tennessee

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

 The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Tennessee

On December 10, 2012, Governor Bill Haslam (R) announced Tennessee would default to a federally-facilitated health insurance exchange.1

Prior to the announcement that the state would not operate its own exchange, the Tennessee Department of Finance and Administration established the Insurance Exchange Planning Initiative to advise the Governor and Legislature on exchange implementation. The Initiative worked closely with a variety of stakeholders and content experts, including agents, brokers, underwriters, actuaries, providers, and advocates.2,3 Stakeholder feedback was compiled into a white paper released in October 2011; findings indicated overwhelming preference for a state-run, rather than a federally-operated, exchange.4

A measure restricting health plans in the exchange from offering abortion coverage, with no exceptions, became law on May 5, 2010, without former Governor Phil Bredesen’s (D) signature (HB 2681/SB 2686).5

Contracting with Plans:
 In September 2012, the Exchange Planning Initiative released a Request for Information for qualified health plans in the individual exchange market.6 In 2012, the state convened a new Technical Assistance Group (TAG) of actuaries to provide expertise on reinsurance and risk adjustment.7

Small Business Health Options Program (SHOP) Exchange: In March 2012, the state released a Request for Information on information technology services for the Small Employer Health Options Program exchange.8 The Department of Finance and Administration had solicited subcontractors to conduct multiple analyses related to the establishment of an exchange, including an analysis of the merger of the individual and small group markets.9

Information Technology (IT): The state released a Request for Proposals (RFP) soliciting subcontractors to implement a significant Medicaid eligibility system upgrade to seamlessly integrate with the Children’s Health Insurance Program (CHIP) and interface with an exchange. Tennessee also participated in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use.10

Tennessee Bridge Option: Tennessee developed the Bridge Option proposal as is an alternative to the Affordable Care Act’s (ACA) Basic Health Program.11 Both options aim to improve the affordability of coverage for individuals with incomes above the Medicaid eligibility threshold and up to 200% of the poverty level. The Bridge Option would enable individuals moving from Medicaid to subsidized coverage in the Exchange to remain in lower-cost Medicaid managed care plans, or bridge plans. This approach would also allow all members of a nuclear family to hold coverage through a common insurer and provider network regardless of their eligibility status. The Department of Health and Human Services has indicated that states will be allowed to offer bridge plans through their exchanges, though it is not clear whether these plans will be offered in the federal exchange.

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since Tennessee has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Blue Cross Blue Shield of Tennessee PPO.

Exchange Funding

The Tennessee State Department of Finance and Administration received a $1 million federal Exchange Planning grant in September 2010. The Department has since received three federal Level One Establishment grants: $1.5 million in November 2011, $2.2 million in February 2012, and $4.3 million in May 2012. The grants are for continued exchange planning including for the procurement of technical expertise, funding staffing needs, planning for a health plan management system, marketing and outreach, and consumer assistance.12

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Tennessee is considering purchasing private coverage for the uninsured as a form of Medicaid expansion.

Next Steps

The federal government will assume responsibility for running a health insurance exchange in Tennessee beginning in 2014.

Additional planning documents for Tennessee’s health insurance exchange can be found at:http://www.tn.gov/nationalhealthreform/exchange.html


1. ‘Haslam Announces State Will Not Run Health-Care Exchange.’ December 10, 2012.https://news.tn.gov/node/10017
2. Insurance Exchanges: What Makes Sense for Tennesssee? Powerpoint presentation. Tennessee Healthcare Financial Management Association. May 24, 2011. http://www.tn.gov/nationalhealthreform/forms/HC21.pdf
3. Press Release. State Insurance Exchange Planning Initiative TAG members.http://www.tn.gov/nationalhealthreform/forms/exhange110810.pdf
4.Best Alternatives to a Federal Exchange in Tennessee: A Summary of Stakeholder Feedback. October 21, 2011. State of Tennessee Insurance Exchange Planning Initiative.http://www.tn.gov/nationalhealthreform/forms/fulldocument.pdf
5. House Bill 2681/ Senate Bill 2686. http://www.capitol.tn.gov/Bills/106/Bill/SB2686.pdf
6. Request for Information. Insurance Exchange Planning Initiative. State of Tennessee.http://tn.gov/generalserv/purchasing/ocr/documents/RFI31865-00709.pdf
7. Tennessee Transitional Reinsurance Program: 3Rs Actuarial TAG. DRAFT. April 10, 2012. Gorman Actuarial, LLC. http://www.tn.gov/nationalhealthreform/forms/rrtagpresentation041012.pdf
8. Request for Information. State of Tennessee- Insurance Exchange Planning Initiative. March 15, 2012.http://tn.gov/generalserv/purchasing/ocr/documents/RFI31865-00707.pdf
9. Exchange Planning Grant Second Quarter Report. May 2, 2011.http://www.tn.gov/nationalhealthreform/forms/planninggrant2ndqtr.pdf
10. Enroll UX 2014 website. http://www.ux2014.org/
11. Bridge Option: One Family, One Card Across Time. Tennessee Insurance Exchange Planning Initiative. November 21, 2011. http://www.tn.gov/nationalhealthreform/forms/onefamily.pdf
12. Tennessee Level One Establishment grant. Department of Finance and Administration. September 30, 2011.http://www.statecoverage.org/files/TN_level1establishmentgrant.pdf

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in South Dakota

Health Insurance Marketplace in South Dakota

If you live in South Dakota, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014.

Spanish language speakers can contact cuidadodesalud.gov

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the Arkansas insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Medicaid in South Dakota

South Dakota has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under South Dakota’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Who can help you (the Navigators)

Get local help

South Dakota Community Action Partnership

The South Dakota Community Action Partnership will work with partners to assist South Dakota’s 92,441 uninsured consumers to prepare electronic and/or paper applications that will establish eligibility and enrollment in coverage through the Marketplace and potentially qualify for an insurance affordability program. The South Dakota Navigators Coalition will also provide outreach and education to raise awareness about the Marketplace, and will refer consumers to consumer assistance programs when necessary.

Great Plains Tribal Chairmen’s Health Board

The Great Plains Tribal Chairmen’s Health Board (GPTCHB) is a community based consumer focused non-profit that will provide enrollment assistance to American Indians residing on and near the eight Reservations in South Dakota and the four Reservations and one Indian Service Area in North Dakota and those residing in major urban areas served by Urban Indian Health Centers in these two States.

Who you can contact for more help

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know  with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter.

Accountable Care Organizations in South Dakota

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in South Dakota

On September 26, 2012, Governor Dennis Daugaard (R) announced that South Dakota would not establish an exchange.1However, the state intends to maintain regulatory authority over the health insurance market and perform the plan management function for the exchange.2 The decision to have a federally-facilitated exchange was made after an inter-agency work group and a taskforce of stakeholders and legislators explored the possibility of establishing a state-based exchange.3,4

On March 19, 2012, South Dakota enacted a law prohibiting plans in a state exchange from offering abortion coverage, except when it is necessary to preserve the life or health of the pregnant woman.5

Contracting with Plans: On March 11, 2013, Director of the Division of Insurance Merle Scheiber sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO) requesting to maintain control over plan management functions despite not having entered into a state-federal partnership exchange. The Division of Insurance (DOI) has the legal authority and operational capacity to oversee certification of Qualified Health Plans (QHPs). DOI will use the System for Electronic Rate and Form Filing (SERFF) to collect and analyze information on plan rates, covered benefits, and cost-sharing requirements. DOI will also ensure continued plan compliance, manage consumer complaints, and oversee decertification of issuers.6

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. In the fall of 2012, Governor Daugaard selected the Wellmark Blue Cross Blue Shield’s Blue Select plan to be the South Dakota’s EHB benchmark.7

Exchange Funding

The South Dakota Office of the Governor received a federal Exchange Planning grant of $1 million in 2010. In May 2012, the Division of Insurance was award a Level One Establishment grant of $5.9 million to further the state’s planning and design of an exchange, including creation of a risk adjustment and reinsurance plan, studying the effects of adverse selection, designing an outreach and education plan, and writing an RFP for a comprehensive IT development plan.8

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

South Dakota is not participating in Medicaid expansion.

Next Steps

On March 29, 2013, South Dakota received approval from CCIIO to perform plan management activities. The federal government will retain control over all other Exchange functions.9


1. Press release from the office of Governor Daugaard. “South Dakota Will Not Build Health Insurance Exchange.” September 26, 2012. http://news.sd.gov/newsitem.aspx?id=13607
2. Division of Insurance Newsletter, South Dakota Department of Labor and Regulation. Fall 2012.http://dlr.sd.gov/insurance/publications/newsletter_fall12.pdf
3. South Dakota’s State Planning and Establishment Grant Project Report, Quarter 4. October 28, 2011.http://healthreform.sd.gov/documents/4thQuarterlyExchangePlanningGrantsReport_000.pdf
4. South Dakota’s Health Insurance Exchange Task Force Subcommittee Listing. June 17, 2011.http://healthreform.sd.gov/reports/HIE%20Task%20Force%20Subcommittee%20Listing.pdf
5. HB 1185. South Dakota’s 2012 act regarding coverage for abortions by plans in the exchange.http://legis.state.sd.us/sessions/2012/Bills/HB1185ENR.pdf
6. Letter from Director Scheiber to Gary Cohen. March 11, 2013.
7. Division of Insurance Newsletter, South Dakota Department of Labor and Regulation. Fall 2012.
8. HealthCare.gov factsheet. “South Dakota Affordable Insurance Exchange Grants Awards List.” Accessed June 8, 2012. http://www.healthcare.gov/news/factsheets/2011/05/exchanges/sd.html
9. Letter from Gary Cohen to Director Scheiber. March 29, 2013. http://cciio.cms.gov/Archive/Technical-Implementation-Letters/sd-pm-letter-03-29-2013.pdf

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in South Carolina

Health Insurance Marketplace in South Carolina

If you live in South Carolina, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014. Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

South Carolina has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under South Carolina’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Consumer Operated and Oriented Plan Program

Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets.  CO-OP in South Carolina:

Consumer Choice Health Plan

Who can help you (the Navigators)

Get local help

DECO Recovery Management LLC

DECO Recovery Management, a national leader in medical assistance eligibility management and patient advocacy, has taken a lead role in the establishment of a consortium with strategically located partners in South Carolina, to perform the cooperative agreement activities as a Navigator. DECO and its consortium partner TBB-SC will conduct targeted marketing campaigns and public education events throughout the state.

The Cooperative Ministry

The Cooperative Ministry is establishing the Health Insurance Education Cooperative to provide pathways to better health and quality for uninsured persons in South Carolina. This effort targets eight counties that comprise the Columbia-Orangeburg-Newberry Region, and aims to reach, engage, and help enroll all eligible consumers in that area.

Beaufort County Black Chamber of Commerce

Beaufort County Black Chamber of Commerce will utilize existing networks and infrastructures within various parts of the region to provide outreach around new coverage options. BCBCC will be conducting workshops, community meetings and individual counseling activities as part of the overall education and outreach efforts.

Who you can contact for more help

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know  with the form below and we’ll get right back to you.

Subscribe to the Obamacare-enrollment newsletter

Accountable Care Organizations in South Carolina

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Health care facilities where Innovation Models are being tested

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in South Carolina

On November 15, 2012, Governor Nikki Haley (R) informed federal officials South Carolina would default to a federally-operated health insurance exchange.1 This decision was largely based on findings from the South Carolina Health Planning Committee which had concluded the state cannot implement a state-based exchange as required by the Affordable Care Act (ACA) and should instead encourage the establishment of private exchanges.2 The Governor created the Committee via Executive Order to assist with policy recommendations regarding whether and how South Carolina should establish a health insurance exchange; however, her influence over the Committee’s findings was called into question in December 2011.3,4

Prior to the announcement that the state would not operate its own exchange, the Governor signed into law S 0102, a bill prohibiting plans in a state exchange from offering abortion coverage, except in cases of rape, incest, or to avert the death of a pregnant woman.5

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since South Carolina has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Blue Cross Blue Shield of South Carolina- Business Blue Complete, PPO.

Exchange Funding

In September 2011, the South Carolina Department of Insurance received a federal Exchange Planning grant of $1 million. Governor Haley stated South Carolina would not pursue any more federal grant money to fund a possible state-run exchange.6

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

South Carolina is not participating in Medicaid expansion.

Next Steps

The federal government will assume full responsibility for running a health insurance exchange in South Carolina in 2014.

Additional information about South Carolina’s Health Planning Committee can be found at: http://www.healthplanning.sc.gov


1. Letter from Governor Haley toHHS. November 15, 2012.http://governor.sc.gov/Documents/Gov%20Nikki%20Haley%20Letter%20to%20HHS%20Secretary.pdf
2. “Improving the Health Care Marketplace in South Carolina: Strategies and Policies Recommended by the South Carolina Health Planning Committee.” November 2011.http://doi.sc.gov/Documents/ACA%20Grants/SCHPCFinalReport.pdf
3. Executive Order 2011-09: http://www.scstatehouse.gov/reports/executiveorders/exor1109.htm
4.  ‘Harkin Blasts South Carolina Over Exchange’. December 23, 2011. Kaiser Health News.http://www.kaiserhealthnews.org/daily-reports/2011/december/23/south-carolina-exchange-grant.aspx
5. S 0102. 2012 Legislative session. Signed June 7, 2012.http://www.scstatehouse.gov/sess119_2011-2012/bills/102.htm
6. Largen, Stephen. ‘Haley to shun federal funds.’ Go Upstate. July 1, 2011.http://www.goupstate.com/article/20110701/ARTICLES/110709990

Also of interest

Provided by the Henry J. Kaiser Family Foundation