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

Obamacare in Rhode Island

Health Insurance Marketplace in Rhode Island

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

Choosing the Right Health Insurance Plan

There are a number of different tiers of plans available on the Rhode Island 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.

Rhode Island health insurers don’t have to offer every tier of plan, but within the Rhode Island 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

If you’re a consumer and you live in Rhode Island, you’ll use HealthCare.gov to apply and enroll. Here’s what to know before you apply. You can see if you qualify for lower costs and preview plans and prices. Small businesses: Learn how to apply for SHOP coverage.

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 Rhode Island

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 Rhode Island

After the legislature failed to pass exchange legislation during the 2011 session, Governor Lincoln Chafee (I) signed Executive Order 11-09 on September 19, 2011, to establish the Rhode Island Health Benefit Exchange.1 In July 2013, Rhode Island announced that its new marketplace would be called HealthSource RI.2

Recommendations by the Rhode Island Healthcare Reform Commission largely informed the Governor’s decision to issue an Executive Order. After SB 87 failed, the Commission regrouped to continue planning a state-based exchange.3 The Commission’s Executive Committee focused on evaluating non-legislative strategies to establish an exchange, while the Commission’s Health Insurance Exchange Workgroup began meeting biweekly to form recommendations on policy options to the Executive Committee.

Structure: The Executive Order establishes the Rhode Island Health Benefit Exchange as “a Division within the Executive Department.”

Governance: The Exchange will be governed by a 13-member board. The Board includes four ex officio members (or their designees): the Director of the Department of Administration; the Health Insurance Commissioner; the Secretary of the Executive Office of Health and Human Services; and the Director of the Department of Health. The Governor appoints nine Board members, two of whom will represent consumer organizations and two to represent small businesses. The remaining appointees will provide demonstrated expertise in a diverse range of health care areas including, but not limited to, individual health care coverage, small employer health care coverage, health benefits plan administration, health care finance and accounting, administering a public or private health care delivery system, state employee health purchasing, electronic commerce, and promoting health and wellness. Board members cannot be affiliated with in any way, an insurer, a health insurance agent or broker, a health care provider, or a health care facility or clinic. No Board member can be a health care provider, unless no compensation is received for services rendered and the provider has no ownership interest in a professional health care practice.

The Exchange Board is required to receive guidance from an Expert Advisory Committee comprised of health industry experts, including representatives of insurers, agents and brokers, and providers. The Board also collects feedback from the Commission’s Health Insurance Exchange Workgroup, which allows for stakeholder participation and input on policy decisions.

Current appointed Board members are:

  • Margaret Curran (Chair), former United States Attorney for Rhode Island
  • Geoffrey E. Grove (Vice-Chair), Pilgrim Screw
  • Michael C. Gerhardt, Save The Bay and former Health Insurance Executive
  • Margaret Holland McDuff, Family Services of Rhode Island
  • Linda Katz, The Economic Progress Institute
  • Marta Martinez, Progresso Latino
  • Pamela McKnight, MD (not currently practicing)
  • Dwight McMillan, The Basics Group
  • Tim Melia, UFCW New England Council

In June 2012, the Board hired an Executive Director to oversee all Exchange activities. The Board has met regularly since October 2011 and receives feedback from the Commission’s Health Insurance Exchange Workgroup and the Expert Advisory Committee. Subcontractors have been solicited to provide Exchange technical assistance including, assistance with business processes, stakeholder support, health plan certification, financial management and oversight, and commercial market activities to support the viability of the Exchange.45

In June 2012, the Governor signed SB 2888 into law requiring the Office of the Health Insurance Commissioner and the state’s Executive Office of Health and Human Services to issues a series of reports to the Joint Committee on Health Care Oversight by October 1, 2012.6 The reports were required to analyze state options regarding the feasibility of implementing a Basic Health Program Option (BHP), the impact of merging of the small-group and individual markets on rates and coverage, and the feasibility of requiring the same insurance products to be sold inside and outside of the Exchange, including an assessment of coverage and rate impacts.

Contracting with Plans: The Exchange will function as an active purchaser that has “the discretion to determine whether health plans offered through the Exchange are in the interests of qualified individuals and qualified employers.” The Advisory Committee has explored Rhode Island’s options for risk adjustment and reinsurance, noting that legislation will be necessary in the future.7

The Exchange began direct negotiations with carriers in the fall of 2012. All four carriers in Rhode Island expressed interested in selling through HealthSource RI–Blue Cross Blue Shield of Rhode Island, Neighborhood Health Plan of Rhode Island and United Healthcare (SHOP only) filed to offer in 2014 and Tufts Health Plan intends to file for 2015. There will be twelve plans offered through the individual market and sixteen on the small group market.8 In June 2013, the Office of the Health Insurance Commissioner approved final forms and rates for plans submitted by carriers.9 The HealthSource RI Board will certify QHPs for inclusion on the marketplace.

Consumer Assistance and Outreach: The state has hired staff to focus on public outreach for the Exchange. In November 2012, the Exchange Board reviewed a draft Request for Proposals for the Exchange Contact Center.10 In addition, a subgroup of the Exchange Board was formed to work on stakeholder issues and consumer support strategies. In May 2013, the Rhode Island Department of Administration/Division of Purchases issued a Request for Proposals (RFP) for a vendor to select and manage the state’s Outreach and Enrollment Support Program (OESP) network. The OESP will consist of assisters and assister entities that will provide outreach and enrollment assistance to individuals and families applying for coverage through HealthSource RI. The awardee will become the Network Manager and will be responsible for training, certifying, managing, and compensating the network of assisters. Applications were due on June 4, and the contract will begin at the end of July.11 In March 2013, the state released a RFP for a vendor to design and implement a contact center and in May 2013 selected a vendor.12 The contact center will be operational by September 15, 2013.

In July 2013, Rhode Island launched the “39 in 3” campaign, through which HealthSource RI officials will visit all 39 Rhode Island cities in three months to educate small employers, community organizations, and individuals about the health coverage options that will be available to them through the marketplace in 2013. Also in July, the state launched a marketplace website and contracted with a marketing firm to develop and produce a media campaign.13

Small Business Health Options Program (SHOP) Exchange: The Exchange Board has begun to engage in a broad discussion of SHOP issues and options, including how to best mitigate against adverse selection, how to broaden employee options in the SHOP, and how to develop sufficient data to be able to offer the consumer and employers information about value. The SHOP will use the full employee choice model; employers will give their employees the choice to enroll in any plan offered through the SHOP.8

Information Technology (IT): Rhode Island envisions building an integrated eligibility system that will make determinations for Medicaid, the Exchange, and eventually for other public programs. In January 2013, the state awarded a $105 million contract to a vendor to design, implement, and operate a technology platform to support the Exchange and the integrated eligibility system.14 In January 2012, the state solicited subcontractors to manage the transition to an upgraded Medicaid Management Information System.5, 15 The state is also part of a consortium participating in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use.16

Financing: The Executive Order authorizes the Exchange to receive funds from insurers or other entities, including the United States Department of Health and Human Services. The Board will determine how the funds are to be received from insurers and the amounts.

Essential Health Benefits (EHB): The Affordable Care Act 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. In September 2012, the state recommended Blue Cross Blue Shield of Rhode Island- Vantage Blue PPO to serve as the benchmark plan.

Exchange Funding

The Rhode Island Department of Business Regulation received a federal Exchange Planning grant of $1 million in 2010 and was awarded a $5.2 million federal Level One Exchange Establishment grant in May 2011 to “strengthen health information technology systems, develop an integrated consumer support program to provide support to individuals and small businesses, and strengthen its business operations.” In addition, Rhode Island 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, Maine, Vermont, and Massachusetts with the University of Massachusetts Medical School as the grant holder. In November 2011, Rhode Island received the first Level Two Exchange Establishment grant. The $58.5 million grant will fund the development, design, and technology procurement of the Exchange through December 2014.17

Rhode Island, along with nine other states, is receiving 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.18

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.

Rhode Island is participating in Medicaid expansion.

 Next Steps

On December 20, 2012, Rhode Island received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange. 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 developing a comprehensive implementation plan. The state must also participate in a working session with the federal government and their system integrator vendor before February 28, 2013, to update timelines, re-prioritize projects, and outline specific opportunities of reuse of IT system components.1920

Additional information about the Rhode Island Healthcare Reform Commission can be found at: http://www.healthcare.ri.gov/.

Footnotes
  1. Executive Order 11-09. Establishment of the Rhode Island Health Benefits Exchange.← Return to text
  2. Rhode Island’s Obamacare marketplace will open Oct. 1 as HealthSource RI.” July 15, 2013.← Return to text
  3. SB87. Rhode Island’s bill to establish a health benefit exchange in 2011.← Return to text
  4. Rhode Island Level One Establishment grant application. Funding Opportunity IE- HBE-11-004.← Return to text
  5. Request for Proposals #7449222: Health Insurance Exchange Technical Assistance. November 9, 2011.← Return to text
  6. SB2888. An Act Relating to Insurance. 2012.← Return to text
  7. Risk Adjustment and Reinsurance. Rhode Island Health Benefits Exchange Expert Advisory Committee. November 22, 2011.← Return to text
  8. Rhode Island Health Benefits Exchange. Update on Qualified Health Plan Filings: Advisory Board Briefing. May 15, 2013.← Return to text
  9. Office of the Health Insurance Commissioner. “OHIC Approves Commercial Health Insurance Contracts, Rates and Rate Factors.” June 28, 2013.← Return to text
  10. RI Health Benefits Exchange Advisory Board. Meeting Minutes. November 13, 2012.← Return to text
  11. Request for Proposals: Rhode Island Outreach and Enrollment Support Program (OESP): Network Manager. May 2, 2013.← Return to text
  12. Request for Proposals: Rhode Island Health Insurance Contact Center. March 20, 2013.← Return to text
  13. HealthSource RI. Communications Plan Launch Messaging & Activities July-August. July 16, 2013.← Return to text
  14. Deloitte Awarded $105m Contract to Create New Healthcare System.” January 24, 2013.← Return to text
  15. Request for Proposals. EOHHS PMO and IV&V Services for MMIS system transition and health information exchange/ eligibility system implementation. January 24, 2012.← Return to text
  16. Enroll UX 2014 website.← Return to text
  17. Rhode Island Affordable Insurance Exchange Awards List. CCIIO.← Return to text
  18. Robert Wood Johnson Foundation. ‘RWJF Seeks Coverage of 95 Percent of All Americans by 2020.’ May 6, 2011.← Return to text
  19. Letter from Governor Chafee to Kathleen Sebelius. July 5, 2012.← Return to text
  20. Letter from HHS to Governor Chafee. December 20, 2012.← Return to text

Also of interest

Obamacare in Pennsylvania

Health Insurance Marketplace in Pennsylvania

If you live in Pennsylvania, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Spanish language speakers can contact cuidadodesalud.gov. Specific plans and prices will be available on October 1, 2013, when Marketplace open enrollment begins. Coverage can start as soon as January 1, 2014.

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

Pennsylvania 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 Pennsylvania’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 you can contact for more help

Who can help you (the Navigators)

Get local help

Resources for Human Development, Inc.

Resources for Human Development, Inc. (RHD), a non-profit organization based in Philadelphia, Pennsylvania, will provide enrollment assistance in the ten counties in Pennsylvania with the highest rates of uninsured people. RHD will target specific groups and individuals who traditionally have poor access to healthcare insurance coverage.

Pennsylvania Association of Community Health Centers

Pennsylvania Association of Community Health Centers (PACHC) represents and supports the largest network of primary health care providers in the Pennsylvania. PACHC will coordinate enrollment assistance efforts in underserved areas throughout the Commonwealth using a connected and networked approach.

Pennsylvania Mental Health Consumers’ Association

Pennsylvania Mental Health Consumers Association (PMHCA) will work in a consortium with Mental Health Association in PA (MHAPA) and Mental Health America Westmoreland County (MHAWC) to provide enrollment assistance to people who use or need behavioral health services in their insurance plans, particularly those who experience serious mental illness or serious psychological distress.

Mental Health America

The Mental Health America Navigator Initiative will target underserved individuals with behavioral health disorders who are uninsured or underinsured. The National Office of Mental Health America (MHA) will serve as the lead agency in the Initiative. The Mental Health Association of Southeastern Pennsylvania (MHASP) will serve Bucks, Chester, Delaware, Montgomery, and Philadelphia counties in Pennsylvania.

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 Pennsylvania

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 Pennsylvania

On December 12, 2012, Governor Tom Corbett (R) notified federal officials that Pennsylvania would default to a federally-facilitated health insurance exchange.1

Prior to the announcement, the Pennsylvania Insurance Department had taken the lead with exchange planning. The Insurance Department, released an extensive report in November 2011 that suggested broad support for a state-run exchange.2 In January 2012, the Department released a conceptual draft for proposed legislation which would establish multiple private exchanges overseen by the Department.3 Consumer representatives expressed concern over the proposed model, citing such an approach would be inconsistent with the exchange requirements under the Affordable Care Act (ACA).4 In May 2012, the Department had begun soliciting for a subcontractor to provide guidance and consultation on exchange planning.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 Pennsylvania has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Aetna POS.

 Exchange Funding

In September 2010, the Pennsylvania Insurance Department was awarded a $1 million federal Exchange Planning grant. In February 2012, the Department was awarded a $33.8 million federal Level One Establishment grant to continue with exchange planning and the procurement of technical expertise.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.

Pennsylvania is participating in Medicaid expansion by reforming Medicaid.

Next Steps

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


1. Press Release PA Insurance Department. Governor Corbett Announces State-based Insurance Exchange Decision. December 12, 2012.
2. Commonwealth of Pennsylvania, Pennsylvania Insurance Department. Insurance Exchange Planning. November 21, 2011. KPMG.http://www.portal.state.pa.us/portal/server.pt/community/health_insurance/9189/health_insurance_exchange_-_archived_exchange_information/1075404
3. Commonwealth Health Insurance Marketplace and Exchange Access Act. Conceptual Draft. January 30, 2012. http://www.phlp.org/wp-content/uploads/2012/03/Draft-exchange-bill-1-31-12.pdf
4. Comments on the Conceptual Draft of the Commonwealth Health Insurance Marketplace and Exchange Access Act. Community Legal Services and Pennsylvania Health Law Project. February 14, 2012. http://www.phlp.org/wp-content/uploads/2012/03/CLS-PHLP-Comments-to-PID-Exchange-Legislation-Conceptual-Draft.pdf
5. Pennsylvania Insurance Department. Request for Quotations for Pennsylvania Insurance Exchange Planning. May 2, 2012. http://www.emarketplace.state.pa.us/FileDownload.aspx?file=6100022192/Solicitation_0.pdf
6. Level One Exchange Establishment Grant application. Submitted December 28, 2011.http://www.portal.state.pa.us/portal/server.pt/community/health_insurance/9189/health_insurance_exchange/1064758

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in Oregon

Obamacare-enrollment.com is a site where you can find detailed information on the Affordable Care Act for individuals and small businesses.

________________

Health Insurance Marketplace in Oregon

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

The Insurance Exchange/Marketplace

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

Establishing the Exchange in Oregon

On June 17, 2011, Governor John Kitzhaber (D) signed SB 99 into law establishing the Oregon Health Insurance Exchange Corporation.1  That same month, the Governor signed SB 91, which specified requirements of health insurance carriers offering coverage in the state.2 On March 6, 2012, the legislature passed HB 4164 to approve the final version of the Exchange’s business plan.3 On October 1, 2012, the Exchange announced that its new name would be Cover Oregon.

Structure: The legislation defines Oregon’s Exchange as a quasi-governmental organization, specifically a “public corporation performing governmental functions and exercising governmental powers.”

Governance: Cover Oregon is governed by a nine-member board, including two ex officio members (or their designees): the Director of the Oregon Health Authority and the Director of the Department of Consumer and Business Services. The Governor appoints seven members who are subject to confirmation by the Senate, with expertise or experience in individual insurance purchasing, business, finance, sales, health benefits administration, individual and small group health insurance, or the use of a health insurance exchange. Also, at least two appointed members must be individual or small business consumers of the Exchange.  No more than two appointed members can be employed by, consultant to, or members of a board of directors of the following organizations: an insurer or third-party administrator; an insurance producer; a health care provider, facility, or clinic; or a trade association for these parties. Board members must declare any conflicts of interest and abstain from voting on related issues.

The Oregon Senate confirmed the Governor’s nominees to the Health Insurance Exchange Board on September 23, 2011.4 They are:

  • Liz Baxter (Chair), We Can Do Better
  • Teri Andrews (Vice-Chair), CG Industries
  • Ken Allen, Oregon American Federation of State and County Municipal Employees
  • Dr. George Brown, Legacy Health Systems
  • Alea Christofferson, ATL Communications
  • Jose Gonzales, Tu Casa Real Estate Corporation
  • Gretchen Peterson, Hanna Anderson

The Board appointed an Executive Director on October 6, 2011.5

As mandated by the Exchange’s authorizing legislation, the Board created a standing Consumer Advisory Committee to facilitate collection of stakeholder input, in addition to the public forum section on the website where policy questions are posted for public feedback. The Committee meets regularly and includes representatives of individual and small businesses, advocacy organizations, and medical and social service providers. Cover Oregon also maintains a standing Tribal Technical Workgroup and multiple ad hoc stakeholder groups : an Actuarial Workgroup, a Small Business Health Options Program (SHOP) Workgroup, a Carrier Technology Workgroup, an Agent Advisory Committee (will be developed after the initial open enrollment period), a Qualified Health Plan Certification Workgroup, and a Stakeholder Engagement Workgroup.6

In addition, a four-member bipartisan and bicameral Legislative Advisory and Oversight Committee for the Oregon Health Insurance Exchange Corporation will oversee the implementation of the Exchange.

Contracting with Plans: Cover Oregon is authorized to act as an active purchaser when contracting with plans, specifically to “limit the number of qualified health plans (QHP) that may be offered through the exchange as long as the same limit applies to all insurers.” While Cover Oregon will not negotiate rates, it will set requirements for QHPs that are stronger than the outside market in several areas. These standards will be the same for all carriers, and carriers’ plans must meet these elevated standards to participate. Carriers may choose to participate in either or both the Individual Exchange and the SHOP, and are not required to participate in the same markets inside and outside the Exchange. Carriers participating in Cover Oregon are required to offer a standard bronze, silver-, and gold-level plan in each service area of each Exchange market – Individual and Small Employer – in which they participate. Carriers offering plans at any metal level must also offer a child-only plan at that level. In addition to the standard plans, carriers have the option to offer the following plans: two non-standard plans; two additional plans that demonstrate innovation in the use of networks, wellness programs or other options not related to premiums or benefits; three platinum plans; and/or one catastrophic plan. However, each carrier may only offer up to three plans in each metal tier, including the standard plans at the bronze, silver, and gold levels.7 Catastrophic plans may only be sold in the Exchange’s Individual Market to specific populations stipulated in the ACA: individuals under age 30, individuals for whom coverage is unaffordable, and individuals with a hardship.8

The Department of Consumer and Business Services created an Advisory Committee to develop standards for bronze- and silver-level plans to help the state monitor and compare plans.9 In addition, information on carrier quality ratings will be available to consumers on Cover Oregon’s website. The website will display quality information about the participating carriers, including an aggregated experience score based on CAHPS data (Consumer Assessment of Healthcare Providers and Systems) that plans already collect and two encounter-based utilization scores.10 Cover Oregon anticipates that displayed quality information will change in later years to include measures of patient experience or the impact on disparities in access to care.

In October 2012,  Cover Oregon released a Request for Applications to health insurance carriers interested in offering benefit plans through the individual and/or small group exchange.8 The state later adopted regulations related to certification of QHPs.11  In May 2013, Cover Oregon announced that twelve health insurance carriers have filed plans to sell on the Marketplace. All twelve have indicated that they will participate in the individual market, and eight will offer plans in the small group market.12 These carriers submitted QHPs and proposed rates for 2014 to the Insurance Division,13 which held two weeks of public hearings on the proposed rates. The Division plans to review and approve rates by early July 2013.14 Cover Oregon must then review the plans for Marketplace-specific requirements and certify the plans as QHPs. Cover Oregon has also released draft medical and dental contracts for carriers.15  Carrier certification occurs once every two years, and carriers that did not apply initially must wait until 2015 to apply (for the 2016 plan year). Changes to existing QHPs can be made annually, and the plan and rates must be approved by the Insurance Division and certified by the Exchange. Carriers may add plans mid-year, but cannot exceed three plans in each metal tier in a service area.

In June 2013, Cover Oregon released a proposed rule that establishes eligibility standards and the application process for enrollment in a QHP, and for insurance affordability programs available through the Exchange.16

Dental and Vision Benefits: QHPs with embedded dental benefits, QHPs without dental benefits, and stand-alone dental plans may be sold on the Exchange. Medical carriers offering plans through Cover Oregon may decide whether to include pediatric dental benefits in a medical offering, and plans that include pediatric dental will be displayed alongside plans that do not. The inclusion or exclusion of pediatric dental benefits will be  indicated in the plan details, in the same way as  other non-mandatory benefits. Cover   Oregon will offer stand-alone dental plans as a separate offer after a medical selection is made. All standalone dental plans must cover the pediatric dental essential health benefit at the high (85%) or low (70%) actuarial value.

Within   the individual exchange, all consumers will be given the option to shop for a dental plan, but will not be required to purchase. Within SHOP, an employee will be given the option to shop for a dental plan only if the employer has agreed to sponsor a dental option. The effective date for the dental plan must align with   medical coverage and carriers are limited to offering three standalone dental plans in each of the individual and small group markets. There is a separate out of pocket maximum for standalone dental issuers, and the “reasonable out of pocket limit” for Pediatric Dental EHB through Cover Oregon will be $1,000 per member.17

Risk Adjustment, Reinsurance, and Risk Corridors: Oregon is considering administering its own risk adjustment and reinsurance programs. Cover Oregon and the Oregon Insurance Division are investigating risk adjustment methodologies, a data model, and potential risk adjustment and reinsurance entities. There is legislation currently in the state senate that would establish an Oregon Reinsurance Program to be operated by the Oregon Medical Insurance Pool Board.18

Consumer Assistance and Outreach: Oregon identified a subcontractor to create a brand identity for the exchange and develop a multi-phased communications plan based on market research and the results of focus groups. Cover Oregon’s logo and website were unveiled in October 2012, along with an online calculator for individuals to find out how much financial assistance they might be eligible for when purchasing coverage in 2014. The website offers instant translation into more than 65 languages available on every page. In March 2013, Cover Oregon identified a contractor to implement the marketing and communications plan.19 The contract will run through December 2014, and may be extended for a maximum of five years.20 Cover Oregon will use a “phased” launch program, with an Awareness and Education phase beginning in July, and an Enrollment phase continuing through enrollment.21

In April 2013, Cover Oregon finalized an intergovernmental agreement with the Oregon Health Authority (OHA) to expand OHA’s existing outreach and application assistance program, which utilizes a network of providers who offer enrollment assistance in public programs.7 The state will use community partners, which are local organizations that are cultural experts on their community. Staff at these organizations will be known as “application assisters,” a term which encompasses Navigators, In-Person Assisters, and application counselors. Application assisters will conduct eligibility and enrollment for public and private health coverage. Application assisters may help consumers with enrolling in a QHP; however, if consumers need information on QHPs beyond what is available through the website, assisters must refer the consumers to an agent.22 Agents and brokers will not participate as Navigators, but will be involved in a separate Agent Management program, which utilizes a network of licensed health insurance producers to improve outreach to all geographic areas of the state and to hard-to-reach populations.23 Insurance producers will be trained annually, be affiliated with the Cover Oregon as certified agents and, when appropriate, coordinate and collaborate with the Navigators. Cover Oregon will collect and pass through any carriers’ commissions or bonus payments to the agents.

OHA released a Request for Proposals (RFP) for community partners on April 11, 2013, and plans to announce grantees in July 2013.24 Training and certification is required for all application assisters, including paid staff and volunteers, and must be renewed annually. In-person and web-based training will be provided free of charge. Application assisters must pass a background check and will receive an identification number.

Community partners will be eligible to receive performance-based grants, though funding will not be available to support all community partners. Funding opportunities will be made available through OHA and posted on the state’s procurement website, the Oregon Procurement Information Network (ORPIN). Proposals are currently being reviewed for the first funding opportunity, and additional opportunities will be posted in early summer 2013.25 Additionally, the U.S. Department of Health and Human Services (HHS) announced in May 2013 that 29 federally qualified health centers in Oregon would be eligible for an additional $2.8 million in outreach and enrollment grants. HHS estimates awarding grants in early July 2013.26 Community partners not receiving a grant will be permitted to provide application assistance as long as they sign an agreement with OHA.

Cover Oregon will also operate a Customer Service Center (call center) to offer assistance to individuals wishing to speak with representatives over the phone. In April 2013, Cover Oregon released an RFP for a customer service contractor(s).27 The Service Center has 50 full-time employees, with up to 100 supplemental staff in the future, and is now live and receiving phone calls.21

Small Business Health Options Program (SHOP) Exchange: Oregon has decided to restrict the SHOP exchange to businesses with 50 or fewer employees in 2014 and 2015, and to 100 of fewer employees beginning in 2016.

Information Technology (IT): The Oregon Health Authority, the state’s Medicaid agency, is managing development of Cover Oregon’s IT infrastructure and web portal, with oversight from an Executive Steering Committee consisting of the directors of Cover Oregon and the Department of Human Services, as well as the Insurance Division Administrator. Oregon has decided to develop a single eligibility and enrollment marketplace for the Exchange, Medicaid, and the Children’s Health Insurance Program (CHIP).28 In 2011, the state selected an enterprise software platform, which leverages integrated commercial off-the-shelf products. The platform will be used to implement functions such as eligibility determination and financial management into the web portal.

In mid-2012, Oregon identified a subcontractor to assist with development of the web portal, based on design specifications formulated by the Enroll UX 2014 project, a public-private partnership creating design standards for exchanges that all states can use. Another subcontractor was identified to develop external interfaces between the exchange and the state’s Department of Human Services systems, federal data systems, insurance carriers, and SERFF (System for Electronic Rates and Form Filings).29 A subcontractor was also identified to develop a user interface and Cover Oregon has since established a testing protocol focused on consumer usability and user acceptance. Testing began in late 2012 and will continue through August 2013.

Exchange IT and Medicaid staff meets regularly to discuss coordination of eligibility functions for enrollees, as well as referrals and verification functions.30 Cover Oregon retained project management consulting services to lay out requirements of the individual and SHOP exchange, a customer service interface, financial systems, and internal IT components. The state has also begun examining business requirements for Medicaid. To assist in financing the IT upgrades of the state’s Medicaid eligibility systems, Oregon applied for and received CMS approval of an Advanced Planning Document for the enhanced federal match.31

Financing: Cover Oregon conducted a significant amount of budgeting and forecasting work in the first quarter of 2013 to set an administrative fee on Qualified Health Plans (QHPs) for 2014. Cover Oregon underwent a public rule-making process to establish the fee, and also provided for public input at both Finance and Audit Committee meetings and Board meetings. At its March 2013 meeting, the Board of Directors adopted an administrative fee on health insurers offering QHPs through the Exchange of 2.68% of premium, or $9.38 per member per month (PMPM), for 2014. The fee, along with a $15 million charge on public programs, will generate $32 million in reserves in 2014 (half of Cover Oregon’s 2015 budget of $64 million).32 Cover Oregon also adopted a temporary rule to establish a monthly administrative fee of $0.93 PMPM on insurers offering standalone dental plans through the Exchange in 2014.

Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through an exchange, cover certain defined health benefits. Governor Kitzhaber created an EHB workgroup to recommend a benchmark plan for the individual and small group market. The workgroup, jointly chartered by the Oregon Health Policy Board and the Oregon Health Insurance Exchange  presented the final recommendation of Small Group PacificSource Preferred CoDeduct plan to the Exchange Board and the Oregon Health Policy Board in mid-2012.33 In addition, the federal BlueVision “High Plan” package was defined as the pediatric vision benefit and the state’s CHIP plan as the pediatric dental benefit.

Evaluation Plan: Cover Oregon has developed a draft evaluation plan to measure how well Cover Oregon is achieving its goals and identify operational adjustments that will help to achieve its goals more effectively. Cover Oregon has identified 12 key goals that fall into three categories: (1) Engaging partners and raising consumer awareness, (2) A seamless eligibility and enrollment process and excellent customer service, and (3) Improving accessibility and affordability of coverage and care and the health of Oregonians. For each of these three categories, Cover Oregon’s Evaluation Team will collect and analyze data in program design, implementation, and outcomes. Data will be collected through an Evaluation Database that will store enrollment data from Cover Oregon’s IT system and data from consumer surveys, and join these data for analysis. The Evaluation Team will also conduct focus groups with individual market consumers, employers, Service Center staff, agents, and community partners. Evaluation findings will be disseminated within Cover Oregon and to the public through annual reports, briefs, online data exploration tools, and ad hoc reports. Cover Oregon is seeking input on the draft evaluation plan and establishing an Evaluation Technical Advisory Workgroup (ETAW) to collect stakeholder feedback and advice about evaluation content and methods.34

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’s in Oregon:

Health Republic Insurance 

Oregon Health Cooperative

Exchange Funding

Oregon has received multiple federal grants: the Exchange Planning grant of $1 million, the Early Innovator grant of $48 million to build a modular and reusable IT system, a Level One Establishment grant of $9 million to support the final design and implementation of the Exchange’s business and operations plans through August 2012, a second Level One Establishment grant of $6.7 million to continue to support the planning process through May 2013, and a Level Two Establishment grant of $226.4 million to cover costs associated with testing and implementation of the IT user interface, staffing the call center, and developing multi-media marketing materials.35 Cover Oregon estimates annual start-up costs between 2011 and 2013 to total approximately $27 million, excluding the development of the IT infrastructure and website which will be funded with the Early Innovator Grant.

In addition, Oregon, along with nine other states, is receiving 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.36

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.

Oregon is participating in Medicaid expansion.

Next Steps

On December 7, 2012, Oregon received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange.37 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 Cover Oregon can be found at:  http://www.coveroregon.com, or on Cover Oregon’s Facebook page: https://www.facebook.com/coveroregon or Twitter feed: https://twitter.com/CoverOregon.

Footnotes
  1. SB 99 (Chapter 415), Oregon’s 2011 Health Insurance Exchange Act. http://www.leg.state.or.us/11reg/measpdf/sb0001.dir/sb0099.en.pdf← Return to text
  2. SB 91 (Chapter 322), Oregon’s 2011 Act Related to Health Benefits Plans. http://www.leg.state.or.us/11reg/measpdf/sb0001.dir/sb0091.en.pdf← Return to text
  3. HB 4164. Oregon’s 2012 legislation related to the Oregon Health Insurance Exchange. http://www.leg.state.or.us/12reg/measpdf/hb4100.dir/hb4164.en.pdf← Return to text
  4. Oregon Health insurance Exchange Board of Directors: Meetings and Members. https://orhix.org/board.html← Return to text
  5. Waldroupe A. “Rocky King Named Permanent Director of Oregon’s Health Insurance Exchange.” The Lund Report. October 6, 2011. http://www.lundreport.org/resource/rocky_king_named_permanent_director_of_oregons_health_insurnace_exchange← Return to text
  6. Cover Oregon Board Meeting. November 8, 2012. http://www.coveroregon.com/pdfs/board/11_8_12_board_documents.pdf← Return to text
  7. Cover Oregon. May 2013 Compliance Report.← Return to text
  8. Cover Oregon. Request for Applications: Qualified Health Plans.← Return to text
  9. Oregon Department of Consumer and Business Services. “Message from the Oregon Insurance Divisions Commissioner Lou Savage.” July 2012. http://www.cbs.state.or.us/ins/about_us/administrators-messages/2012/administrators-message-0712.pdf← Return to text
  10. Cover Oregon. Application for Carriers: Questions. December 21, 2012. http://coveroregon.com/pdfs/carrier_RFA/application_carrier_questions.pdf← Return to text
  11. Oregon Health Insurance Exchange. Certification of Plans as Qualified Health Plans. http://coveroregon.com/pdfs/oar_945_qhp_rules.pdf← Return to text
  12. Cover Oregon. Press Release: Plan Filings Show Cover Oregon will be Competitive Online Marketplace. http://us4.campaign-archive1.com/?u=7b25be8a3597cc17bd5a34a32&id=d41f915dfd&e=4e74d3936b← Return to text
  13. Oregon Insurance Division. New Rate Requests. http://www.oregonhealthrates.org/?B64=nZzVWZjFGdvljbo12bl1TJFJ2cvhyd1UmRpZGbul3ZmMETOF1RBV0R9UDMmEHd0h3XvNnc9Q0Qm41UFRDU10kJNNlQJ9lTfNFVQlTRw0lJFJFVSVlTPRWPvhWblUkMzVGa39TJGVHatRCbSZERf91UBRFVTVVPFBkTJRkTmc0QN9FUG9USUxVR9IWYsx  and Samples of Proposed Rates for 2014 by Age and Region http://www.oregonhealthrates.org/?pg=proposed_rates.html← Return to text
  14. Oregon Insurance Division. 2014 Plans Public Hearings/Materials. http://www.oregonhealthrates.org/?pg=archived_2014.html← Return to text
  15. Cover Oregon. Carrier Information. http://coveroregon.com/carrier_application.php← Return to text
  16. Cover Oregon. Proposed Rule: Eligibility Standards and Application Process. OAR-945-040-0010 through 945-040-0090. http://coveroregon.com/pdfs/temp_rule_eligibility_945-%C2%AD040-%C2%AD0010.pdf← Return to text
  17. Cover Oregon Dental Requirements, updated March 4, 2013. Cover Oregon Dental Guidelines, updated May 22, 2013. Cover Oregon Application for Carriers: Dental Questions, answered March 8, 2013.← Return to text
  18. HB 3458. http://gov.oregonlive.com/bill/2013/HB3458/← Return to text
  19. Cover Oregon. Board Meeting Minutes, March 14, 2013.← Return to text
  20. Cover Oregon. Request for Proposals. Marketing and Communication Services. Released December 14, 2012. http://coveroregon.com/pdfs/Marketing_RFP.pdf?utm_source=Cover+Oregon&utm_campaign=2fb60eb215-New_Contracting_Opportunity12_14_2012&utm_medium=email← Return to text
  21. Cover Oregon. Consumer Advisory Committee meeting minutes, 6/1/13.← Return to text
  22. Cover Oregon. Community Partners Frequently Asked Questions.← Return to text
  23. Oregon Health Insurance Exchange Corporation. Draft Agent Management Program. Revised September 2012.  http://www.hca.wa.gov/hbe/documents/HBE_RABTAC_121031_Oregon_Agent_Program.pdf← Return to text
  24. Oregon Health Authority. RFGP #OHA-3516-13: Outreach and Enrollment Grant Program.← Return to text
  25. Cover Oregon. Agents and Community Partners.← Return to text
  26. Health Resources and Services Administration. Health Center Outreach and Enrollment Assistance.← Return to text
  27. Cover Oregon. Request for Proposal: Customer Service Contractor.← Return to text
  28. Presentation by Rusell Hargrave. “Oregon HIX-IT Strategies and Status.” May 22, 2012. http://www.nescies.org/sites/www.nescies.org/files/cciio_exchange_conference_-_it_in_support_of_exchanges_and_eligibility_systems_presentation.pdf← Return to text
  29.  Press release. “Oregon Health Authority Awards Cognosante Health Insurance Exchange Interfaces Contract.” August 28, 2012. http://finance.yahoo.com/news/oregon-health-authority-awards-cognosante-145700116.html← Return to text
  30. Oregon Health Insurance Exchange’s Second Level One Grant Narrative. Funding Opportunity #IE-HBE-11-004. March 30, 2012. https://orhix.org/pdfs/level_1_grant_workplan.pdf← Return to text
  31. Heberlein M, et al. “Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2011-2012” Kaiser Commission on Medicaid and the Uninsured. (January; #8272). http://www.kff.org/medicaid/upload/8272.pdf← Return to text
  32. Cover Oregon Board Meeting Minutes, May 9, 2013.← Return to text
  33. Memo from the Essential Health Benefits Workgroup to the Oregon Health Insurance Exchange Corporation and Oregon health Policy Board. July 3, 2012. http://www.statereforum.org/sites/default/files/finalrecletter.pdf← Return to text
  34. Cover Oregon. Draft Cover Oregon Evaluation Plan. April 1, 2013. http://coveroregon.com/pdfs/cac/4_5_13_cac_documents.pdf← Return to text
  35. Oregon Affordable Insurance Exchange Grants Awards List. http://www.cms.gov/CCIIO/Resources/Marketplace-Grants/or.html← Return to text
  36. The Robert Wood Johnson Foundation. ‘RWJF Seeks Coverage of 95 Percent of All Americans by 2020.’ May 6, 2011.  http://www.rwjf.org/coverage/product.jsp?id=72289← Return to text
  37. Letter from Acting Administrator Tavenner to Exchange Director King. December 7, 2012. http://coveroregon.com/pdfs/CMS_ltr_to_cover_oregon.pdf?utm_source=Cover+Oregon&utm_campaign=3cb1b546b1-Cover_Oregon_Receives_fed_approval12_10_2012&utm_medium=email← Return to text

Provided by the Henry J. Kaiser Family Foundation

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 at obamacare-enrollment.com and we’ll get right back to you.

Obamacare in Oklahoma

Health Insurance Marketplace in Oklahoma

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

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

Oklahoma 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 Oklahoma’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

Oklahoma Community Health Centers, Inc.

Oklahoma Community Health Centers, Inc., a consortium comprised of a variety of non-profit organizations will apply a statewide approach to providing enrollment assistance to Oklahomans. Consortium members will have Navigators located in 57 cities across the states, enabling them to provide services in 45 counties in Oklahoma. Among other activities, funds will be used to target outreach to small business and small business groups, conduct outreach at community events and health fairs, target outreach to special populations served by consortium partners, and develop state-specific outreach materials for use by consortium members.

Little Dixie Community Action Agency, Inc.

Little Dixie Community Action Agency, Inc. plans on providing enrollment assistance to lower income families and individuals in local communities in Oklahoma by forming a consortium with 14 additional Community Action Agencies across Oklahoma, serving 63 counties in Oklahoma. Funding will be used to provide Navigator services in each of the 15 service areas, with an emphasis on leveraging existing staff with local ties to be trained as Navigators.

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 Oklahoma

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 Oklahoma

On November 19, 2012, Governor Mary Fallin (R) announced that Oklahoma would not pursue the creation of a state-based health insurance exchange.1

Prior to the announcement, Oklahoma had established the Joint Committee on Federal Health Care Law to explore the state’s options regarding federal health reform, including exchange implementation in the state.2 The Joint Committee convened in 2011 and released final exchange recommendations to the Governor and the Legislature in late February 2012.3,4 Committee recommendations included establishing a state-based private marketplace network to avoid federal involvement in the state; this would resemble a Utah model for small-businesses but would not include an individual exchange. A bill based on these recommendations was introduced in the 2012 legislative session (SB 1629) but failed at the end of the legislative session.5

The Oklahoma Health Insurance Exchange Project, led by the Secretary of Health as liaison to the Governor’s Office and State Legislature, the Oklahoma Department of Mental Health and Substance Abuse Services, the Insurance Department, and the Oklahoma Health Care Authority, began planning efforts in early 2011; however, the Project suspended activities in 2012 due to the exhaustion of federal grant funds.

On April 4, 2011, Governor Fallin signed into law a measure prohibiting any health insurance plans offered in the exchange from covering abortions except in cases of rape, incest, or life endangerment of the pregnant woman (SB 547).6 The bill allows health plan enrollees the option to purchase additional abortion coverage if desired.

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 Oklahoma 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 Oklahoma- BlueOptions PPO.

Exchange Funding

Oklahoma’s Department of Mental Health and Substance Abuse Services received a $1 million federal Exchange Planning grant. In addition, the Oklahoma Health Care Authority received a $54.5 million Early Innovator grant to develop model technological infrastructure for a health insurance exchange.7 In April 2011, Governor Fallin announced that Oklahoma planned to return 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.

Oklahoma is considering an alternative proposal that would use money from the expansion and tobacco tax revenue to help state residents purchase coverage.

Next Steps

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

For more information on Oklahoma’s health insurance exchange planning, visit: http://www.okhealthcare.info/


1. Press Release Governor Mary Fallin. Oklahoma will not pursue a state-based Exchange or Medicaid Expansion. November 19, 2012.http://www.ok.gov/triton/modules/newsroom/newsroom_article.php?id=223&article_id=9750
2. Press release. Health Care Law to be Studied over Interim. May 18, 2011.http://www.okhouse.gov/OkhouseMedia/ShowStory.aspx?MediaNewsID=4000
3. Summary of the Meetings of the Joint Committee on Federal Health Care Law. September 14, 2011- November 3, 2011.http://garystanislawski.net/okhealthcare.info/Presentations/Joint%20Comm%20Fed%20Health%20Care%20Laws%20summ.pdf
4. Final Report of the Joint Committee of Federal Health Care Law. Oklahoma Legislature. February 22, 2012.http://www.tulsaworld.com/webextra/content/items/FINAL%20Joint%20Committee%20on%20Federal%20Health%20Care%20Law%20Report.pdf
5. SB 1629. 2012 Regular Session. http://www.ok.gov/redirect.php?link_id=332
6. Senate Bill 547. Approved by Governor April 20, 2011.http://www.oklegislature.gov/BillInfo.aspx?Bill=sb547
7. Early Innovator Grant Awards. HHS announcement. February 16, 2011.http://www.healthcare.gov/news/factsheets/exchanges02162011a.html (Accessed August 23, 2011)
8. Politico. ‘Oklahoma governor returns $54M health care grant.’ April 14, 2011.http://www.politico.com/news/stories/0411/53216.html

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in Ohio

Health Insurance Marketplace in Ohio

If you live in Ohio, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Spanish language speakers can contact cuidadodesalud.gov. Specific plans and prices will be available on October 1, 2013, when Marketplace open enrollment begins. Coverage can start as soon as January 1, 2014.

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

Ohio 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 Ohio 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

Ohio Association of Foodbanks

Since 1991 the Ohio Association of Foodbanks has benefited thousands of people in need in the State of Ohio. The Ohio Association of Foodbanks will provide outreach support through a variety of phone, online, and promotional tools.

Children’s Hospital Medical Center

Children’s Hospital Medical Center serves the medical needs of infants, children and adolescents with family-centered care, innovative research and outstanding teaching programs. They plan on reaching out and enrolling the uninsured through the main hospital location in urban inner city geographic area as well as two satellite locations.

Clermont Recovery Center, Inc.

Clermont Recovery Center, Inc., a not-for-profit drug and alcohol outpatient treatment and prevention agency located in the county seat of Batavia, Ohio. The organization will educate and help enroll the uninsured in coverage in several counties in Ohio, including Clermont, Brown and Adams.

Helping Hands Community Outreach Center

Helping Hands Community Outreach Center is a nonprofit organization serving the Dayton Ohio region and provides resources to families and individuals who are hospitalized. The organization will attend local events and will work with businesses and public agencies to promote education and awareness of the Marketplaces.

Neighborhood Health Association

The Neighborhood Health Association (NHA), a Federally Qualified Health Center (FQHC) system located in Northwest, Ohio will through its Affordable Care Act Insurance Enrollment Project, raise community awareness regarding the insurance Exchange and facilitate enrollment in for the uninsured.

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’s in Ohio:

Coordinated Health Plans of Ohio, Inc.

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 Ohio

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 Ohio

On November 16, 2012, Governor John Kasich (R) notified federal officials that Ohio would default to a federally-facilitated exchange; however, the state would maintain regulatory control over its insurance industry.1 The Governor also indicated Ohio would maintain control over Medicaid eligibility determinations.

Prior to the announcement, the Department of Insurance in collaboration with other stakeholder agencies solicited subcontractors’ assistance for the first year of exchange planning and implementation. Contractors evaluated financing options and sustainability, provided actuarial services and economic modeling, and an information technology (IT) gap analysis.2,3,4

On December 21, 2011, the Governor signed HB 79, which prohibits qualified health plans purchased through an exchange from covering abortions, except in cases of rape, incest, or to avert death of the pregnant woman.5

Contracting with Plans: On February 14, 2013, Lieutenant Governor Mary Taylor sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO) reiterating the state’s intention to perform plan management activities. The Ohio Department of Insurance (ODI) has the legal authority and operational capacity to oversee certification of Qualified Health Plans (QHPs). ODI will use the System for Electronic Rate and Form Filing (SERFF) to collect, review, and approve plan rate and benefit information. ODI will also ensure continued plan compliance, manage consumer complaints, and oversee decertification of issuers.6

Essential Health Benefits (EHB): The Affordable Care Act (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 Ohio has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Community Insurance Company (Anthem Blue Cross Blue Shield)- Blue Access PPO.

Exchange Funding

In September 2010, the Ohio Department of Insurance received 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.

Ohio is expected to participate Medicaid expansion pending General Assembly approval.

Next Steps

On March 8, 2013, Ohio received approval from CCIIO to perform plan management activities. The federal government will retain control over all other Exchange functions.7

For more information on Ohio’s exchange planning, visit: www.ohioexchange.ohio.gov


1. John Kasich. “Ohio Says No to an Obamacare Health Exchange.” November 16, 2012.http://governor.ohio.gov/exchange.aspx
2. Assist with the first year of planning for design and implementation of a federally mandated American Health Benefit Exchange. August 31, 211. Milliman. http://www.ohioexchange.ohio.gov/Documents/MillimanReport.pdf
3. State of Ohio Health Insurance Exchange Planning: Strategic Architecture Roadmap and Budget Report. September 14, 2011. KPMG. http://www.ohioexchange.ohio.gov/Documents/KPMGBlueprintReport.pdf
4. State of Ohio Health Insurance Exchange Planning: Strategic Architecture Blueprints Report. September 13, 2011. KPMG. http://www.ohioexchange.ohio.gov/Documents/KPMGBlueprintReport.pdf
5. HB 79. 129th General Assembly. Signed December 21, 2011. Enrolled version.http://www.legislature.state.oh.us/bills.cfm?ID=129_HB_7911.
6. Letter from Lieutenant Governor Taylor to Gary Cohen. February 14, 2013.
7. Letter from Gary Cohen to Lieutenant Governor Taylor. March 8, 2013.

Also of interest

Obamacare in North Dakota

Health Insurance Marketplace in North Dakota

If you live in North Dakota, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Spanish language speakers can contact cuidadodesalud.gov. Specific plans and prices will be available on October 1, 2013, when Marketplace open enrollment begins. Coverage can start as soon as January 1, 2014.

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

North Dakota 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 North Dakota 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)

Find local help

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.

Minot State University – North Dakota Center for Persons with Disabilities

The North Dakota Center for Persons with Disabilities will use grant funds to establish a collaborative network of regional Navigators who already have established the trust of their neighbors. NDCPD will hire Regional Navigators stationed in each of the state’s eight Human Service Regions. Navigator support will be provided to currently uninsured and underinsured people, specifically targeting those most at risk of being uninsured in North Dakota, including people with mild disabilities, people with mental health disorders, farmers, young adults, Native Americans, small business persons, people who are unemployed and people who are drug or alcohol addicted.

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 North 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 North Dakota

In November 2012, Governor Jack Dalrymple (R) announced that North Dakota was not planning a state exchange.1 In the previous year, North Dakota had explored the possibility of a state-based exchange, spurred in part by enacted legislation stating North Dakota’s intent to create a health insurance exchange.2 The Insurance Department collected stakeholder feedback and identified a vendor to analyze the state’s demographics, insurance market, and policy options.3,4However, planning efforts halted after a second 2011 bill to establish an exchange failed.5

The legislative Health Care Reform Review Committee continues to receive regular updates from the Insurance Commissioner and Department of Human Services regarding the state’s planning and implementation of the Affordable Care Act.6 The Committee’s July meeting included a discussion of a state-federal partnership exchange and the possibility of the state taking over a federally-run exchange at a later date.7

Information Technology (IT): Although the state is not currently moving forward with building an exchange, it is focusing on improvements to North Dakota’s Medicaid eligibility system with the goal of ensuring a seamless connection with an exchange.8 The legislature passed HB 1475 which provides for an IT update of the Medicaid eligibility system within the Department of Human Services.9 This legislation, considered necessary for either a state- or federally-run exchange in North Dakota, was signed into law by Governor Dalyrmple on November 11, 2011.

In addition, the Health Benefit Exchange Interagency Planning Committee was formed by the Insurance Department in 2011 and includes the Department of Human Services, Information Technology Department, the Department of Human Services, the Governor’s Office, and the Office of Management and Budget.10 In 2012, the Committee shifted its focus away from exchange planning and towards upgrading the Medicaid eligibility IT system.

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. The Health Care Reform Review Committee discussed EHB benchmark options after receiving a subcontractor analysis and public comments. On October 1, 2012, the North Dakota Insurance Department submitted Sanford Health Plan, an HMO plan, as the EHB benchmark.11 The state also submitted the Children’s Health Insurance Program (CHIP) as supplemental benefits for pediatric dental and vision services.

Exchange Funding

In September 2010, the North Dakota Insurance Department received a federal Exchange Planning grant of $1 million. The Department was denied the appropriation to use the funds until the legislature appropriated the funds during 2011 legislative session. The appropriation became available on July 1, 2011.

As of January 25, 2012, over three-quarters of the Planning Grant funds remained unspent.12 The Insurance Department proposed transferring the remaining funds to the Department of Human Services to allow for additional planning and development of the tools necessary to create a one-stop eligibility system for Medicaid and the exchange.

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.

North Dakota is participating in Medicaid expansion.

Next Steps

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


1. Wetzel D. “ND GOP Leader Rethinking Options on Health Care Law, Says State Administration Possible.” The Republic. November 15, 2012.http://www.therepublic.com/view/story/a769f030589848afad9db0d40ae69867/ND–Health-Care-North-Dakota
2. HB 1126, North Dakota’s 2011 act announcing the state’s intent to create a Health Benefit Exchange. http://www.legis.nd.gov/assembly/62-2011/documents/11-8110-05000.pdf
3. Odney Advertising. “North Dakota Health Benefit Exchange Stakeholder Final Report.” September 23, 2011. http://www.nd.gov/ndins/uploads%5Cresources%5C689%5Cfinal-stakeholder-meeting-report.pdf
4. Health Technology Management Services (HTMS). “Health Benefit Exchange Planning Services: Narrative Summary.” December 2, 2011. http://www.nd.gov/ndins/uploads/resources/700/final-hbe-planning-narrative.pdf
5. HB 1474. North Dakota’s 2011 act to establish a Health Benefit Exchange.http://www.legis.nd.gov/assembly/62-2011/special-session/documents/11-0806-08000.pdf
6. North Dakota Health Care Reform Review Committee. http://legis.nd.gov/assembly/62-2011/docs/committeestructure/hc.pdf (Accessed September 5, 2012).
7. Minutes of the Health Care Reform Review Committee meeting on July 25, 2012.http://legis.nd.gov/assembly/62-2011/interim-info/minutes/hc072512minutes.pdf
8. North Dakota’s “State Planning and Establishment Grant for the Affordable Care Act’s Exchange: Final Project Report.” January 25, 2012.
9. HB 1475. North Dakota’s 2011 Act to Provide Appropriations for Certain Medical Services, Health Insurance, Economic Assistance, and Information Technology and Programs.http://www.legis.nd.gov/assembly/62-2011/special-session/documents/11-0836-02000.pdf
10. North Dakota’s “State Planning and Establishment Grant for the Affordable Care Act’s Exchange: Final Project Report.” January 25, 2012.http://www.nd.gov/ndins/uploads/resources/702/final-report.pdf
11. North Dakota EHB Communication (Accessed November 16, 2012).http://www.statereforum.org/sites/default/files/ehb_communication.pdf
12. North Dakota’s “State Planning and Establishment Grant for the Affordable Care Act’s Exchange: Final Project Report.” January 25, 2012.

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in North Carolina

Health Insurance Marketplace in North Carolina

If you live in North Carolina, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Spanish language speakers can contact cuidadodesalud.gov. Specific plans and prices will be available on October 1, 2013, when Marketplace open enrollment begins. Coverage can start as soon as January 1, 2014.

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

North 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 North 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.

Who can help you (the Navigators)

Find local help

Randolph Hospital, Incorporated

Randolph Hospital, Inc., will use Navigator funds to serve a three county area in North Carolina. Randolph Hospital plans on targeting specific geographic regions with high uninsured populations, and working with community organizations in those areas to leverage resources and reach the most people. Additionally, Randolph Hospital will work with hospital financial counselors that already work with uninsured hospital patients to inform those patients of their coverage options.

Mountain Projects, Inc.

Mountain Projects, Inc. is a non-profit Community Action Agency serving Haywood and Jackson counties in North Carolina. Mountain Projects plans on providing Navigator services to the seven western-most rural counties of North Carolina, including Haywood, Jackson, Macon, Swain, Graham, Clay, and Cherokee. They will leverage existing relationships in these rural communities with the goal of educating the uninsured and facilitating access to the new insurance options now available.

North Carolina Community Care Networks

North Carolina Community Care Networks, Inc. are consortia that total more than 100 organizations who will work to inform consumers statewide, with particular focus in areas where there is a higher concentration of uninsured. These networks will be serving to reach out, inform, educate and help enroll North Carolinians, and include organizations in the legal rights, faith-based, agricultural, and aging communities.

Alcohol/Drug Council of North Carolina

The Alcohol/Drug Council of North Carolina plans on using Navigator grant funds to establish Project Jumpstart, implemented by a consortium formed to provide specialized navigation services to people in recovery from mental illness and/or substance abuse. A majority of people working on Project Jumpstart will have personal experience with mental illness, an addictive disorder, and/or a chronic disease, and will draw on these experiences to reach out to and help enroll this target population in new coverage options.

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 North 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 North Carolina

On November 15, 2012, Governor Beverly Perdue (D) declared the state’s intent to establish a state-federal partnership health insurance exchange.1 However, on February 12, 2013, newly-elected Governor Pat McCrory (R) issued a statement indicating that North Carolina will abandon efforts to establish a partnership exchange and will instead allow the federal government to operate the exchange.2

In 2011, Governor Perdue had signed into law HB 22 which indicated the General Assembly’s intent to establish and operate a state based health insurance exchange.3 Legislators introduced three bills to establish a state-based health insurance exchange in 2011; however, all failed at the close of the legislative session in July 2012.

In the absence of exchange legislation, the North Carolina Department of Insurance (NCDOI), the North Carolina Department of Health and Human Services (NCDHHS), and the North Carolina Institute of Medicine (NCIOM) led exchange planning in the state. As of January 2012, the Department of Insurance leads a Market Reform Technical Advisory Group (TAG) comprised of insurers, agents, consumers, and providers. The NCIOM Health Benefit Exchange and Insurance Oversight Workgroup released a final report in May 2012 on the impact of federal reform on the state.4

Contracting with Plans: In September 2012, the North Carolina Department of Insurance issued a Request for Proposals to solicit work on exchange plan management activities including, technical assistance and training; the Department intends for the contract to begin in October 2012.5 In the spring of 2012, the Department of Insurance’s TAG recommended that North Carolina initially defer to the federal risk adjustment model, but evaluate developing a state model in the future.6The TAG also suggested the state administer the reinsurance program, while deferring the responsibility of collecting contributions to the federal government. In April 2012, the NCIOM Workgroup explored the exchange’s authority to limit the number of plan designs per metal level in 2014.

Consumer Assistance and Outreach: In April 2012, the NCIOM Workgroup identified outstanding issues including, conflict of interest provisions for agents and brokers as well as patient Navigators.7 The Workgroup created a subcommittee to consider the role of Navigators in educating the public and helping them enroll in appropriate coverage.

North Carolina used federal funds to establish a pilot call center that became operational in August 2012. The call center fielded almost 3,000 calls in September and October about various issues, including assistance with enrolling in a health plan and questions about the Affordable Care Act. The call center collects data by county so that concerns can be identified by geographic regions to inform future consumer assistance efforts. The call center hired a Community Resource Manager in October 2012 to work with Navigators and Assisters.

Small Business Health Options Program (SHOP) Exchange: In March 2011, a subcontractor for the Department of Insurance released a report including insurance market analysis of the impact of health reform on enrollment and premiums, the impact of merging the individual and small group health markets, the impact of allowing large groups to participate in the exchange beginning in 2014, and recommended strategies to mitigate adverse selection.8 A year later, the Insurance Department’s TAG recommended that the small group and individual exchange markets maintain separate risk pools and only employers with 50 or fewer employees be allowed participate in the SHOP until the state is required to open the SHOP to employers with 100 or fewer employees in 2016.9

Information Technology (IT): In December 2008, North Carolina hired a contractor to provide a commercial off-the-shelf (COTS) software package that replaced its existing eligibility determination and case management system. The new system, called North Carolina Families Accessing Services Through Technology (NC FAST), currently provides electronic Medicaid/CHIP application, eligibility, and enrollment functionality. North Carolina plans to expand upon the existing system to develop a multiple-service eligibility system to include the Exchange and other public programs.

NCDOI had used federal funding to hire contractors to develop a RFP for all non-eligibility related Exchange systems, including financial management, plan selection functionality, plan management, Navigator/assister management, call center operations, data warehousing, and SHOP eligibility. These services will be required to be interoperable with NC FAST for both Exchange and Medicaid/CHIP functions.10

Essential Health Benefits (EHB): The Affordable Care Act 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 Department of Insurance released an analysis of benchmark plan options for the state in May 2012; the report found that all of the state’s options except for the federal employee health benefit plan covered all state mandates, there was relatively little difference in the cost among benchmark plans, and all benchmark options needed to be supplemented for pediatric oral and vision care.11Therefore, the state was comfortable with defaulting to the largest small-group plan, Blue Cross Blue Shield of North Carolina- Blue Options, PPO.

Exchange Funding

In September 2011, the North Carolina Department of Insurance received a federal Exchange Planning grant of $1 million. The Department, working in partnership with the North Carolina Department of Health and Human Services, then received a $12.4 million federal Level One Establishment grant on August 12, 2011. North Carolina will use the grant to engage stakeholders, prepare analyses of outstanding policy decisions, and expand the existing eligibility system of the North Carolina Department of Health and Human Services to accommodate the exchange. In January 2013, North Carolina was awarded a second Level One grant of $74 million to develop an IPA program and support implementation of the HCR Module, including integration of the module with current state IT systems and federal data sources.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.

North Carolina is not participating in Medicaid expansion.

Next Steps

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

Additional information about North Carolina’s exchange Workgroup meetings can be found at:
http://www.nciom.org/task-forces-and-projects/?hr-hbeandinsurance

More information on the state’s exchange planning can also be found at:http://www.ncdoi.com/lh/LH_Health_Care_Reform_ACA.aspx


1. “Gov Perdue chooses state-federal partnership.” The News-Herald. November 16, 2012.http://www.roanoke-chowannewsherald.com/2012/11/16/gov-perdue-chooses-state-federal-partnership/
2. “Governor McCrory Recommends Healthcare Implemenation Strategy.” State of North Carolina Governor’s Office. February 12, 2013. http://www.governor.state.nc.us/newsroom/press-releases/20130212/governor-mccrory-recommends-healthcare-implementation-strategy
3. House Bill 22. “An Act to Make Technical, Clarifying, and other Modifications to the Current Operations and Capital Improvements Appropriations Act.” Session Law 2011-391.http://www.ncga.state.nc.us/Sessions/2011/Bills/House/PDF/H22v4.pdf
4. Examining the Impact of the Patient Protection and Affordable Care Act in North Carolina. Draft Final Report Pending US Supreme Court Decision. May 2012. North Carolina Institute of Medicine.http://www.nciom.org/wp-content/uploads/2012/05/Full-Report-Online-Pending.pdf
5. North Carolina Health Insurance Rate Review and Health Benefit Exchange Plan Management Projects. Request for Proposals Issued September 5, 2012. NC Dept. of Insurance.https://www.ips.state.nc.us/ips/AGENCY/PDF/09194300.pdf
6. Risk Adjustment and Reinsurance Issues and Recommendations from the Market Reform Technical Advisory Group. Issue Brief #3. Department of Insurance. Spring 2012.http://www.ncdoi.com/lh/Documents/HealthCareReform/ACA/Issue%20Brief%203%20-%20Risk%20Adjustment%20and%20Reinsurance%20Issues.pdf
7. HBE Workgroup: Outstanding Discussion Questions. April 13, 2012. North Carolina Institute of Medicine. http://www.nciom.org/wp-content/uploads/2012/04/Outstanding-Discussion-Questions.pdf
8. Milliman Report for the North Carolina DOI. March 31, 2011. http://www.nciom.org/wp-content/uploads/2010/12/Health-Benefits-Exchange-Study-DRAFT-4-2011-03-31-FULL-REPORT.pdf
9. Selected Small Group Market Issues and Recommendations from the Market Reform Technical Advisory Group. Issue Brief #1. Department of Insurance. Spring 2012.http://www.ncdoi.com/lh/Documents/HealthCareReform/ACA/Issue%20Brief%201%20-%20Small%20Group%20Issues.pdf
10. North Carolina Exchange Establishment Level I: Project Narrative. North Carolina Department of Insurance. December 19, 2012.http://www.ncdoi.com/Smart/Documents/November%202012%20Level%20One%20Exchange%20Establishment%20Cooperative%20Agreement%20Application.pdf
11. Analysis of Benchmark Plan Options for the Essential health Benefits Package in North Carolina. Prepared for the Dept. of Insurance. May 14, 2012. Oliver Wyman and Manatt Health Solutions.http://www.ncdoi.com/lh/Documents/HealthCareReform/Analysis%20of%20Benchmark%20Plan%20Options%20Study%20Report.pdf
12. North Carolina Affordable Insurance Exchange Grants Awards Listhttp://cciio.cms.gov/archive/grants/states-exchanges/nc.html

Also of interest

Provided by the Henry J. Kaiser Family Foundation

Obamacare in New York

Health Insurance Marketplace in New York

If you live in New York, New York State of Health is the Health Insurance Marketplace to serve you. Instead of HealthCare.gov, you’ll use the New York State of Health website to apply for coverage, compare plans, and enroll. You can apply as early as October 1, 2013. Visit New York State of Health now to learn more.

Choosing the Right Health Insurance Plan

There are a number of different tiers of plans available on the New York 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 New York 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. New York health insurers don’t have to offer every tier of plan, but within the New York 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

New York 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 New York 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’s in New York:

Health Republic Insurance

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 New York

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.

Models Run at State Level

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 New York

After the New York State legislature failed to pass exchange legislation, Governor Andrew Cuomo (D) signed Executive Order 42 on April 12, 2012, to establish the New York Health Benefit Exchange.1 In August 2013, the state announced that the online marketplace would be called NY State of Health.2

Structure: The Executive Order establishes the New York Health Benefit Exchange “within the Department of Health” and gives the Exchange authority to work in conjunction with the Department of Financial Services and other agencies to carry out requirements of the Affordable Care Act.  

Governance:  Although the Executive Order does not create an independent governing board for the Exchange, it establishes regional advisory committees, consisting of consumer advocates, small business representatives, health care providers, agents, brokers, insurers, labor organizations, and other stakeholders, to advise and provide recommendations on Exchange operations. Over 180 members have been appointed to five regional advisory committees representing Western NY, Central NY/Finger Lakes, Capital District/Mid-Hudson/Northern NY, New York City/Metro, and Long Island.3 Meetings to collect feedback on Exchange development will take place every 4-8 weeks and began in September 2012.

In July 2012, Governor Cuomo named an Executive Director to head the state’s Exchange. In October 2012, the Exchange released an organizational chart that details leadership positions within the Exchange and how the Exchange will interact with other agencies.4

Contracting with Plans: Insurers may participate in the individual marketplace, the SHOP, or both and must offer one standard product at every metal level, in every county of their service area. Insurers must offer a standard catastrophic product, but if there is more than one catastrophic plan offered in a county, QHPs may be allowed to opt out of offering the product. An insurer that offers an out-of-network product in a county’s commercial market must offer an out-of-network product through NY State of Health at the silver and platinum levels in that county (an out-of-network product offers coverage for services provided by health care providers that are not in the insurer’s network). QHPs may choose to offer up to three non-standard plans per metal level and can offer non-standard products in a portion of their service area. Child-only plans, catastrophic products, and required out-of-network products will not count towards the non-standard maximum. Standard products must cover the Essential Health Benefits; however, insurers may substitute benefits in the Preventive/Wellness/Chronic Disease Management and Rehabilitation/Habilitation categories in non-standard product offerings.5

In July 2013, the Department of Financial Services (DFS) approved rates for seventeen carriers seeking to offer coverage through NY State of Health,6 and in August 2013 the marketplace announced the plans that will be available for purchase.7 All plans will be posted to the marketplace website in September 2013, with open enrollment set to begin October 1, 2013. Plans that will be offered during calendar year 2015 must be recertified by the Department of Health (DOH) and DFS in 2014. Insurers that were not approved to sell through NY State of Health in 2014 will not have another opportunity to apply for marketplace participation until 2015, for Plan Year 2016. 8

Insurers must maintain a provider network that is consistent with federal law and DOH managed care network adequacy standards. Each insurer’s county network must include a hospital, a choice of three primary care physicians, and a choice of two of each required specialist provider type; however, more providers may be required based on enrollment and geographic accessibility. Each county network must also fulfill provider type and ratio requirements established through the state’s Provider Network Data System (PNDS) and meet various time and distance standards. Insurers must make a good faith effort to include the essential community providers defined by the federal law in their networks and are required, at a minimum, to include a federally qualified health center and a tribal operated health center in each county network, if available. Behavioral health networks must include individual providers, outpatient facilities, and inpatient facilities that can provide detoxification and rehabilitation services. The DOH will review network adequacy quarterly, on a county-by-county basis.9

The DOH currently collects quality data for commercial products, Medicaid, and Child Health Plus through a reporting system called the Quality Assurance Reporting Requirements (QARR). All insurers selling products through NY State of Health will be required to participate in the QARR. QARR data collected will be posted on the DOH website and will be essential to determining the plan quality rankings that will be made available on the marketplace website. Insurers participating on the marketplace must also survey a sample of their members using the standardized Consumer Assessment of Health Care Providers and Systems (CAHPS) tool. The DOH will not require insurers to be accredited in order to participate on the marketplace in 2014 and 2015; however, this requirement will be reconsidered for 2015.10

Dental and Vision Benefits: QHPs are required to offer pediatric dental benefits as a separately priced benefit for each standard and non-standard product. However, if there are adequate stand-alone dental products available, QHPs may decide not to offer a pediatric dental product. Stand-alone dental carriers must offer one standard pediatric dental product in each service area county and can elect to offer a high coverage (85% actuarial value) or low coverage (75% actuarial value) plan. Carriers may choose to offer up to two non-standard products, such as adult or family dental, in each service area county. 11  In August 2013, the marketplace announced the dental plans that will be available for purchase through NY State of Health.12

Consumer Assistance and Outreach: New York contracted with an advertising agency to create the marketplace name and logo and to develop a media campaign that will launch on October 1, 2013. The campaign will utilize television, radio, online, and print advertising, as well as social media, to deliver messages tailored to target populations. Marketing materials, such as brochures and fact sheets, will be provided in the nine most common languages spoken in New York. The marketplace is also working to develop partnerships with entities such as local government agencies and advocacy organizations to build public awareness of NY State of Health, educate organizations that work with target populations, and guide potential enrollees towards enrollment.13

Navigators and In-Person Assisters (IPAs) are a crucial component of the state’s outreach efforts. In July 2013, the DOH announced that 50 organizations were awarded a total of nearly $27 million in conditional grants to serve as Navigators/IPAs for the marketplace. Grantees will subcontract with 96 entities to perform outreach activities and provide in-person enrollment assistance to individuals, families, and small businesses seeking coverage through NY State of Health. There will be over 430 individual assisters who will provide services in 48 languages. Navigators and IPAs will have the same responsibilities and will undergo training and certification throughout August and September.14 The marketplace website features a map of assister awardees and subcontractors by county and borough.15

New York will build upon its existing call center, New York Health Options, to include marketplace  application support. NY Health Options currently provides general program information, application support, and telephone renewals for Medicaid, Family Health Plus, and Family Planning Benefits Program.  There will be four customer service center facilities that could employ up to 1,325 customer representatives in total.16 In August 2013, the state launched the NY State of Health website, including a tax credit and premium estimator.

Small Business Health Options Program (SHOP) Exchange: In July 2012, the Department of Health released a report completed by subcontractors evaluating standardizing benefit designs in the SHOP Exchange.17 Additionally, the state completed analyses on the impact of merging the individual and small-group insurance markets and estimated costs of Exchange development, implementation, and on-going operations.1819 New York decided to limit the size of small employers in the SHOP Exchange to 50 or fewer employees but is considering increasing small group size to 100, on or before 2016.

The SHOP will offer both the employee choice and the employer choice models. Through the employer choice model, employers will be able to offer their employees all products within one metal level, a specific product offered by a specific insurer, multiple products from a specific insurer, or all health insurer products on all metal levels. In order for an employer to enroll in non-HMO options offered through NY State of Health, a minimum of 50% of employees must have health insurance coverage. The employer will be eligible for HMO options only if the 50% participation requirement is not met. 20

The Exchange will partner with producers to assist employers with enrolling in New York’s SHOP Exchange. Producers must have an active producer’s license, from the Department of Financial Services, and certification that they have completed educational requirements specific to SHOP. Producer compensation levels will be the same inside and outside the Exchange and the Exchange will not be involved in determining commission levels. Web-brokers will not be used in the SHOP Exchange in 2014, but the option remains open for the future.  

Information Technology (IT): New York intends to establish an integrated, scalable, consumer-centric IT system. The Department of Health released a Funding Availability Solicitation to identify subcontractors to develop an IT infrastructure for the Exchange in 2011.21 In March 2012, New York awarded the five-year contract for Exchange development to the same state contractor running the state’s billing system for Medicaid.22 State officials acknowledged that by October 2013, the new system would likely be able to accommodate only eligibility and enrollment for the Exchange and newly eligible Medicaid enrollees. Current Medicaid beneficiaries would initially be processed through the existing system and eventually be moved into the new system. Over time the new system will also incorporate eligibility and enrollment for other social service programs.23

New York is also one of 11 states participating in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use.24 The Department of Health has been working with UX 2014 to determine if the interface can be customized to fit the state’s needs and is also exploring plan selection and how UX 2014 can be used to filter eligible health plans while keeping health information secure.25

Essential Health Benefits (EHB): The Affordable Care Act (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 Exchange Executive Director recommended the state use Oxford EPO as the benchmark plan and the Children’s Health Insurance Program (CHIP) as the pediatric dental and vision supplement.26

Exchange Funding

The Department of Insurance received a federal Exchange Planning grant of $1 million in 2010. The state has since received multiple federal grants. In 2011, the Department of Health received an Early Innovator grant of $27.4 million to develop an exchange information technology infrastructure that could be replicated by other states. The Department has also received three federal Level One Establishment grants: $10.7 million, $48.5 million, and $95 million to fund IT systems, expand consumer assistance, redesign the state’s eligibility and enrollment system, and create an all payer database, hire Exchange executive leadership and staff, develop back-end customer support functions, and conduct consumer outreach and program integration.. In January 2013, the state received a Level Two Establishment Grant for $185.2 million to support outreach and marketing, fund IPA training and certification, purchase an accounting system, and support IT development.27

The New York State Health Foundation has contributed to New York’s exchange planning process by funding an information technology gap analysis for the state and numerous reports including, the coordination of Medicaid and the exchange and passive and active purchasing.  

New York, along with nine other states, is receiving 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.28

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.

New York is participating in Medicaid expansion.

Next Steps

On December 14, 2012, New York received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange.29 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.

For additional information on New York’s exchange planning see:

http://healthbenefitexchange.ny.gov/ and

http://healthbenefitexchange.ny.gov/resource/blueprint-application

 Footnotes

  1. Executive Order 42. Establishment of the New York Health Benefit Exchange. April 12, 2012. http://www.governor.ny.gov/press/04122012-EO-42← Return to text
  2. NY State of Health. Press Release: New York Health Benefit Exchange Announces New Name and Health and Dental Plans to be Offered. August 20, 2013. http://nystateofhealth.ny.gov/news/press-release-new-york-health-benefit-exchange-announces-new-name-and-health-and-dental-plans-0  ← Return to text
  3. New York Health Benefit Exchange Blueprint. Section 2.0 Consumers and Stakeholders. November 2012. http://www.healthcarereform.ny.gov/health_insurance_exchange/blueprint_documents/02/← Return to text
  4. New York Health Benefit Exchange Blueprint. Section 7.1 Organization Charts and Hirign Strategy. November 2012. http://www.healthcarereform.ny.gov/health_insurance_exchange/blueprint_documents/07/7-1_exchange_organizational_charts.pdf← Return to text
  5. New York State Department of Health, Office of the New York Health Benefit Exchange. Invitation to Participate in the New York Health Benefit Exchange. January 31, 2013. http://www.healthbenefitexchange.ny.gov/sites/default/files/Invitation%20to%20Participate%20in%20NYHBE_0.pdf← Return to text
  6. “Governor Cuomo Announces Approval of 2014 Health Insurance Plan Rates for New York Health Benefit Exchange. July 17, 2013. http://www.governor.ny.gov/press/07172013-health-benefit-exchange← Return to text
  7. NY State of Health. Press Release: New York Health Benefit Exchange Announces New Name and Health and Dental Plans to be Offered. August 20, 2013. http://nystateofhealth.ny.gov/news/press-release-new-york-health-benefit-exchange-announces-new-name-and-health-and-dental-plans-0← Return to text
  8. New York Health Benefit Exchange Blueprint. Section 4.0 Plan Management. November 2012. http://www.healthcarereform.ny.gov/health_insurance_exchange/blueprint_documents/04/← Return to text
  9. New York State Department of Health, Office of the New York Health Benefit Exchange. Invitation to Participate in the New York Health Benefit Exchange. January 31, 2013. http://www.healthbenefitexchange.ny.gov/sites/default/files/Invitation%20to%20Participate%20in%20NYHBE_0.pdf← Return to text
  10. Ibid.← Return to text
  11. Ibid.← Return to text
  12. NY State of Health. Press Release: New York Health Benefit Exchange Announces New Name and Health and Dental Plans to be Offered. August 20, 2013. http://nystateofhealth.ny.gov/news/press-release-new-york-health-benefit-exchange-announces-new-name-and-health-and-dental-plans-0← Return to text
  13. New York Health Benefit Exchange Regional Advisory Committee Meetings Presentation May 2013. http://www.healthbenefitexchange.ny.gov/sites/default/files/May%202013%20RAC%20Meetings%20Presentation.pdf← Return to text
  14. NY State of Health. Press Release for In-Person Assistors/Navigators Conditional Grant Awards. July 12, 2013. http://nystateofhealth.ny.gov/news/press-release-person-assistorsnavigators-conditional-grant-awards← Return to text
  15. NY State of Health. Map of In-Person Assistor/Navigator Conditonal Grants. July 10, 2013. http://www.healthbenefitexchange.ny.gov/IPANavigatorMap← Return to text
  16. New York Health Benefit Exchange Regional Advisory Committee Meetings Presentation May 2013. http://www.healthbenefitexchange.ny.gov/sites/default/files/May%202013%20RAC%20Meetings%20Presentation.pdf← Return to text
  17. Benefit Standardization Study for the State of New York. Wakely Consulting. June 2012. http://www.healthcarereform.ny.gov/health_insurance_exchange/docs/wakely_benefit_standardization_study.pdf← Return to text
  18. Holahan, Danielle. Health Insurance Exchange Planning in New York. February 13, 2012. http://www.healthcarereform.ny.gov/timeline/docs/2012-2-13_nhpf_holahan_presentation.pdf← Return to text
  19. New York State Exchange Level One Establishment Grant Project Narrative. June 29, 2012 http://www.healthcarereform.ny.gov/health_insurance_exchange/docs/project_narrative_level1_funding.pdf← Return to text
  20. New York State Department of Health, Office of the New York Health Benefit Exchange. Invitation to Participate in the New York Health Benefit Exchange. January 31, 2013. http://www.healthbenefitexchange.ny.gov/sites/default/files/Invitation%20to%20Participate%20in%20NYHBE_0.pdf← Return to text
  21. A Funding Availability Solicitation for the Office of Health Insurance Programs New York State Health Benefit Exchange. New York State Department of Health. July 15, 2011.  http://www.nescies.org/sites/www.nescies.org/files/New%20York%20State%20HIX%20RFP%20July%202011.pdf← Return to text
  22. Gershman, Jacob. ‘Troubled Firm Wins Health Exchange Bid.’ Wall Street Journal. April 3, 2012. http://online.wsj.com/article/SB10001424052702303816504577321902924427774.html← Return to text
  23. New York Site Visit Report. RWJF. April 2012. http://www.rwjf.org/files/research/74197.newyork.site.rpt.041712.pdf← Return to text
  24. Enroll UX 2014 website. http://www.ux2014.org/← Return to text
  25. Bajaj, Ruchika. Division of Health Reform and Health Insurance Exchange Integration, New York State Department of Health. Presentation for Enroll America and Enroll UX 2014, Washington, DC Policy Briefing. July 18, 2012.← Return to text
  26. Letter from New York Health Benefit Exchange to CCIIO. October 1, 2012. http://www.healthcarereform.ny.gov/health_insurance_exchange/docs/ehb_letter_to_hhs_10-1-2012_final.pdf← Return to text
  27. New York Affordable Insurance Exchange Grants Awards List. http://cciio.cms.gov/archive/grants/states-exchanges/ny.html← Return to text
  28. Robert Wood Johnson Foundation. ‘RWJF Seeks Coverage of 95 Percent of All Americans by 2020.’ May 6, 2011.  http://www.rwjf.org/coverage/product.jsp?id=72289← Return to text
  29. Letter from HHS to Governor Cuomo. December 14, 2012. http://healthbenefitexchange.ny.gov/sites/default/files/12-14-12%20Conditional%20Approvel%20Letter.pdf← Return to text

Provided by the Henry J. Kaiser Family Foundation

Obamacare in New Mexico

Health Insurance Marketplace in New Mexico

If you live in New Mexico, BeWellNM is the Health Insurance Marketplace to serve you. Instead of HealthCare.gov, you’ll use the BeWellNM website to apply for coverage, compare plans, and enroll. You can apply as early as October 1, 2013. Visit BeWellNM now to learn more.

Choosing the Right Health Insurance Plan

There are a number of different tiers of plans available on the New Mexico 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 New Mexico 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. New Mexico health insurers don’t have to offer every tier of plan, but within the New Mexico 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

New Mexico 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 New Mexico 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

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’s in New Mexico:

New Mexico Health Connections

Accountable Care Organizations in New Mexico

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 New Mexico

On March 28, 2013, Governor Susana Martinez (R) signed legislation creating the New Mexico Health Insurance Exchange (NMHIX). Governor Martinez had vetoed previous legislation that would have established an Exchange in 2011; however, the state had moved forward with a plan to create the New Mexico Health Insurance Exchange within the New Mexico Health Insurance Alliance.1 The Alliance was created in 1994 to provide small employer groups and qualifying individuals with access to health insurance.2 The new legislation creates a Board of Directors for the Exchange,  requires the establishment of strong conflict of interest policies, and allows the creation of a Native American Service Center to help with outreach to Native American populations.3,4 The Board of Directors of the Exchange will also oversee the Alliance until all the individuals and employers currently receiving coverage through the Alliance, along with enrollees in the New Mexico medical insurance pool, the state’s high risk pool, are transitioned into the Exchange.

Prior to enactment of exchange authorizing legislation, a 15-member Health Insurance Exchange Advisory Task Force was created by the Human Services Department to advise the state regarding development of an Exchange. The Task Force consisted of eight workgroups focused on specific topics: Essential Health Benefits; outreach, education, adoption, and enrollment; legislation; market regulation; Native Americans; program integration; financial sustainability; and employer participation.5 Based in part on the insight collected by these workgroups, the Task Force released final recommendations on April 9, 2013.6

Structure: The New Mexico Health Insurance Exchange is a quasi-governmental organization, specifically a non-profit public corporation.

Governance: The New Mexico Health Insurance Exchange is governed by a Board of Directors  consisting of thirteen voting members. These members include: the state Superintendent of Insurance; six members appointed by the Governor, including the Secretary of Human Services, a health insurance issuer, and a consumer advocate; and six members appointed by the state Legislature, including one health care provider and one health insurance issuer.3

In April 2013 the board members were selected and include:7Dr. James R. Damron (Chair), University of New Mexico School of Medicine

  • Jason Sandel (Vice Chair), New Mexico Medical Insurance Pool
  • Terriane Everhart, Property Consultants
  • John Franchini, New Mexico Superintendent of Insurance
  • Teresa Gomez, Futures for Children
  • Dr. Martin Hickey, New Mexico Health Connections
  • Dr. Larry Leaming, Roosevelt General Hospital
  • Gabriel Parra, Presbyterian Healthcare Services
  • Patsy Romero, Easter Seals El Mirador
  • David Shaw, Nor-Lea General Hospital
  • Ben Slocum, Lovelace Health Plan
  • Sidonie Squier, Secretary, New Mexico Human Services Department
  • Dr. J. Deane Waldman, University of New Mexico Health Sciences Center

The board named Mike Nunez, Executive Director of the New Mexico Health Insurance Alliance, to be the interim CEO of the New Mexico Health Insurance Exchange at least through the first quarter of 2014, when the board hopes to hire a long-term CEO. The Exchange plans to issue bids for a national firm, which should be hired by November 1, to conduct a search for a long-term CEO.8

Contracting with Plans: The New Mexico Division of Insurance (DOI) has the regulatory responsibility for licensing Qualified Health Plan (QHP) issuers and reviewing and approving QHP policies. On April 15, 2013, DOI released its submission guidelines for qualified health plans (QHPs).9 Carriers have submitted plans and preliminary rates to DOI, which are currently being reviewed.10 Carriers are required to offer Silver and Gold levels of coverage, and  must offer at least one statewide plan at each metal level for which the carrier submits a plan. (For example, if Carrier A has submitted a plan available at all the metal levels, then it needs to provide at least one statewide plan at all the metal levels. If Carrier A has only submitted plans at the Silver and Gold levels, then it only needs to provide statewide plans at the Silver and Gold Levels.) A carrier must offer three silver plan variations for each silver QHP to reflect the cost-sharing subsidies, and one zero cost sharing plan variation and one limited cost sharing plan variation for each metal level QHP. Benefits, networks, non-essential health benefits (EHB) cost sharing, and premiums must be the same across the silver plan variations. Carriers can offer plans in either the individual Exchange or SHOP, and will not be required to offer the same plan in both Exchanges. Plans that do not participate in the Marketplace initially will not be able to participate until the 2016 plan year.11

The New Mexico Health Insurance Exchange (NMHIX) will use geographic and tobacco rating. It is defining the number of geographic rating areas in New Mexico as four Metropolitan Service Areas (MSAs) plus one. The cap on a maximum differential between the highest and lowest rated area is 40%. The maximum ratio for tobacco rating will be 1:1.5.

In addition to ACA requirements, carriers offering QHPs will be required to report New Mexico-specific quality information to the New Mexico Health Insurance Exchange and DOI. Quality reporting will not be required for dental carriers; however dental-specific quality measures may be created by DOI for future plan years.9

At least five companies have filed with DOI to sell health insurance on New Mexico’s Exchange, including Lovelace Health Plan, Presbyterian Health Plan, Blue Cross Blue Shield of New Mexico, New Mexico Health Connections, and Molina Healthcare of New Mexico.12 The Marketplace has not yet defined its assessment fees for participating carriers.

Dental and Vision Benefits: DOI will allow either embedded pediatric dental benefits at a minimum actuarial value level of 70% or the health plan can opt out of embedding. DOI has received Notices of Intent to Participate from dental plans, and therefore expects that pediatric dental stand-alone plans will be available.11 DOI has adopted the reasonable limit of annual cost sharing for stand-alone pediatric dental plans to be at or below $700 for a single child enrollee plan, and $1400 for two or more children enrolled in a plan. Plans sold through the SHOP exchange are not required to embed pediatric dental benefits, but stand-alone pediatric policies will be available on the SHOP exchange.13

Risk adjustment, Reinsurance, and Risk corridors: Governor Martinez stated in her letter to Secretary Sebelius that New Mexico intends to administer a risk adjustment and reinsurance program during the first year of the Exchange, but noted that the State would not be able to come to a final determination until it has an opportunity to examine the federal risk adjustment methodology.  Governor Martinez also noted New Mexico’s intention to use the federal service for Advance Premium Tax Credit/Cost-Sharing Reduction eligibility determinations.14

Consumer Assistance and Outreach: On July 9, 2013 the New Mexico Human Services Department received a Level One Establishment grant of $18.6 million. This award will be used to support comprehensive outreach, education, and marketing activities, as well as the state’s “Healthcare Guide” program (Navigators and In-person Assisters). The state will partner with nonprofit organizations, counties, schools and universities, faith communities, providers, and business organizations to provide extensive outreach at local events.  The State will also provide targeted outreach and education to tribal sovereign Nations at health fairs and events, and create an educational website and hotlinks for Native Americans.15

On June 18, 2013, the New Mexico Health Insurance Exchange issued an RFP for advertising and marketing assistance, educational content, and public relations services, to be funded by the state’s Level One grant award. Through this RFP, the Exchange is seeking contractors to design and implement a comprehensive advertising and marketing campaign aimed at reaching uninsured and insured individuals and small employer populations that will be impacted by health reform. The purpose of this campaign is to educate these populations on the availability and benefits of health insurance to be offered through the Exchange beginning on January 1, 2014. Applications are due July 3, and the award is estimated to be announced the week of July 15.16 The New Mexico Health Insurance Alliance offered recommendations to the board on marketing channels, PR, and advertising messaging for specific populations.17

On June 28, 2013 the Exchange released a Request for Information (RFI) for “Healthcare Guides,” which is how NMHIX will refer to Navigators and Assisters. The Exchange envisions contracting with two or more umbrella entities to develop Navigator/Assister programs and implement comprehensive outreach, education, and enrollment strategies. It is assumed that these umbrella entities will utilize subcontractor organizations to provide a Healthcare Guide program. Separate contracts may be needed to provide services to specialized populations or certain geographic areas. The Exchange is encouraging partnerships and coalitions of organizations to submit applications together. Some partner organizations may propose to do outreach and education and some may propose to do enrollment and application assistance, but the overall proposal must include comprehensive services of outreach, education, and enrollment. These programs will hire individual Healthcare Guides, who must complete a training and certification program, as well as a criminal background check. Healthcare Guides will deliver education, outreach, and in-person assistance to result in enrollment in NMHIX, and connect customers to the Customer Service Center, NMHIX website, or certified and licensed brokers if additional support is needed. Targeted Native American assistance programs will also be developed to serve New Mexico’s Native American population.18 Applications are due July 15.19

Agents and brokers who wish to sell Exchange products will be required to meet licensing requirements and take additional training on NMHIX protocols. They will be required to register with the Exchange, receive training on QHP options and other publicly subsidized insurance programs and comply with Exchange privacy and security standards. Web brokers will be delayed until the 2015 operational year.20

NMHIX is working towards a “triage” call center to address unresolved federal call center issues during the interim period in which New Mexico will rely on federal platform functions. The Exchange is also investigating the possibility of developing its own SHOP call center or obtaining those services through outsourcing.

The current New Mexico Health Insurance Alliance staff will undergo Navigator, IPA, federal call center, and SHOP training. They will become Triage Center Representatives (TCRs) for escalated federal call center calls and will be responsible for carrier and federal subsidy reconciliations. The Exchange website will provide a premium calculator and employer decision tool, and will route member information to either SHOP or the federal individual Exchange.20

Small Business Health Options Program (SHOP) Exchange: The Advisory Task Force adopted the Employer Participation Workgroup’s recommendations regarding the SHOP Exchange in April 2013. Generally, the Workgroup emphasized the importance of affordability, simplicity, and education in attracting small businesses to the Exchange. The Workgroup recommended that state wait until 2016, when federal mandates go into effect, to change its definition of “small employer” to 100 or fewer employees.

The Workgroup recommended that in addition to its minimum bronze-level plans, every employer in a defined contribution exchange should be required to offer plans from one other actuarial value level. The same recommendation applies if an employer offers more than one plan in a traditional defined-benefit setting. In addition, the Exchange (not employers) should be responsible for premium aggregation.6

Financing: The Exchange Advisory Task Force made several recommendations related to the financing of the Exchange.  It recommended that an assessment be placed on insurers both inside and outside of the Exchange to remove the potential disincentive for Exchange participation, and that an assessment be placed on self-insured plans to contribute to financing the Exchange’s administrative costs. In addition, the Task Force recommended that if/when the High Risk Pool and the Health Insurance Alliance are absorbed into the Exchange, the assessments currently placed on plans for their administrative support be transferred to support the Exchange.6

Information Technology (IT): The New Mexico Health Insurance Exchange Board selected an IT vendor and project manager at its May 2013 board meeting.8 The project manager will provide support and oversight of the IT vendor, business analysis and testing, and technical architecture review of the Exchange.21 The IT vendor contract includes shopping and comparison of IT systems, quality assurance and user acceptance testing, website development, and functionality related to the Small Business Health Options Program (SHOP) Exchange.22 The IT vendor has developed a roadmap and timeline for getting the Exchange IT systems up and running by October 2013.20

The IT vendor is expected to coordinate with the Medical Assistance Division and Income Support Division of the New Mexico Human Services Department, such that eligibility determinations for Medicaid and the Children’s Health insurance Program (CHIP) can be transmitted to ASPEN (Automated System Program and Eligibility Network), the state’s current Medicaid eligibility system. The ASPEN system and the Medicaid Management Information System (MMIS) will coordinate enrollment activities for individuals found eligible for Medicaid or CHIP.  The state is in the process of replacing ASPEN, which is approximately 25 years old.23 Integration of the Exchange and ASPEN is expected to be functional in 2015. To assist in financing the information technology upgrades of the state’s Medicaid eligibility systems, New Mexico applied for and received CMS approval of an Advanced Planning Document for the enhanced federal match.24

New Mexico is also participating in the Enroll UX 2014 project, which is a public-private partnership creating design standards for exchanges that all states can use.

Basic Health Program (BHP): New Mexico has explored establishing an optional coverage 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 selected a subcontractor to create a health care reform fiscal model, which includes the estimated impact of a BHP.25 In its final recommendations, the Advisory Task Force recommended that the BHP continue to be studied as the Exchange moves forward. Workgroup members believe the BHP is necessary to mitigate the effects of churn and avoid possible loss of coverage.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.  On October 17, 2012, the Public Regulation Commission’s Insurance Division recommended that New Mexico’s EHB benchmark be the Lovelace Classic Preferred Provider Organization, a small group plan.26

Exchange Funding

The New Mexico Human Services Department received a federal Exchange Planning grant of $1 million in 2010.  The Office of Health Care Reform requested and was granted a 12-month budget extension on the Planning grant funds for a new project end date of September 29, 2012.27 On November 29, 2011, the New Mexico Department of Human Services received a federal Level One Establishment grant of almost $35 million.1 The grant funding will be used to refine the vision and objectives of the Exchange, continue stakeholder engagement, develop a multi-year business and operational plan, and examine the information technology infrastructure and functionality necessary to operate the Exchange by 2014. In October 2012, New Mexico requested an extension of the Level One grant. On July 9, 2013 the New Mexico Human Services Department received an additional Level One Establishment grant of $18.6 million. This award will be used to support comprehensive outreach, education, and marketing activities, establishing the state’s Navigator program, and supporting the state’s in-person assistance personnel.15

In addition, New Mexico, along with nine other states, is receiving 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.28

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.

New Mexico is participating in Medicaid expansion.

Next Steps

On January 3, 2013, New Mexico received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based Exchange.29 However, due to time constraints in implementing an IT system, on May 17, 2013, the Board of Directors voted to work with the federal government to run the individual Exchange until October 2014. Under this arrangement, the state will maintain plan management and consumer assistance functions, while the federal government will operate the IT system. The state will also run the SHOP Exchange.30 8

Additional information about the New Mexico Health Insurance Exchange can be found at http://www.nmhix.com/

Footnotes
  1. New Mexico Level I Health Insurance Exchange Establishment Grant. September 2011. http://www.hsd.state.nm.us/pdf/hcr/NM%20Health%20Insurance%20Exchange%20Establishment%20Grant.pdf← Return to text
  2. Title 13, Chapter 10, Part 11. Health Insurance Alliance Plan of Operation and Eligibility. http://www.nmcpr.state.nm.us/nmac/cgi-bin/hse/homepagesearchengine.exe?url=http://www.nmcpr.state.nm.us/nmac/parts/title13/13.010.0011.htm;geturl;terms=Health+Insurance+Alliance+Act← Return to text
  3. SB 221. New Mexico Health Insurance Exchange Act. http://www.nmlegis.gov/lcs/_session.aspx?chamber=S&legtype=B&legno=221&year=13← Return to text
  4. “Governor Susana Martinez Signs Bipartisan Legislation to Establish State-Based Health Insurance Exchange By New Mexicans, For New Mexicans.” State of New Mexico, Office of the Governor. March 28, 2013. http://governor.state.nm.us/uploads/PressRelease/191a415014634aa89604e0b4790e4768/Governor_Susana_Martinez_Signs_Bipartisan_Legislation_to_Establish_State_Based_Health_Insurance_Exchange_.pdf← Return to text
  5. Presentation to the New Mexico Insurance Exchange Advisory Task Force. August 22, 2012. http://www.hsd.state.nm.us/pdf/hcr/08.22.12%20Advisory%20Task%20Force%20Presentation.pdf← Return to text
  6. New Mexico Health Insurance Exchange Advisory Task Force Recommendations. New Mexico Human Services Department. April 9, 2013. http://www.hsd.state.nm.us/pdf/hcr/Final%20Advisory%20Task%20Force%20Recommendations%2004%2009%202013%20(2).pdf← Return to text
  7. First Board Members Named for New Mexico Health Insurance Exchange. Albuquerque Business First. http://www.bizjournals.com/albuquerque/news/2013/04/08/board-members-named-nm-health-exchange.html and Governor Susana Martinez Announces Appointments to the New Mexico Health Insurance Exchange Board. State of New Mexico Office of the Governor.← Return to text
  8. New Mexico Health Insurance Exchange Board Meeting Minutes. May 17, 2013. http://www.nmhia.com/nmhix/boardmeetings/NMHIX_5-17-2013_BoardMinutesRevised_Approved.pdf← Return to text
  9. New Mexico Qualified Health Plan Submission Guidelines. 4/15/13. http://www.osi.state.nm.us/healthcare-reform/docs/New%20Mexico%20Qualified%20Health%20Plan%20Submission%20Guide%20Final.pdf← Return to text
  10. New Mexico Health Insurance Rate Review. New Mexico Health Insurance Premium Summary 2014. http://nmhealthratereview.com/attachments/PrintFormat_NMHI_2014.pdf← Return to text
  11. New Mexico Public Regulation Commission. FAQ about QHP submissions in New Mexico. http://www.osi.state.nm.us/healthcare-reform/index.html#faq← Return to text
  12. “See who’s filed to sell plans on NM’s health exchange so far.” Albuquerque Business First. http://www.bizjournals.com/albuquerque/news/2013/05/03/several-insurers-applied-health-exchange.html← Return to text
  13. New Mexico Public Regulation Commission. FAQ s for Qualified Dental Plan Submission. http://www.nmprc.state.nm.us/insurance/healthcare-reform/docs/FAQs%20for%20Qualified%20Dental%20Plan%20Submission.pdf← Return to text
  14. Letter from Governor Martinez to Secretary Sebelius. December 13, 2012. http://cciio.cms.gov/Archive/Technical-Implementation-Letters/nm-declaration-letter.pdf← Return to text
  15. Center for Consumer Informaiton and Insurance Oversight. New Mexico Health Insurance Marketplace Grants Awards List. http://www.cms.gov/cciio/Resources/Marketplace-Grants/nm.html← Return to text
  16. New Mexico Health Insurance Exchange. RFP: Advertising and Marketing Assistance, Educational Content, and Public Relations Services. http://www.nmhia.com/nmhix/RFPs/NMHIX-Combined-RFP_6-14-13-HSD-mn.pdf← Return to text
  17. Report to the New Mexico Health Insurance Exchange. April 29-30, 2013. http://www.nmhia.com/nmhix/boardmeetings/NMHIA%20Report%20to%20NMHIX_2013-04-29.pdf← Return to text
  18. New Mexico Health Insurance Exchange. RFI: Assister/Navigator. http://www.nmhia.com/nmhix/RFPs/Health%20Care%20Submission.pdf← Return to text
  19. New Mexico Health Insurance Exchange. Healthcare Guides RFI Addendum #1. http://www.nmhix.com/wp-content/uploads/2013/01/Health-Care-Submission-RFI-Addendum-1.pdf← Return to text
  20. New Mexico Health Insurance Exchange. Board Meeting Agenda: June 7, 2013. http://www.nmhia.com/nmhix/boardmeetings/NMHIA-Board-Agenda_6-7-13_rev2.pdf← Return to text
  21. New Mexico Health Insurance Alliance. Requests for Proposals. Project Management Services,  New Mexico Health Insurance Exchange (NMHIX). November 2, 2012.  http://www.nmhia.com/nmhix/RFPs/Project_Management_Services.pdf← Return to text
  22. New Mexico Health Insurance Alliance. Request for Proposals. Information Technology and Integrated Services. http://www.nmhia.com/nmhix/rfps.php← Return to text
  23. Jennings T. “Medicaid Tech System Gets Overhaul As State Preps for Exchange.” Santa Fe New Mexican. November 8, 2011. http://www.santafenewmexican.com/SantaFeNorthernNM/Medicaid-tech-systems-get-overhaul-as-state-preps-for-exchange← Return to text
  24. Heberlein M, et al. “Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2011-2012” Kaiser Commission on Medicaid and the Uninsured. (January; #8272). http://www.kff.org/medicaid/upload/8272.pdf← Return to text
  25. The Hilltop Institute. “New Mexico Health Care Reform Fiscal Model: Detailed Analysis and Methodology.” March 2012. http://www.hsd.state.nm.us/pdf/hcr/New%20Mexico%20Health%20care%20Reform%20Fiscal%20Model%20Report.pdf← Return to text
  26. Press Release by the New Mexico Public Regulation Commission. October 17, 2012. http://www.hsd.state.nm.us/pdf/hcr/Division%20of%20Insurance%20press%20release,%2010.17.12,%20regarding%20Benchmark%20selection.pdf← Return to text
  27. New Mexico Office of Health Care Reform. 4th Quarterly Report Project Summary for CCIIO.← Return to text
  28. Robert Wood Johnson Foundation. “RWJF Seeks Coverage of 95 Percent of All Americans by 2020.” May 6, 2011.  http://www.rwjf.org/coverage/product.jsp?id=72289← Return to text
  29. Letter from Secretary Sebelius to Governor Martinez. January 3, 2013. http://cciio.cms.gov/resources/files/nm-blueprint-exchange-letter-01-03-2013.pdf← Return to text
  30. “NM Changing its Plans for Health Exchange.” Associated Press. http://www.lcsun-news.com/las_cruces-news/ci_23284657/nm-changing-its-plans-health-exchange← Return to text

Provided by the Henry J. Kaiser Family Foundation