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State Legislators for Progressive Health Care Reform - State Implementation of Federal Reform: Resources

Healthcare Reform Resources

State Implementation of Federal Reform: Resources

Following the passage of the Patient Protection and Affordable Care act, statehouses will be the critical venues where the battle for the implementation of federal reform will play out. Here are some resources on the various aspects of the implementation of federal reform in the states:

High Risk Pools | Insurance Market Reforms | Health Insurance Subsidies | Health Insurance Exchanges | Funding for States | Individual Mandates | Medicaid, Medicare, and S-CHIP | Health Care Delivery | Politics of Reform | Implementation Timelines | State Models for Implementation

High Risk Pools
  • Department of Health and Human Services - Letter from HHS Secretary Sebelius to Governors (April 2, 2010)
    Sec. Sebelius asks Governors to indicate if their state will participate in the temporary high risk pool. She explains that HHS will provide individual assistance to states if they agree to participate, both in preparation of their application and during the application review process. The Secretary explains the available implementation options including requirements as they relate to eligibility, benefits, coverage, and premiums. She also outlines the flexibility that states have in the implementation and operation of the pool. The Patient Protection and Affordable Care Act (PPACA) provides for $5 billion in funding through January 1, 2014 when the program ends. The letter sets an April 30th deadline for states to submit their intent.
  • Sign-On Letter to HHS (PSN signed) - Letter to HHS on High Risk Pool (April 13, 2010)
    The letter recommends four conditions in the implementation of the pool: (1) Eligibility rules should be uniform to the maximum extent possible across all states and benefits should at least include a federally-set package, (2) The use of “standard rates,” as specified in the law, needs to be quickly and clearly defined by HHS so that premium rates are not subject to manipulation, (3) Income related assistance should be available at a level that is consistent with what will ultimately be available under PPACA for individuals and families in the health exchanges, and (4) The administrative process must be simple and transparent. A final recommendation suggesting that if states cannot establish their pools within 90 days, HHS should utilize one or more of the nationwide FEHBP plans as an alternative, with risk pooled separately from FEHBP current enrollees.
  • AARP - Advocacy Brief: Assuring the Promise of Federal Health Care Reform in 2010: State High Risk Pools (April 7, 2010)
    This brief explains the options available to states in operating the high risk pools as well as the design of existing pools in the 35 states that now provide the benefit (enrollment, deductibles, premiums, costs to the state, et. al.). The brief also explains the opportunities available to advocates for influencing the structure and implementation of the pools. The brief provides resources, a listing of the 35 states with existing pools, and text of the applicable sections within the PPACA.
  • Kaiser Family Foundation — Issues for Structuring Interim High-Risk Pools (January 2010)
    This paper examines the role of high-risk pools as a coverage safety net and reviews key issues involved in implementing a national high-risk pool including eligibility standards, covered benefits and premiums, subsidies, consumer protections, state administration of the pools and funding limitations.
  • Department of Health and Human Services - High-Risk Pool Programs Take a Step Forward (April 2010)
    This update details the 43 states that as of April 30, 2010 had told the Department of Health and Human Services how they plan to participate in high-risk pool programs: 28 indicating they would run a state-based high risk pool program, and 15 saying they would let HHS administer the high-risk program for their state's residents.
  • Oregon Medical Insurance Pool (OMIP) - Summary of the Oregon Medical Insurance (High Risk) pool (May 2010)
    Through the passage of HB 3659, Oregon will administer the federal temporary high risk pool through their existing pool. The bill established a Health Authority, which is now grappling with how to administer the federal temporary high risk pool.
  • Maine's Notice of Intent to apply for funding for participation in federal high risk pool (May 2010)
    This letter from Maine’s Director of Health Policy and Finance to HHS Secy Sebellius explains the state’s approach to extending this coverage through their existing Dirigo Health plan and the potential mechanisms that will provide the coverage.
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Insurance Market Reforms
  • National Association of Insurance Commissioners — Synopsis of Immediate Insurance Market Reforms (April 2010)
    A six page table with detailed notes explaining insurance market reforms within the PPACA that take effect in 2010 or 2011. These include: Annual and lifetime limits, Rescissions, Preventive health coverage, Extension of adult dependent coverage, Preexisting condition exclusions, Uniform coverage documents and standardized definitions, Prohibition on salary discrimination, Quality of care, Cost controls, Appeals Process, and Other patient protections. The chart explains the compliance requirements for insurance carriers relative to each reform topic, including a summary of the statutory language of each provision, the entity responsible for developing standards, effective date of implementation and the relevant section within the Act.
  • Families USA — What Will the New Health Reform Law Do in the First Year (April 2010)
    This fact sheet discusses how health reform will help people with pre-existing conditions, young adults, people on Medicare, small businesses, community health centers, and others in its first year.
  • Sign-On Letter to HHS (PSN signed) - Implementation of Immediate Insurance Market Reforms (April 2010)
    A letter addressed to Secretaries of HHS, Treasury and Labor offering suggestions and recommendations on the 2010 insurance with respect to their impact on consumers. Some of the reform topics addressed include: Enforcement, Non-discrimination, Rate review, Grandfathered plans, Appeals process, Rescissions, Medical Loss Ratios, Transparency/Disclosure, and other topics.
  • National Association of Insurance Commissioners — Synopsis of PPACA Provisions Taking Effect in 2014 or later (April 2010)
    A ten page table with detailed notes explaining all of the reform provisions which begin in 2014 or later. This includes a summary of the statutory language of each provision, the entity responsible for developing standards, effective date of implementation and the relevant section within the Act. Included in this table are five specific issue areas.
  • Families USA - Rate Review: Holding Health Plans Accountable for Your Premium Dollars (April 2010)
    This fact sheet discusses common problems with the process of reviewing health insurance premium rates, the lessons learned from state rate review procedures, and how health reform will address these problems.
  • Families USA - Medical Loss Ratios: Making Sure Premium Dollars Go to Health Care—Not Profits (February 2010)
    This fact sheet discusses medical loss ratios, state requirements regarding medical loss ratios, and why medical loss ratio requirements are so important for protecting consumers.
  • Congressional Research Service - Grandfathered Health Plans Under PPACA (April 7, 2010)
    This report addresses key questions concerning grandfathered plans (e.g., who is covered under such a plan) and insurance reforms affecting such plans, including reporting and consumer information requirements, benefits package, and access to coverage. It also addresses issues regarding the discontinuation of grandfathered plans and interaction with the individual mandate. This is a critical issue for health care consumers because grandfathered health plans are exempt from the vast majority of the new insurance reforms.
  • National Association of Insurance Commissioners — Health Reform Central
    New section in NAIC website providing a wealth of information regarding the implementation of health care reforms and the vital role of state insurance departments in protecting consumers.
  • National Association of Insurance Commissioners — Commissioner Tasks and Responsibilities (April 2010)
    This table outlines State Insurance Commissioner roles and responsibilities categorized according to issue area, the responsibility, timeline and citation.
  • Kaiser Family Foundation's Commission on Medicaid and the Uninsured - Explaining Health Care Reform: Questions About the Extension of Dependent Coverage to Age 26 (updated May 2010)
    This issue brief discusses the requirement in the law that private health insurers offer dependent coverage to children to allow young adults up to age 26 to remain on their parents' insurance policy. This provision is among the first in the reform law to take effect.
  • Kaiser Family Foundation's Commission on Medicaid and the Uninsured - How Will Health Reform Impact Young Adults? (updated May 2010)
    This issue brief explains the key ways in which the new law will affect adults ages 19 to 29, an age group that includes 13.7 million uninsured people who comprise nearly a third of the overall uninsured population.
  • White House - Fact Sheet on Young Adults and the Affordable Care Act (May 2010)
    This fact sheet outlines the key elements of the new federal law’s provision that offers dependent coverage to young adults. It also includes a link to new IRS guidance for employers, employees, health insurers and other interested taxpayers regarding this provision of the new law.
  • NCSL Fact Sheet on Health Reform - Extension of dependent health coverage up to the age of 26 (May 2010)
    This NCSL publication provides an overview of provisions dealing with dependent coverage. It includes a reference to new regulations issued by HHS, Labor and the Treasury Departments, regulatory requirements and issues for states.
  • Kaiser Health News - Health Law's "Grandfather" Clause Could Deprive Consumers Of Key Benefits (May 10, 2010)
    This news piece deals with the grandfathering provisions in the federal law, which Congress included to give employers and insurers a time for transition. Because grandfathered or existing health plans are exempt from several consumer protections, the issue has touched off a debate over how existing or grandfathered health plans are defined, with consumer and employer groups squaring off against each other.
  • National Association of Insurance Commissioners - Comments to HHS on Medical Loss Ratios (May 11, 2010)
    In response to an April 14, 2010 HHS request for information on Medical Loss Ratios, this document are comments prepared and approved by the NAIC is based on their survey and data collected from 27 state departments of insurance.
  • National Association of Insurance Commissioners - Comments to HHS on Review of Premium Rate Increases (May 11, 2010)
    In response to an April 14, 2010 HHS request for information on premium rate increases, this document are comments prepared and approved by the NAIC is based on their survey and data collected from state insurance departments.
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Health Insurance Subsidies
  • Kaiser Family Foundation — Explaining Health Care Reform: Questions About Health Insurance Subsidies (April 2010)
    To encourage broad participation in health insurance and provide affordable coverage for families, the Patient Protection and Affordable Care signed into law in March 2010 includes provisions to lower premiums and cost-sharing requirements for Americans with low and modest incomes. This brief describes the subsidies available in the law, including premium subsidies that would be provided in the form of tax credits, as well as other subsidies that would lower cost sharing to eligible Americans. It explains the sliding scale of subsidies available to Americans in 2014 with annual incomes between 133 and 400 percent of the federal poverty level, and describes the cost-sharing assistance and the impact of the subsidies on reform’s overall cost.
  • NCSL Fact Sheet on Health Reform - The Early Retiree Reinsurance Program (May 2010)
    This NCSL publication provides an overview of provisions establishing a temporary program dealing with the early retiree reinsurance program that will providing reimbursement to participating employment?based plans for a portion of the cost of health benefits for early retirees that takes effect June 1, 2010.
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Health Insurance Exchanges
  • National Association of Insurance Commissioners — Synopsis of the Insurance Exchanges
    A ten page table with detailed notes explaining each of the insurance exchange provisions of the PPACA found in Subtitle D — Available Coverage Choices for all Americans.
  • National Governors Association — Establishing a State Level Exchange discussion draft (March 15, 2010)
    This issue brief describes some of the important questions a state may want to consider before establishing an exchange. It presents some of the operational and implementation issues associated with establishing a state-level exchange; and discusses how an exchange might interact with other private and public functions within a state. Examples from three states, Massachusetts, Utah and Washington (public launch pending) that have already implemented exchanges will be considered to illustrate some of the options regarding the establishment of a state-level exchange.
  • Kaiser Family Foundation — Explaining Health Care Reform: Questions About Health Insurance Exchanges (April 2010)
    Initially Exchanges will serve primarily individuals purchasing insurance on their own and smaller employers. States will have the option of opening Exchanges to larger employers a few years after implementation. This summary provides responses to questions about the purpose and function of Exchanges and how they relate to regulation of the insurance market. Certain details of how provisions in the law will actually be implemented will not be available until regulations are issued by various government agencies, primarily the Department of Health and Human Services (DHHS).
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Individual Mandates
  • Center on Budget and Policy Priorities - Key Health Insurance Market Reforms Not Achievable without an Individual Mandate (April 7, 2010)
    Issue brief arguing that insurance reforms without a mandate would encourage people to wait until they are sick to buy coverage. The insurance pool would then have primarily older, sicker people, which would raise premiums for everyone. The individual mandate will help get healthy people into the health insurance market, which would keep premiums at a more reasonable level.
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Medicaid, Medicare, and S-CHIP
  • Centers for Medicare and Medicaid Services (CMS) — New Option for Coverage of Individuals under Medicaid (April 9, 2010)
    This is a letter from CMS directed to State Health and Medicaid Directors that provides initial guidance on Section 2001 of the PPACA: Medicaid Coverage for the Lowest Income Populations, which establishes a new eligibility group and the option for States to begin providing medical assistance to individuals eligible under this new group as of April 1, 2010. Under the law, for the first time since the Medicaid program was established, States will receive Federal Medicaid payments to provide coverage for the lowest income adults in their States, without regard to disability, parental status or most other categorical limitations, under their State Medicaid plans.
  • Center on Budget and Policy Priorities - Federal Government Will Pick Up Nearly All Costs of Health Reform’s Medicaid Expansion (April 20, 2010)
    This issue brief raises sound and in-depth arguments to counter the claim of health reform critics that states will be left with the burden of paying for the expansion of Medicaid under the PPACA. One of the counter arguments made in this report is in the its first five years, the Medicaid expansion will add just 1.25 percent to what states were projected to spend on Medicaid over that
    period in the absence of health reform, while providing health coverage to 16 million more low-income adults and children. Another finding is that the federal government will assume 96 percent of the costs of the Medicaid expansion over the next ten years, according to an analysis of CBO estimates.
  • Center on Budget and Policy Priorities - No Need to Wait Until 2014: States Can Cover Low-Income Adults in Medicaid Now (April 20, 2010)
    This issue brief explains that provisions within the PPACA include a new coverage option included in PPACA allows states to cover low-income adults now. Adopting this option could provide needed federal funds to states that currently fund their own coverage programs for low-income adults who are not eligible for Medicaid. It also provides a new pathway for states that want to expand coverage to adults without children before 2014. The new provisions also allow the state to bypass the far more complex waiver process. The brief answers key questions such as the benefits states can offer, limitations on enrollment, the flexibility for states to set a threshold below 133% of the federal poverty line and the federal matching rate.
  • Kaiser Family Foundation — Medicaid and Children’s Health Insurance Program Provisions in the New Health Reform Law (April 2010)
    This brief summarizes all the new Medicaid and CHIP provisions and includes a chart listing all of the relevant provisions and how they compare pre- and post-reform. The explanations focus on coverage and financing, benefits and access, dual eligibles and long-term care, and cost estimates.
  • Families USA - Early Medicaid Expansions under Health Reform (April 2010)
    This report discusses how states can expand their Medicaid programs earlier than federal reform requires them to do so (2014), and why they should. Starting in April 2010, states will be able to phase in Medicaid expansion through a state amendment process.
  • Kaiser Family Foundation - Financing New Medicaid Coverage Under Health Reform: The Role of the Federal Government and States (May 2010)
    Under the health reform law, the Medicaid program will undergo a significant expansion by 2014. Millions of low-income adults who currently cannot qualify for coverage in most states will be made eligible for Medicaid. The federal government will finance the vast majority of the new costs of coverage. This issue brief examines how the federal government and the states are expected to split responsibility for financing the expanded Medicaid coverage.
  • Alliance for Health Reform - Webcast: the New Health Reform Law and Medicare (May 7, 2010)
    This archived webcast, cosponsored by Kaiser and the Alliance for Health Reform, examined how the health reform law affects Medicare, including a detailed look at the key provisions that made it into the final law and what it means for Medicare beneficiaries, the federal budget and the health care industry. An interim final rule was released by HHS on May 5th and comments will be accepted until June 4, 2010.
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Health Care Delivery
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Politics of Reform
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Health Care Reform Implementation Timelines
  • Kaiser Family Foundation — Timeline for Implementation of PPACA Provisions (April 2010)
    This table provides a timeline for implementation dates of key PPACA provisions. It reflects provisions in the new law and incorporates modifications to the law included in the Health Care and Education Reconciliation Act of 2010.
  • Families USA - First 90 Days State Advocates' To-Do List (April 2010)
    Many provisions in the Patient Protection and Affordable Care Act take effect within 90 days after enactment. Families USA created a "to-do list" for state advocates to help ensure federal reform is implemented effectively from the start.

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State Models For Implementation
  • In California, Assembly bill 1595 and Senate bill 890 establish the intent of the Legislature to enact legislation that would implement federal health care reform.
  • In Illinois, SB 3047 creates a bipartisan Health Care Justice Implementation Task Force whose primary goal is to monitor the implementation of the federal health care reforms and make recommendations for state implementation.
  • An Iowa bill, Senate File 2356, received Senate approval by a bipartisan vote. This health care reform bill sets the groundwork for how potential federal health care funding may be used to benefit Iowans. It includes an insurance exchange and it also expands the state's unofficial public option program for adults below 200% FPL.
  • A Joint Select Committee to study Maine's role in the implementation of federal health care reform has passed both the House and Senate and does not require the Governors’ signature.
  • In Nebraska, LR 372 would set up a committee to study the potential effect of national health care reform proposals on Nebraska and analyze policy options for responding to and implementing health care reform measures.
  • The Texas House established a House Select Committee on Federal Legislation, with a specific emphasis on implementing health care reform efforts.
  • Two 2010 bills in Minnesota, HF3709 and SF3296, make conforming and other changes related to federal health care reform; provide funding for health care subsidies; establish accountable care organizations and a publicly administered health plan, expand eligibility for medical assistance, and establish the Minnesota Health Insurance Exchange.
  • In Maryland, Gov. O'Malley appointed a commission to make recommendations about the implementation of federal health care reform, which he predicted would save his state $1 billion.
  • In Rhode Island, S2552, the Rhode Island Health Reform Act of 2010, would provide for a state-sponsored system of universal health care, including the establishment of a quasi-public non-profit organization through which all public and private purchases of insurance or health care services will be transacted for all Rhode Island employers and individuals.
  • In Wisconsin, Gov. Doyle created an Office of Health Care Reform to prepare for the sweeping changes from health care reform that effect in 2014, from creating a state-based insurance exchange to communicating to the public to explain the changes to the state's health care system.
  • Gov. Gregoire in Washington signed an executive order declaring the formation of a Health Care Cabinet directed to guide implementation of reform. The group will consist of the state Health Care Authority administrator, the state Health Department secretary, the Department of Social and Health Services secretary, as well as the governor's executive policy director and state budget director.
  • New Mexico is preparing to implement federal reforms (including its own innovative high risk insurance pool and a state insurance exchange) through the passage of SJM 1, which establishes a Health Care Reform Working Group.
  • In Vermont, the Senate passed S88 by a landslide bipartisan vote of 28-2. Three highlights of the bill include: A design of three options that would ensure universal access to quality health care, with a single payer plan and a public option included among the possible options; an expansion of the state's Blueprint for Health and Community Health Systems pilot program that addresses the coordination of services for individuals with chronic health conditions; and the institution of cost controls targeting hospitals.
  • In Colorado, Gov. Ritter signed an executive order to create a board of advisers on health care policy that will oversee the implementation of federal reforms, including setting up a state insurance exchange.
  • In New Jersey, the Health Insurance Exchange Act, SB 1288, establishes the New Jersey Health Insurance Exchange as an independent public entity, in but not of the Department of Banking and Insurance, with certain authority to facilitate the availability and choice of health benefits plans offered to employees of small employers that employ between two and 50 employees, and other eligible persons not employed by small employers.
  • In Oregon, the state legislature laid the groundwork to implement federal reform in 2009 with the passage of HB 2009, which created the Oregon Health Authority, a state agency which is overseeing the interaction between state and federal health reform.
  • In Connecticut, the state legislature in 2009 passed SustiNet, which created a board of directors now charged with making recommendations on the implementation of federal reform.
  • In Michigan, Gov. Granholm signed Executive Order No. 2010-4 which created a council to oversee and develop recommendations for the implementation of the Patient Protection and Affordable Care Act.
  • The state legislature in Montana prepared for the implementation of federal health care reform in 2009 with the passage of SJR 35, a resolution that created a legislative committee which is now studying opportunities and requirements for state action under federal reform.
  • In Louisiana, HB303 would "provides for compliance with federal law" for expanded coverage by the Louisiana Health Plan.
  • In Mississippi, SB 2554 created the Mississippi Health Insurance Exchange Study Committee to make recommendations on the implementation of federal reform. It was signed into law by Gov. Barbour on April 14, 2010.
  • In Pennsylvania, legislation to create a Health Insurance Reform Implementation Authority (HB 2462) has been introduced with bipartisan support. In addition, Gov. Rendell issued an Executive Order to immediately create two committees that will oversee the implementation of health care reform, including one specifically focused on designing the state's high-risk pool.
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Please email Enzo Pastore, PSN's Health Care Policy Specialist, at epastore@progressivestates.org with any questions or further information on the progress of implementation of federal reform in the states.