In the Patient Protections and Affordable Care Act (PPACA) aka, Health Care Reform, aka, Obamacare, the 50 States are required to set up Health Insurance Exhanges. A “Health Insurance Exchange” is basically an online portal where individuals and small group employers will be able to view, compare and purchase the health insurance plans approved for offer through the exchange. These plans are required to meet the essential benefits and maximum out-of-pocket guidelines along with other guidelines, to be offered in the exchanges. So, how are the States coming along in their development of Exchanges?? The National Association of Health Underwriters has provided us with a state by state update. (see below). Some states are advancing, some states are moving slowly, some states have taken a “wait and see” attitude (waiting for the Supreme Court’s ruling on constitutionality of the individual madate as well as other provisions of the law) and some states are refusing to participate at all.

This just in from the National Association of Health Underwriter (NAHU)
State Legislative Update

Region 1

Connecticut
Exchange implementation efforts are moving along in Connecticut. The exchange announced appointments to its advisory committees last month. The Connecticut chapter members were pleased by the announcement as many of them were tapped to participate. Come rain or shine, Connecticut will have an exchange, as recently Governor Malloy announced that he will continue with the state exchange even if the Patient Protection and Affordable Care Act (PPACA) is repealed at the federal level

Maine
The legislature is coming to the close of a busy session. The exchange bill is now dead, but L.D. 1497, a bill addressing navigators, was passed and now awaits the governor’s signature. The bill does not establish an exchange, but restricts navigators to non-producer activities and requires them to be subject to a registration or limited license as determined by the superintendent of insurance.

Massachusetts
MassAHU President Mark Gaunya coordinated an expansive effort to deem March 26-30, 2012 Consumer Driven Health Improvement Week by receiving proclamations from all six governors in New England. The goal of the week was to educate and draw consumers’ attention to the importance of taking responsibility for health and welfare choices.

New Hampshire
Live free or die trying? The New Hampshire legislature has dug in its heels on an exchange and now all action has come to a halt. Chapter members are working to determine what their relationship will be with a federally facilitated exchange should it come into fruition in the state.

New York
Last week, Governor Cuomo signed an executive order to establish a New York state exchange within the state’s department of health. Originally the state budget passed included language to enact a state exchange, but through Senate negotiations the bill was stripped of the language. Governor Cuomo had been on record of supporting a legislative approach to exchange enactment.

Vermont
Last week the Vermont Senate considered state exchange legislation. Recently, an amendment was accepted to the bill allowing agents to sell qualified health plans through the exchange. The amendment was modeled to also create transparency in producer commissions, which has been a concern of the legislature.

Region 2

Delaware
The consulting group hired by the state to work on exchange efforts is recommending a state/federal partnership for the state as the most cost-effective means of operating an exchange. However, state policymakers are still waiting on guidance from HHS on the parameters of a federal exchange partnership before taking any concrete steps to move forward.

District of Columbia
The District’s health reform implementation committee (HRIC) released its initial recommendations relative to the market structure of the district’s exchange. While GWAHU is pleased that the plans call for the exchange to accept any willing carrier who meets the requirements to offer a qualified plan, the chapter is concerned about some of the other preliminary thoughts offered in the report. Of top concern is the proposal to limit both the individual and small group markets in the District to the exchange, as is the recommendation to merge the individual and small group market rating pools. The very limited size of the DC market is the basis for these recommendations, but GWAHU is concerned about the projected impact on small group rates and product choices. The chapter is preparing a comment letter to the HIRC and working for grassroots action on the issue within the small employer community.

Maryland
The Maryland legislature adjourned on April 9 without passing a revenue and spending agreement, so a special session will have to be called later this year to resolve the budget issue. However, the two big goals of the producer community were met this session. S.B. 238, the Maryland Health Benefit Exchange Act of 2012, passed, and includes the vitally important protection of limiting products offered through the exchange to health, vision and dental insurance only, as well as a clear delineation of the duties and authority of navigators versus those of producers. Legislation also passed that allows licensed producers for the first time to provide administrative services in conjunction with the provision of health benefit plans to employers and charge for those services beyond their normal commission.

New Jersey
Exchange legislation is sitting on Governor Christie’s desk, but many believe he will veto it. Even though the bill’s treatment of brokers is generally favorable, the structure of the exchange and other market-related issues promoted in the bill have resulted in opposition by NJAHU, the business community, all other agent groups and health insurance carriers in the state. The passage of the bill was rushed so that New Jersey could apply for additional exchange establishment grant funds from HHS, but since the grant deadline was extended and the Supreme Court decision still pending, few see the need for the measure. Meanwhile, NJAHU is also working on comments to the state Department of Banking and Insurance regarding a proposed regulation concerning the regulation of stop-loss insurance to small groups in the state.

Pennsylvania
PAHU members had their Capitol Day in Harrisburg on April 3. Two bills attacking PPACA are currently seeing movement. The first is S.B. 10, which amends the Pennsylvania constitution to prohibit a health insurance individual mandate. On March 28, the Senate passed it along party lines. If it also passes the House this year, it must be reintroduced and passed by the General Assembly in the 2013-14 session and then face the voters in a referendum before the constitution is amended.

On the House side, the State Government Committee is slated to take up House Resolution 49. It is much broader in scope in that it does not specifically reference PPACA. Rather, it aims at what it terms as a usurpation of states’ rights by the federal government by imposing mandates or requiring states to pass certain legislation or lose federal funding. Of note is that five Democrats joined 32 Republicans in sponsoring this legislation.

Virginia
The Virginia Health Reform Initiative, the group established by Governor McDonnell to develop PPACA-implementation recommendations for the state, has published its preliminary analysis of what may be considered essential health benefits for the Commonwealth should health reform move forward.

Region 3

Illinois
Discussions toward an “agreed bill” to move forward on the health insurance exchange are ongoing. ISAHU members were interviewed regarding their views about navigators by the consultants advising the state.

Indiana
The Department of Insurance (DOI) has contacted Indiana members for their input on the newest exchange regulations released from Washington. Members will meet with DOI staff to provide feedback to the department on the latest exchange regulation.

Kentucky
Exchange preparations are taking place in Kentucky, but the bulk of the action is behind the scenes. Governor Beshear has not yet released an executive order but members expect one to come any time. Political rumblings are beginning to indicate that Kentucky will likely move forward with a state-based insurance mandate if the federal law is changed in the Supreme Court ruling.

Michigan
Michigan’s new insurance mandate on autism spectrum disorders is a bit different than other mandates we have seen before. The new autism coverage mandate comes with a state funding mechanism and reimbursement function for those employers and TPAs who have not included autism benefits in their coverage in the past. This policy tweak was made to help alleviate some of the financial burden to employers.

Ohio
Policymakers are holding tight in Ohio as nothing will happen on exchange legislation before the Supreme Court ruling and the November elections. Although there is no exchange in Ohio for now, OAHU is working with the Health Policy Institute of Ohio in drafting a response to latest federal exchange regulations.

West Virginia
Exchange implementation is slow and steady in West Virginia. The exchange board has yet to be named, but the state insurance commission continues to hold meetings on implementation. Members attended an exchange meeting last week where discussion began on defining the role of the agents versus navigators in the exchange.

Region 4

Iowa
IAHU has seen some exciting headway on their legislative efforts. An amendment to license navigators and require equitable producer compensation inside and outside the exchange was added to an omnibus bill and passed the House. Both the majority and minority leaders spoke on the floor to the importance of agents.

Minnesota
Legislation to create a “unified premium account,” S. 2313, passed the Senate. The unified premium account allows contributions from employers or other sources that can then be used to pay health insurance premiums. Policymakers are considering the use of the state high risk pool as a reinsurance mechanism to comply with PPACA.

Nebraska
The Nebraska agent groups have defined “key components” for an exchange in their state. They defined the role of navigators as follows: “Exchange Navigators should educate consumers on how the Exchange functions, assist in navigating the Exchange web site, explain subsidies available, assist in enrollment for Medicaid and subsidies, and refer consumers to a licensed insurance agent to assist with choosing and enrolling in an insurance plan.”

Wisconsin
Wisconsin’s legislative session ended without action on exchanges. There is another session starting April 24, but between waiting for the Supreme Court to act and the imminent recall election of Governor Walker, nothing much is expected to happen. WAHU recently hosted a meeting with Dr. John Toussaint, author of Potent Medicine.

Region 5

Alabama
Republicans are dealing with a family feud in Alabama between the governor and legislature on exchanges. To the dismay of the legislature, Governor Bentley is working behind the scenes to develop the exchange structure with limited outside involvement. AAHU members have been looped in, but many others have been left in the dark throughout the governor’s effort. State Representative Greg Wren, who is also a licensed producer, has developed an exchange bill to bring more legislative control back to the state’s exchange implementation process.

Florida
The Florida legislature is now out of session until next year. Many policymakers believe that if need be, the existing Florida Healthy Choices program, which functions as a coverage portal for small employers, will be used as the framework for an exchange, but the transition will require a heavy legislative lift in order to make it work. Right now, Florida is waiting for the Supreme Court to act before considering legislation.

Georgia
GAHU members recently held a meeting with Governor Deal’s lead health policy staff to discuss the new exchange regulations.

The Tea Party in the state is looking to identify states that would potentially pass coverage across state lines bills. Georgia passed this legislation last session and has yet to act upon it due to the limited ability of other states to participate.

Mississippi
Mississippi held their second health insurance exchange advisory board meeting to begin exploring essential benefits. The advisory board is working with Leavitt Partners to break down Mississippi’s mandates and top plan benefits in order to determine the essential benefits benchmark.

South Carolina
Grassroots movements are activating in South Carolina on exchange and navigator issues. The United Way of South Carolina wants to partner with SCAHU agents as a navigator group.

SCAHU’s state symposium was at the end of March and attracted a record number in attendance. The Deputy Director of the Department of Health and Human Services’ regional office (HHS) spoke to the group.

Region 6

Missouri
The legislature is waiting on the outcome of the Supreme Court case before moving on an exchange. In the interim, a bill is under consideration to prohibit Governor Nixon from pursuing or implementing an exchange. The governor applied for and received a $20.8 million exchange grant from HHS, but the legislation will prevent Missouri from moving forward with any exchange planning efforts.

Louisiana
The legislative session began on March 12 and the chapter held its Day at the Capitol on April 10. This session LAHU will be working to push a bill requiring carriers to disclose claims experience on groups of all sizes. The legislature may also consider legislation to address network adequacy

Texas
In terms of state activity, things are quiet in Texas as the legislature is not in session this year. TAHU’s efforts have been focused on getting more members of the Texas congressional delegation signed on to H.R. 1206. They currently have 13 potential co-sponsors they are targeting.

Oklahoma
The state legislature chose not to move forward with the exchange bill and is working on other insurance-related matters. The Department of Insurance wants to repeal a portion of the producer licensing law that allows for brokers to charge both a fee and a commission. Agent groups are working to achieve grandfathering of those agents licensed prior to the bill’s effective date.

An association bill which would impact how health plans are sold is also moving through the legislature, although the Department of Insurance has indicated that they would like to do a “study” before moving forward.

Kansas
There is no legislative exchange activity at this time, but Commissioner Praeger is overseeing work groups who have been assigned to construct the operational elements of an exchange. None of their reports have been finalized.

Region 7

Arizona
Arizona’s Day at the Capitol was March 22, and AAHU members visited with a number of key health committee members. Monthly meetings regarding an exchange continue but there is no legislation pending.

Colorado
Several bills not related to health exchanges are causing concern this legislative session. One bill of particular interest would have allowed for professionals (brokers, lawyers, doctors, etc.) to practice for a year before being required to obtain a license from the state. This bill has been defeated.

Idaho
IAHU’s Day on the Hill was March 1, and IAHU has conducted an ambitious multi-pronged effort to get legislators to act on the exchange. Unfortunately, political concerns have sidelined any progress.

Montana
Helena is quiet for now, as the Montana legislature does not meet in 2012. The Montana co-op was one of the organizations to receive federal start-up funding from the federal government. MAHU members would like to know more about this new effort and hope to make contact with the co-op board.

New Mexico
The University of New Mexico’s $10 million grant for the state’s navigator program has been vacated since proper procedures were not followed in awarding the money. The head of the New Mexico exchange has resigned.

Two new domiciled insurance companies are expected to start up in New Mexico in the coming months. One may be the co-op that recently received a start-up loan from HHS.

Utah
Utah’s legislative session ended in early March. UAHU had a very successful legislative session outcome with all opposed bills failing and all supported bills passing.

Wyoming
Efforts to move forward on an exchange have come to a halt as the steering committee suspended operations following pressure from the governor. Members of the legislature also expressed concerns that the Supreme Court may strike down PPACA.

Region 8

Alaska
Alaska legislators surprised many exchange watchers by introducing a bill in January, S.B. 70, to establish the Alaska Health Benefit Exchange. Despite this and some initial research, efforts have ceased pending the decision by the Supreme Court.

California
The legislature is in session and CAHU continues to closely monitor several bills regarding exchanges and product advertising restrictions. The group has roughly one dozen bills on the priority list for this session. The CAHU Day at the Capitol was held April 10-11.

Hawaii
A push was made for an autism mandate to be approved by the legislature, but so far the bill has not moved out of committee. The exchange governance structure may be revised to reduce the influence of insurers.

Nevada
NVSAHU members are considering an education strategy to ensure that exchange board members truly understand the role of the broker in the health insurance marketplace. Members are concerned that the board assumes that navigators will be sufficient.

Oregon
The state is establishing a work group to determine how essential health benefits will be defined in Oregon. ORAHU members are submitting applications in hopes of being appointed to the group. A health exchange related bill was passed by the legislature to approve the exchange’s business plan and correct drafting errors.

Washington
Governor Gregoire signed the exchange bill without vetoing the provisions identified by WAHU as problematic. Of particular concern to members is language that exempts navigators from state producer licensing requirements if they are acting within the scope of PPACA.

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