This section provides information on implementation, including technical materials that examine the parts of the law that go into effect over the coming years. See also Understanding the New Law for more resources on specific aspects of the law and how to talk about it.
Health Insurance Exchange Resources
States Should Take Additional Steps to Limit Adverse Selection among Health Plans in an Exchange explains how the health care law seeks to minimize adverse selection in the exchanges and recommends additional steps that states can take to do so, such as requiring insurers that sell in the exchanges to offer plans in every coverage level. (Center on Budget and Policy Priorities, June 2011)
Families USA's Comments on the National Association of Insurance Commissioners' (NAIC) white paper entitled "Health Insurance Exchanges under the Affordable Care Act: Governance Options and Issues" (May 16, 2011)
Implementing Exchanges: A series of guides on implementing state health insurance exchanges.
Building an Effective State Exchange offers 15 benchmarks to guide advocates and legislators as they develop the new health care exchanges that are required by the Affordable Care Act. Advocates are free to take this document and adapt it to the needs of their states. (Families USA, December 2010)
Designing an Exchange: A Toolkit for State Policymakers suggests ways to build on the National Association of Insurance Commissioners' (NAIC) model exchange legislation to address a number of policy issues. The toolkit includes legislative language and discussions of key issues. (National Academy of Social Insurance, January 2011)
Governance Issues for Health Insurance Exchanges discusses the options that are available to states to structure their exchanges: through a state government agency (either existing, newly created or quasi-governmental), a nonprofit entity established by the state, a multi-state exchange, or a federally operated exchange. It also outlines the issues and challenges states are likely to face. (National Academy of Social Insurance, January 2011)
Active Purchasing for Health Insurance Exchanges: An Analysis of Options describes the various ways in which state exchanges can serve as "active purchasers," negotiating for the best quality and price on behalf of health insurance consumers. It also outlines the ways that active purchasing activities may differ based on states' different environments. (Georgetown University Health Policy Institute and the National Academy of Social Insurance, June 2011)
HHS Grant Announcement: Cooperative Agreement to Support Establishment of State Operated Health Insurance Exchanges explains how states can apply for another year or more of funding to plan for exchanges. The timeline of tasks for states that begins on p. 55 will help you write your "to do" list and help you advocate for a strong exchange. States can also provide funding for consumer assistance programs with these grants. (Department of Health and Human Services, January 2011)
Evaluative Framework for Assessing SHOP and Health Benefit Exchange Proposals is a chart that will help you identify potentially harmful language in exchange proposals. (American Cancer Society Cancer Action Network)
State Refor(u)m provides an up-to-date compilation of state Affordable Care Act implementation legislation and planning documents, including many state exchange bills. (National Academy for State Health Policy)
General Information on Implementation
How Can We Establish an Essential Health Benefits Package that Meets Consumers’ Needs? provides background information and talking points on the critical issues that need to be addressed to ensure that consumers in the exchanges, individual and small group markets, and Medicaid benchmark plans have access to comprehensive coverage. (November 2011)
The Super Committee: Where They Stand on Medicaid, Medicare, and the Affordable Care Act provides a profile of each member's position on these key issues. It also includes each member’s stance on increasing revenues as an option for reducing the deficit. (Families USA, August 2011)
The Next 90 Days: A State Advocate's To-Do List provides an overview of the provisions to be implemented in the next 90 days, including coverage for dependents up to age 26, the appeals process, the prohibition of rescissions, and other protections, as well as follow-up on other important issues for advocates. | pdf version(Families USA, June 2010)
Recommendations for Regulators and Lawmakers on Health Reform Implementation provides an overview of specific provisions in health reform, including rate review, grants for consumer assistance programs, and others, and recommendations on the best way to implement them. This is a great resource to help advocates navigate the regulatory and implementation process. (Consumer representatives to the National Association of Insurance Commissioners—NAIC, May 2010)
Implementation Timeline Reflecting the Affordable Care Act (White House, May 2010)
The First 90 Days: A State Advocate's To-Do List provides an overview of the provisions to be implemented in the first 90 days, including coverage for uninsured people with pre-existing conditions, grants for consumer assistance offices, and Medicaid and CHIP maintenance of effort requirements. | pdf version (Families USA, April 2010)
Specific Implementation Issues Affecting the States
Designing Consumer-Friendly Beneficiary Assignment and Notification Processes for Accountable Care Organizations discusses the challenges advocates will face when developing these processes, and it recommends certain notification requirements and beneficiary protections. (January 2012)
Putting the Accountability in Accountable Care Organizations: Payment and Quality Measurements examines some of the challenges that advocates will face when working with policy makers, insurers, and providers to develop mechanisms that ensure that beneficiaries receive high-quality care at a lower cost. | Determining Shared Savings or Losses (January 2012)
Simplifying Enrollment and Eligibility with Modified Adjusted Gross Income (MAGI) explains the benefits of aligning income calculation rules in Medicaid, CHIP, premium tax credits, and Basic Health programs (where applicable) through MAGI. (October 2011)
States Making Progress on Rate Review highlights state efforts to protect consumers from unreasonable increases in insurance premiums. It also explains provisions of the Affordable Care Act that encourage improvements to states' rate review processes. (October 2011)
Presumptive Eligibility: A Step toward Streamlined Enrollment in Medicaid and CHIP explores how the Affordable Care Act expands presumptive eligibility to help states streamline enrollment and discusses the important role that presumptive eligibility can play in helping low-income people get access to care during and after the implementation of the new law. (September 2011)
To Build a Strong Affordable Care Act, Protect Medicaid explains that Medicaid is the foundation for health reform and briefly discusses the proposals that could damage Medicaid. Those working to implement health reform need to understand how threats to Medicaid could undermine their work. (September 2011)
Making the Most of Accountable Care Organizations (ACOs): What Advocates Need to Know provides an overview of ACOs; the promise they hold; and how they could change Medicare, Medicaid, and the health care landscape. It also identifies key challenges in their development and suggests how advocates can get involved in ways that benefit patients. (September 2011)
The Perils of Health Insurance Sold Across State Lines explains the hidden dangers in legislation—being pushed at the state and the federal level—that lets out-of-state insurers evade state regulation. (July 2011)
The Basic Health Option: Will It Work for Low-Income Consumers? provides a framework for advocates to think about whether this option, created by the health care law, will work for their state. It covers program basics, discusses the problems it might address, and raises key issues that can affect the direction such a program might take. (July 2011)
A Guide for State Advocates: State Demonstrations to Integrate Medicare and Medicaid explains the requirements for demonstrations, discusses possible models of integration, and provides guidance to advocates on how to get involved in the planning process. (April 2011)
Navigators Need Not Be Licensed as Insurance Brokers or Agents explains the Affordable Care Act's requirement that state exchanges establish "navigator" programs to help consumers make informed choices, explores the different roles navigators will need to play, and looks at the appropriate roles for insurance brokers and agents. The brief, which advocates may use freely and brand as their own, was produced with input from the Center on Budget and Policy Priorities, Health Care for America Now, and the Center for Public Policy Priorities. (March 2011)
Applying for Health Coverage Online: The Affordable Care Act Helps Americans Enroll discusses provisions in the Affordable Care Act that call for states to have one streamlined online application that allows consumers to apply for Medicaid, CHIP, and premiums credits available to purchase health coverage in state exchanges. The brief also examines where states are now in the implementation of an online application process. (March 2011)
Express Lane Eligibility: Early State Experiences and Lessons for Health Reform reviews the early experiences of four states under the Children's Health Insurance Program Reauthorization Act (CHIPRA) and how those experiences can be instructive as states move to implement health reform. The states are Alabama, Iowa, Louisiana, and New Jersey. (January 2011)
Preventing Unwarranted Exceptions to the Affordable Care Act's Medical Loss Ratio (MLR) Requirements explains the opportunities for advocacy if state insurance regulators file for adjustments to the MLR requirements. It also provides a list of questions to ask regulators if your state seeks an adjustment; these questions can be adapted for your state. (January 2011)
Grandfathered Plans under the Patient Protection and Affordable Care Act discusses health plans that existed on the date that health reform was enacted and are therefore exempt from some provisions of the law. It explains the requirements health plans must meet to maintain grandfathered status and outlines which protections in the health reform law apply to such plans and which do not. 6 pp. (Updated December 2010)
How States Are Making Sure Coverage Is Available to Children notes that, under health reform, insurers are required to accept children regardless of any pre-existing conditions in all group plans and in newly sold individual plans, and it examines what several states are doing to make sure that child-only policies are still available. (October 2010)
Consumer Health Assistance Programs: The Department of Health and Human Services has announced the availability of grants to states to establish or expand consumer assistance programs. Applications are due by September 10, 2010. For more information on these programs, see our publication, Designing a Consumer Health Assistance Program, which discusses how health reform will dramatically expand the assistance such programs provide. It also reviews key considerations to keep in mind when designing these programs, including grants and other funding, function, scope, location, staffing, training, and outreach. (August 2010)
Health Care Workforce Grants: The Department of Health and Human Services (HHS) has announced $250 million in primary health care workforce grants. The grants include funding for state health care workforce planning and implementation, as well as for personal and home care aide training programs. Grant application deadlines range from June 28 through July 22. Application guidelines are available on the Health Resources and Services Administration (HRSA) grants page.
Early Medicaid Expansions under Health Reform discusses how states can expand their Medicaid programs under a state plan amendment prior to 2014—and why they should. (Families USA, May 2010)
Rate Review: Holding Health Plans Accountable for Your Premium Dollars 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, Updated April 2010) l For a good example of a new state law that implements a strong rate review process, see New York A11369/S8088.
Maintenance of Effort Requirements under Health Reform discusses how health reform changes the maintenance of effort requirements that are already in place for state Medicaid and CHIP programs. (Families USA, March 2010)
Medical Loss Ratios: Making Sure Premium Dollars Go to Health Care—Not Profits discusses medical loss ratios, state requirements regarding medical loss ratios, and why medical loss ratio requirements are so important for protecting consumers. (Families USA, February 2010) | Families USA's Position Statement on Medical Loss Ratio Implementation (August 2010)
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