Update: Mississippi's Department of Insurance's spokesperson has told NU it will not apply for a state-federal health exchange partnership. Applications are due Feb. 15 for this model. It is unclear if the partnership model also requires the buy-in of the governor's office and other state agencies. Section 3.0 Eligibility and Enrollment under PPACA makes one of the requirements of a State-Based Marketplace a coordination strategy with other agencies administering Insurance Affordability Programs and the SHOP that enable the Exchange to carry out the eligibility and enrollment activities.
The Department of Health and Human Services (HHS) last week rejected approval of the Mississippi insurance commissioner’s state-based exchange application, citing the opposition by the Mississippi governor as the key obstacle, a decision highlighting the divisive nature of the exchange process in some states.
Insurance Commissioner Mike Chaney was pitted against Republican Gov. Dewey Phillip "Phil" Bryant in the struggle to implement the health exchange portion of the Patient Protection and Affordable Care Act (PPACA).
To be successfully approved and to even work as a marketplace, a state-based exchange would need working relationships with other state agencies under the requirements of a state-based marketplace under the Act. Specifically, the application must show that “the Exchange has developed and documented a coordination strategy with other agencies” administering insurance affordability programs that enable the exchange to carry out the eligibility and enrollment activities.
With Bryant’s well-publicized refusal to work with HHS or Chaney, there was no possibility of coordinating strategy with other agencies under his authority, HHS concluded.
“I have said repeatedly that the health insurance exchanges mandated by ObamaCare are not free-market exchanges. Instead, they are a portal to a massive and unaffordable new federal entitlement program. They trigger new taxes on businesses and will ultimately drive more people onto Medicaid rolls. I firmly maintain my position that Mississippi will not willfully implement a mechanism that will compromise our state’s financial stability,” stated Gov. Bryant in response to the decision.
“Make no mistake, the federal government will control all exchanges established under the Affordable Care Act,” Bryant stated.
Bryant is echoing the sentiments of other Republican governors, who have sometimes put their insurance commissioners in awkward positions as they try to work with HHS. Some states are feeling friction between state agencies, including the governor’s office and the insurance departments or other voter-mandated impediments.
In Kansas, where moderate Republican Insurance Commissioner Sandy Praeger chairs the state regulatory association’s health insurance committee, works well with HHS and wants some kind of exchange partnership, the governor, Sam Brownback, has been opposed to implementing the PPACA at all, including a state-based exchange.
In Missouri, even with a Democratic governor, a ballot measure passed barring state officials from helping carry out a state-based exchange. In Minnesota, exchange planning was removed from state insurance department oversight by Gov. Mark Dayton.
“With a lack of support from your governor and no formal commitment to coordinate from other state agencies, we do not see a feasible pathway to conditionally approve a state-based exchange in Mississippi for 2014,” the letter from Gary Cohen, director for the Center for Consumer Information and Insurance Oversight (CCIIO) wrote to Chaney Feb. 8.
A state’s declaration letter must be signed by the state’s governor.
HHS did leave open the possibility that Chaney, also a Republican, could submit a partnership exchange model.
HHS stated, “The exchange blueprint requires that a state-based exchange has developed and documented a coordination strategy with other agencies administering Insurance Affordability Programs.” The letter goes on to say that with a lack of support from the governor and no formal commitment to coordinate with other state agencies, HHS “does not see a feasible pathway to conditionally approving a state-based exchange in Mississippi.”
Commissioner Chaney submitted an exchange proposal to HHS in mid-November. HHS praised his commitment in its rejection letter and held out promise for a new solution.
“Although we are unable to conditionally approve your application at this time, we are impressed with the work you have completed to date and encourage you to submit an application for the partnership exchange model by Feb. 15,” Cohen stated in the letter.
“The work your insurance department has done thus far to ensure that Mississippi maintains broad authority over its health insurance market makes Mississippi an excellent candidate for a state partnership exchange,” Cohen wrote.
Under the federal health law enacted in 2010, every state is required to have a health insurance exchange so people can get coverage starting in January 2014, much of it federally subsidized. States that don't create their own will have one run by Washington, with enrollment beginning Oct. 1, 2013.
To date, about 20 states/jurisdictions have been conditionally approved to partially or fully run their marketplaces – with the remaining states having until Feb. 15 to apply for a state partnership exchange. More than half the states will rely on the federal government, whether they welcome this development or not, as some have made clear.
The Mississippi Insurance Department “will continue to work with HHS in the future to develop a free market state-operated small business exchange independent of and not connected to any federal program." It is unclear how this would proceed – the department did not elaborate further.
This effort "would be an effort to alleviate some of the health insurance problems faced by the state’s small business owners. This would be a free-market approach to solving some of the state’s insurance problems faced by small businesses,” Chaney’s office said in a statement.
Chaney’s office did not respond on whether the state or his office would try for a state partnership by the end of next week.