2017 Georgia Legislative Policy Forum Empowering States for Better Healthcare Rea S. Hederman Jr. Executive Vice President rea@buckeyeinstitute.org

The 4 Guardrails of State Innovation Waivers 1) A state must demonstrate that “at least a comparable number of residents” would have health coverage under its plan as under existing law. 2) That coverage must be “at least as comprehensive” as under the law. 3) Coverage must be “at least as affordable” as under that law. 4) A state must achieve these objectives without increasing the federal deficit.

What Can and Cannot be Waived Provisions the Secretary MAY waive Provisions the Secretary MAY NOT waive Definition of qualified health plan. Prohibition on annual/lifetime coverage limits Essential health benefits requirement Prohibition of rescissions Annual limitation on cost-sharing Required coverage of preventive services Levels of coverage (e.g., Silver, Bronze) Dependent coverage until age 26 Abortion coverage limitations Medical loss ratio requirements Open enrollment periods Prohibition of pre-existing condition exclusions Single risk pools Guaranteed issue and renewal of coverage Federal regulations pertaining to enrollment by agents/brokers Prohibition of medical underwriting Exclusion from exchanges of incarcerated persons and those not lawfully present in the U.S. 3:1 age band Table 1. Examples of ACA Provisions the HHS Secretary May/May Not Waive Provisions the Secretary MAY waive Provisions the Secretary MAY NOT waive Definition of qualified health plan. Prohibition on annual/lifetime coverage limits Essential health benefits requirement Prohibition of rescissions Annual limitation on cost-sharing Required coverage of preventive services Levels of coverage (e.g., Silver, Bronze) Dependent coverage until age 26 Abortion coverage limitations Medical loss ratio requirements Open enrollment periods Prohibition of pre-existing condition exclusions Single risk pools Guaranteed issue and renewal of coverage Federal regulations pertaining to enrollment by agents/brokers Prohibition of medical underwriting Exclusion from exchanges of incarcerated persons and those not lawfully present in the U.S. 3:1 age band

Current 1332 Waivers Vermont Single Payer (Withdrawn) Hawaii Exchange (Approved) Alaska Reinsurance Waiver (Approved) Minnesota Reinsurance Waiver (Approved) Other States Asking for Reinsurance Iowa, Oklahoma (withdrawn), Oregon, Massachusetts Vermont Single Payer (Withdrawn) Hawaii Exchange (Approved) Alaska Reinsurance Waiver (Approved) Minnesota Reinsurance Waiver (Approved) Other States Asking for Reinsurance Iowa, Oklahoma (withdrawn), Oregon, Massachusetts

Thinking Big on State Innovation Waivers Oklahoma Move to a more market based approach. Flat Premium Subsidy based only on age/income Expand Health Savings Accounts Use $ from federal government to help 0-300% FPL Use some state $ for reinsurance/subsidies Change Benefits and only 1 metal tier

Thinking Big on State Innovation Waivers 2) Iowa Flat Premium Subsidy based only on age/income. Only use $ From federal government to provide subsidy. All Consumers on exchange market get subsidy, even over 400% of FPL. Only 1 metal tier (likely silver plan).

“CMS previously displayed its ability to be flexible in its adherence to the provisions of the ACA in its continued extensions of the transitional relief program requested by former President Barack Obama as related to grandmothered plans. CMS created a ‘transitional policy’ allowing for health insurance carriers to continue to offer certain non-compliant ACA policies to existing consumers. This continued policy position demonstrates that CMS does have authority to be accommodating and adaptable in its interpretation and implementation of the ACA.” Iowa 1332 Waiver