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State Innovation Waivers:
January 29, 2021
Frequently Asked Questions
Ryan J. Rosso
Section 1332 of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as , as
Analyst in Health Care
amended) provides states with the option to waive specified requirements of the ACA.
Financing
In the absence of these requirements, a state is to implement its own plan to provide
health insurance coverage to state residents that meets the ACA'’s terms.
Under a state innovation waiver, a state can apply to waive ACA requirements related to qualified health plans, health insurance exchanges, premium tax credits, cost-sharing subsidies, the individual mandate, and the employer mandate. The state can apply to waive any or all al of these requirements, in part or in
their entirety.
To obtain approval for a waiver application, a state must show that the plan it will wil implement in the absence of the waived provision(s) meets certain requirements. Under current guidance, the state'’s plan must ensure that a comparable number of state residents have health insurance coverage under the plan as would have had coverage
absent the waiver. It also must provide a comparable number of residents with the opportunity to purchase coverage that is as affordable and comprehensive as would have been available absent the waiver. However, applications do not need to demonstrate that the comparable number of residents would be enrolled in the affordable and comprehensive coverage, as would have been required under previous guidance. FinallyFinal y, the state's ’s
plan cannot increase the federal deficit.
The Secretary of the Department of Health and Human Services (HHS) and the Secretary of the Treasury share responsibility for reviewing state innovation waiver applications and deciding whether to approve applications. State innovation waivers cannot extend longer than five years, unless a state requests continuation and the appropriate Secretary does not deny such request. The earliest a state innovation waiver could have gone into effect was January 1, 2017.
In October 2018, the Centers for Medicare & Medicaid Services (CMS) released updated guidance regarding the
state innovation waiver process that superseded previously issued CMS guidance from December 2015. In general, the updated guidance attempts to make it easier for a state plan to be approved. The updated guidance applies to all al waiver applications that had not been approved prior to the date of the guidance'’s release. Waivers
approved under the previously issued guidance did not require reconsideration.
As of the date of this report, 1316 states—Alaska, Colorado, Delaware, HawaiiGeorgia, Hawai , Maine, Maryland, Minnesota, Montana, New Hampshire, New Jersey, North Dakota, Oregon, Pennsylvania, Rhode Island, and Wisconsin—have approved state innovation waivers. Eight of these waivers were considered and approved under the initial state innovation waiver guidance, and fiveeight were considered and approved under the current state
innovation waiver guidance. TwelveFifteen of the 1316 approved waivers implement a variant of a statewide individual
market reinsurance program.
Idaho, Massachusetts
Idaho, Massachuset s, Ohio, and Vermont have submitted applications and received notification that their applications were incomplete. It does not appear that any of these states has modified its application in response to the notification (as of the date of this report). If these states take action, any further review of their waiver application would be under the updated state innovation waiver guidance. Three states—California, Iowa, and
Oklahoma—submitted waiver applications and have since withdrawn their applications.
Section 1332 of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) allows
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Contents
Which ACA Provisions May a State Waive Under a State Innovation Waiver? .......................... 1 Which Federal Agencies Have the Authority to Grant a Waiver?............................................. 2 What Are the Minimum Requirements for a Successful Application? ...................................... 2 May a State Modify Its Use of the Federal y Facilitated Health Insurance Exchange
Platform Under a State Innovation Waiver? ...................................................................... 6
Are There Any Limitations on the Scope of State Innovation Waivers? .................................... 6 What Is the Application Process for a State Innovation Waiver? ............................................. 7 Is Any Federal Funding Available Under a State Innovation Waiver?....................................... 8 How Long Can a State Innovation Waiver Be in Effect?........................................................ 8 May States Submit State Innovation Waiver Applications in Coordination with Other
Federal Waiver Applications? ......................................................................................... 8
How Many States Have Applied for State Innovation Waivers? .............................................. 9
Tables Table 1. Requirements for a Successful State Innovation Waiver Application............................ 3 Table 2. States That Have Applied for State Innovation Waivers ........................................... 10
Contacts
Author Information ....................................................................................................... 23
Congressional Research Service
State Innovation Waivers: Frequently Asked Questions
ection 1332 of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) al ows states to apply for waivers of specified provisions of the ACA. Under a
S states to apply for waivers of specified provisions of the ACA. Under a state innovation waiver, a state is expected to implement a plan (in place of the waived
provisions) that meets certain minimum requirements. The Centers for Medicare & Medicaid Services' (CMS'Services’ (CMS’s) initial interpretation of these requirements was published in guidance released in 2015 but has since been superseded, as with other aspects of the waiver process, in updated
guidance released by the agency on October 24, 2018.1
1 Many aspects of the 2018 guidance were
codified in a final rule issued on January 19, 2021.2
Under current guidance, the state'’s plan must ensure that a comparable number of state residents have health insurance coverage under the plan as would have had coverage absent the waiver. It also must provide a comparable number of residents with the opportunity to purchase coverage that is as affordable and comprehensive as would have been available absent the waiver. However, applications do not need to demonstrate that the comparable number of residents would be enrolled in the affordable and comprehensive coverage, as would have been required under
previous guidance. FinallyFinal y, the state'’s plan cannot increase the federal deficit.
This report answers frequently asked questions about how states can use and apply for state innovation waivers. It also addresses changes to the Section 1332 waiver process, as made by the 2018 CMS guidance.
A state may apply to waive any or all of the ACA provisions listed below for plan years
beginning on or after January 1, 2017.2
7
Each part noted above is comprised of many provisions, which makes the scope of the provisions that can be waived under a state innovation waiver quite broad. For example, Part I of Subtitle D of the ACA includes provisions that outline requirements for health plans to be certified as QHPs. It defines the essential health benefits (EHB) package that each QHP must offer, places limitations on the enrollee cost sharing that QHPs may impose, and requires that QHPs provide
coverage meeting a minimum level of actuarial value.7 Additionally, 8 Additional y, Part I of Subtitle D
establishes requirements for catastrophic health plans and determines eligibility for such plans.
The Secretary of the Department of Health and Human Services (HHS) is to review and grant waiver requests for provisions not included in the IRC; the Secretary of the Treasury is to review and grant requests to waive provisions in the IRC (the availability of premium tax credits and the
application of the employer and individual mandates).8
The Secretary of HHS or the Treasury is to assess a waiver application to determine whether the state'
state’s plan meets the requirements related to coverage, affordability, comprehensiveness, and
5 For more information about the current status of the cost-sharing reductions, see archived CRS Insight IN10786, Paym ents for Affordable Care Act (ACA) Cost-Sharing Reductions.
6 For more information about the employer mandate, see CRS Report R45455, The Affordable Care Act’s (ACA’s) Em ployer Shared Responsibility Provisions (ESRP).
7 For more information about the individual mandate, see CRS Report R44438, The Individual Mandate for Health Insurance Coverage: In Brief. T he 2017 tax revision, P.L. 115-97, effectively eliminated the individual mandate penalty beginning in 2019. However, the 2017 tax revision did not make any other substantive changes to the statutory language establishing the mandate and its associated penalty.
8 Note that essential health benefit (EHB) and related cost-sharing and actuarial value requirements apply to all non-grandfathered plans in the individual and small group markets, including QHPs. For more information about the essential health benefits package, see CRS Report R44163, The Patient Protection and Affordable Care Act’s Essential Health Benefits (EHB).
9 42 U.S.C. §18052(a)(6).
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s plan meets the requirements related to coverage, affordability, comprehensiveness, and federal-deficit neutrality outlined in statute and further described in guidance.910 These requirements are described inin Table 1. The Secretary or Secretaries (as appropriate) may grant a request for a state innovation waiver if a state'’s application meets the requirements. In making this determination, the Secretaries will "wil “consider favorably"” any waiver that incorporates some or all al of the following principles: provide increased access to affordable private market coverage, encourage sustainable spending growth, foster state innovation, support and empower those in
need, and promote consumer-driven health care.10
11
In guidance, HHS and the Treasury note that their assessment of a state'’s waiver application
considers changes to the state'’s health care system that are contingent only upon approval of the waiver.1112 Their assessment does not consider policy changes that are dependent on further state action or other federal determinations. For example, the Secretary'’s or Secretaries'’ (as appropriate) assessment of a state innovation waiver application would not consider changes to Medicaid or the state Children'’s Health Insurance Program (CHIP) that require approval outside of the state innovation waiver process, and savings accrued as a result of changes to Medicaid or
CHIP would not be considered when determining whether the state innovation waiver meets the deficit-neutrality requirement. HHS and the Treasury indicate that this is the case regardless of whether a state'’s application for a state innovation waiver is submitted alone or in coordination with another waiver application. (For more information about the coordinated waiver process, see "“May States Submit State Innovation Waiver Applications in Coordination with Other Federal
Waiver Applications?")
”) Table 1. Requirements for a Successful State Innovation Waiver Application
(as described in statute and guidance)
Statute
Current Guidancea
Previous Guidance
Coverage: The state’s
At least a comparable number of
At least as many individuals who are
plan must provide
individuals who are forecasted to have
forecasted to have minimum essential
coverage to at least a
health care coverage absent a waiver must
coverage (MEC) absent a waiver must
comparable number of
have health care coverage under the
have MEC under the waiver.c This
individuals as the
waiver.b This requirement general y must
requirement general y must be forecast to
provisions of Title I of
be forecast to be met for each year the
be met for each year the waiver is in
the Patient Protection
waiver is in effect, but a waiver may be
effect.
and Affordable Care
approved if a temporary reduction in
In considering whether this requirement
Act (ACA; P.L. 111-
coverage would produce longer-term
is met, the plan’s impact on al state
148, as amended)
increases in coverage.
residents, regardless of coverage type, wil
would provide.
In considering whether this requirement
be considered and the plan’s effects on
is met, the plan’s impact on al state
(as described in statute and guidance)
|
Statute |
Current Guidance |
Previous Guidance |
|
Coverage: The state's plan must provide coverage to at least a comparable number of individuals as the provisions of Title I of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) would provide. |
In considering whether this requirement is met, the plan's impact on all state residents, regardless of coverage type, will be considered. Whether the plan sufficiently prevents gaps in or discontinuations of coverage also will be considered. |
|
|
Affordability: The state's plan must provide coverage and cost-sharing protections that are at least as affordable as the provisions of Title I of the ACA. |
Affordability is generally measured by comparing the sum of an individual's premium contributions and cost-sharing responsibilities for a health plan or direct payments for health care to the individual's income. In considering whether this requirement is met, the plan's impact on all state residents, regardless of coverage type, and the plan's effects on all groups of individuals in the state, including low-income residents and those with high expected health care costs, will be considered. In assessing the plan, access to affordable coverage will be considered according to the number of individuals for whom available coverage has become more affordable and the magnitude of such changes. | Individuals' health care coverage under the waiver must be as affordable as coverage would be absent the waiver.
comparing the sum of an individual’s
health plan may be considered if the
premium contributions and cost-sharing
services are affected by the state’s plan.
responsibilities for a health plan or direct
This requirement general y must be
payments for health care to the
forecast to be met for each year the
individual’s income.
waiver is in effect.
In considering whether this requirement
In considering whether this requirement
|
|
Comprehensiveness is measured by comparing coverage under the plan to coverage under the state's EHB benchmark plan, any other state's benchmark plan chosen by the state, or any benchmark plan chosen by the state that could potentially become its EHB benchmark plan. In considering whether this requirement is met, the proposal's impact on all state residents, regardless of coverage type, will be considered. | Individuals' health care coverage under the waiver must be at least as comprehensive overall as their coverage would be absent the waiver.
|
Deficit Neutral: |
|
|
application.g
by the state as part of its application.g
Source: Congressional Research Service's compilation ’s compilation and summary of statute (42 U.S.C. §18052(b)(1)) and guidance (80 Federal Register 78131, December 16, 2015, and 83 Federal Register 53575, October 24, 2018). The requirements requirements are not covered in regulations.
Notes: Previous guidance applies to all waivers al waivers approved prior to October 24, 2018. The Secretary of the Department of Health and Human Services (HHS) is to review requests to waive provisions not included in the Internal Revenue Code (IRC); the Secretary of the Treasury is to review requests to waive provisions p rovisions in the IRC (the availability of premium tax credits and the application of the employer and individual mandates).
a. Health care coverage includes all types of coverage that would qualify as MEC in the tax code (26 U.S.C. §5000A(f)) a. Many aspects of the current guidance were codified in a final rule issued on January 19, 2021. This rule did
not take effect before the presidential transition. As a result, it may be reviewed by the Biden Administration in accordance with a memorandum issued by Ronald A. Klain, Assistant to the President and Chief of Staff. See “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2022; Updates to State Innovation Waiver (Section 1332 Waiver) Implementing Regulations,” 86 Federal Register 6138, January 19, 2021 and Office of Management and Budget, “Memorandum for the Heads of Executive Departments and Agencies,” 86 Federal Register 7424, January 28, 2021.
b. Health care coverage includes al types of coverage that would qualify as MEC or would be included in the
or would be included in the definition of the term in regulations (45 C.F.R. §144.103). MEC ishealth insurance coverage in regulations. MEC, as defined in the tax code (26 U.S.C. §5000A(f)) and, includes most types of comprehensive coverage, including public coverage, such as coverage under programs sponsored by the federal government (e.g., Medicaid, Medicare), as well as wel as private insurance (e.g., employer-sponsored insurance, non-group coverage). Health insurance coverage is, as defined in regulations (45 C.F.R. §144.103) to include, includes group health insurance coverage (e.g., employer-sponsored insurance, association health plans), individual health insurance coverage, and short-term, limited-duration insurance.
b. insurance.
c. MEC is defined in the tax code (26 U.S.C. §5000A(f)) and includes most types of comprehensive coverage,
including public coverage, such as coverage under programs sponsored by the federal government (e.g., Medicaid, Medicare), as well wel as private insurance (e.g., employer-sponsored insurance, non-group coverage).
c.
d. Vulnerable individuals include "“low-income individuals, elderly individuals, and those with serious health issues
issues or who have a greater risk of developing serious health issues"” (80 Federal Register 78131, December 16, 2015, p. 78132).
d.
e. The affordability and comprehensiveness guardrails guardrails are considered in conjunction and not in isolation (i.e., a a
state plan must make coverage that is both comprehensive and affordable available to a comparable number of individuals).
e.
f.
Under the ACA, certain health plans must cover the EHB. The ACA does not explicitly define theth e EHB; rather, it lists 10 broad categories from which benefits and services must be included and requires the Secretary of HHS to further define the EHB. For information about the 10 categories as well as wel as how the EHB are currently defined, see CRS In Focus IF10287, The Essential Health Benefits (EHB).the Center for Consumer Information and Insurance Oversight (CCIIO) webpage, “Information on Essential Health Benefits (EHB) Benchmark Plans,” at https://www.cms.gov/cci o/resources/data-resources/ehb.
g. The state innovation waivers cannot extend longer than five years unless a state requests continuation and
such request is not denied by the appropriate Secretary. Statute requires that an application for a waiver include a 10-year budget plan that is budget neutral for the federal government (42 U.S.C. §18052(a)(1)(B)(iii )). This determination takes into account costs associated with changes to federal administrative processes.
Although not possible initially HHS administers al federal y facilitated exchanges (FFEs), and it operates the same information technology platform (Healthcare.gov) in each state that has an FFE. Some states administer their own state-based exchanges, except they also use the federal information technology platform
(SBE-FP).13
Initial y, it was not possible for states that use the federal technology platform to make eligibility and enrollment changes related to that platform.14 However, HHS and the Treasury indicated in
, HHS and the Treasury indicated in the updated guidance released in October 2018 that technical enhancements made it feasible for CMS to support certain variations.CMS to support some federally facilitated health insurance exchange (FFE) variation.12 For example, waivers that would require a state to create its own website to replace the consumer-facing aspects of HealthCare.gov can incorporate CMS's ’s enrollment functionalities (e.g., account creation, application, enrollment and coverage maintenance experience for consumers). States are asked to work with HHS early in the waiver
application process to determine whether specific modifications can be accommodated.
States are responsible for funding all FFEal FFE platform modifications and associated operational support. Any changes to CMS administrative processes are taken into account when determining
whether a waiver application satisfies the deficit neutrality requirement; however, waiver costs for technical and specialized services that CMS typicallytypical y provides to states (and states cover the
cost of) would not be included in such determinations.13
In guidance issued in October 2018, HHS and the Treasury described some federal operational considerations that may limit the scope of the waivers.14 Specifically16 Specifical y, the Internal Revenue
Service (IRS) generallygeneral y is not able to accommodate any state-specific changes to tax rules.
However, the IRS may be able to accommodate small smal changes to the administration of federal tax provisions, in particular when such changes overlap with the IRS'’s current capabilities.1517 For example, waivers that would require the IRS to expand premium tax credit eligibility to individuals to
individuals with household income under 100% of the federal poverty level may be feasible,
because it incorporates a similar special rule that the IRS currently administers.16
A state seeking a state innovation waiver must enact a law that allowsal ows the state to carry out the actions under the waiver prior to submitting an application for a waiver.1719 In certain
circumstances, a state can be considered to have enacted such a law by coupling a state law that enforces ACA provisions and/or the state plan with administrative or executive actions.1820 Prior to submitting an application, a state must provide a public notice and comment period and conduct public hearings regarding the state'’s application.1921 Upon conclusion of these activities, a state may submit its application to the Secretary of HHS. The Secretary of HHS is to transmit any
application seeking to waive requirements in the IRC to the Secretary of the Treasury for review.
The Secretary or Secretaries (as appropriate) are to review a state'’s application to determine whether it is complete. A state'’s application is not considered complete unless it includes the
materials identified in regulations.2022 The materials include, but are not limited to, information about the enacted state legislation allowingal owing the state to carry out the actions under the waiver, a description of the plan or program the state expects to implement in place of the waived provisions, and analyses showing that the state'’s plan or program meets the requirements for granting a waiver. If a state'’s application is not complete, the state is to be notified about the
missing elements and given an opportunity to submit them. Once the Secretary or Secretaries (as appropriate) make a preliminary determination that a state'’s application is complete, the entire
application is to be made available to the public for review and comment.21
23
The final decision of the Secretary or Secretaries on a state'’s application must be issued no later than 180 days after the determination that the Secretary of HHS received a complete application
from a state.22
It is possible for a state to receive federal funding under an approved waiver. A state'’s receipt of a state innovation waiver could result in the residents of the state not receiving the "“premium tax
credits, cost-sharing reductions, or small smal business credits under sections 36B of the Internal Revenue Code of 1986 or under part I of subtitle E for which they would otherwise be eligible."23 ”25 If this occurs, the state is to receive the aggregate amount of subsidies that would have been available available to the state'’s residents had the state not received a state innovation waiver—this is referred to as pass-through funding. The amount of pass-through funding is to be determined annually
annual y by the appropriate Secretary and may be updated at any time to account for changes in state or federal law. The state is to use the pass-through funding for purposes of implementing the
plan or program established under the waiver.24
in Effect? State innovation waivers cannot extend longer than five years, unless a state requests continuation and the appropriate Secretary does not deny such request.2527 Requests for continuation are to be deemed granted unless, within 90 days of submission, the appropriate Secretary either denies the
request or informs the state that additional information is needed for the Secretary to consider
such request.
The Secretaries were required to develop a process for coordinating applications for state
innovation waivers and applications for other existing waivers under federal law relating to the
provision of health care, including waivers available under Medicare, Medicaid, and CHIP.
Under the coordinated process, a state must be able to submit a single application for a state
innovation waiver and any other applicable waivers available under federal law.2628 The single application must comply with the procedures described for state innovation waiver applications
and the procedures in any other applicable federal law under which the state seeks a waiver.27
29
As discussed in the answer to the question "“What Are the Minimum Requirements for a Successful Application?,",” HHS and the Treasury have indicated that an application for a state innovation waiver will wil be assessed on its own terms and that assessment of the state innovation waiver will
25 42 U.S.C. §18052(a)(3). 26 42 U.S.C. §18052(a)(3). 27 42 U.S.C. §18052(e). 28 42 U.S.C. §18052(a)(5). 29 45 C.F.R. §155.1302(a).
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waiver wil not consider the impact of changes that require separate federal approval. This is the
case even if the state submits a single application for multiple waivers.
Innovation Waivers? As of the date of this report, 2023 states have submitted applications for state innovation waivers—Alaska, California, Colorado, Delaware, HawaiiGeorgia, Hawai , Idaho, Iowa, Maine, Maryland, Massachusetts, Minnesota, Montana, New Hampshire, New Jersey, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Vermont, and Wisconsin.2830 HHS and the Treasury have approved 1316 applications, from Alaska, Colorado, Delaware, Hawaii, Georgia, Hawai ,
Maine, Maryland, Minnesota, Montana, New Hampshire, New Jersey, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Wisconsin.
Eight of these waivers were considered and approved under the initial state innovation waiver
guidance, and fiveeight were considered and approved under the current state innovation waiver guidance. TwelveFifteen of the 1316 approved waivers implement a variant of a statewide individual
market reinsurance program.29
Idaho, Massachusetts31
Idaho, Massachuset s, Ohio, and Vermont received notification from HHS and the Treasury that their applications were incomplete, and it does not appear that any of these states has modified its application in response to the notification. If one of these four states does take action, any review of its waiver application would be under the updated state innovation waiver guidance (even if
such state initiallyinitial y submitted its waiver under the initial guidance). California, Iowa, and Oklahoma have withdrawn their applications.30
See32 See Table 2 for more details.
30 For information about each state’s application, see CMS, Center for Consumer Information and Insurance Oversight (CCIIO), “Section 1332: State Innovation Waivers,” at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html.
31 CMS issued a data brief that compares various aspects of the state-based reinsurance programs implemented through the Section 1332 waiver process. See CMS, CCIIO, State Relief and Em powerm ent Waivers: State-based Reinsurance Program s, June 2020, https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Downloads/1332-Data-Brief-June2020.pdf. As described in Table 2, Georgia’s waiver included two parts: a reinsurance program and the Georgia Access Model. For more information on reinsurance, see CRS In Focus IF10707, Reinsurance in Health Insurance. 32 T o read the withdrawal letters, see CMS, CCIIO, “Section 1332: State Innovation Waivers,” at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html.
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Table 2. States That Have Applied for State Innovation Waivers
(as of January 29, 2021)
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Approved Waivers
Alaska
Jan. 3, 2017
Approved—
Alaska established a state-based reinsurance program, the Alaska Reinsurance Program (ARP), The Centers for
CY2018-
July 17, 2017
to help health insurance issuers offering plans in the individual market offset the cost of
Medicare & Medicaid CY2022
covering enrol ees with 1 or more of 33 specified high-cost conditions.
Services (CMS)
for more details.
|
State |
Application Information |
Waiver Information |
|||
|
Submitted |
Status |
Overview |
|
Effective Period |
|
|
Approved Waivers |
|||||
|
Alaska |
December 29, 2016 |
Approved—July 17, 2017 |
Alaska established a state-based reinsurance program, the Alaska Reinsurance Program (ARP), to help health insurance issuers offering plans in the individual market offset the cost of covering enrollees with 1 or more of 33 specified high-cost conditions. Under the approved waiver, the Patient Protection and Affordable Care Act (ACA; P.L. 111-
$68.7 mil ion for
market-wide index rates.
CY2019, and $76.7
mil ion for CY2020.
The expected effect of and continuing
through CY2022. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Alaska.
CRS-10
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Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Colorado
May 20, 2019 Approved—
Colorado established a state-based reinsurance program. From CY2020 through CY2021, the CMS indicated
CY2020-
July 31, 2019
program is reimbursing issuers sel ing coverage in the state’s individual market for a
Colorado would
CY2021
percentage of enrol ees’ claims between an attachment point and a cap. The reimbursement
receive $169.4
percentage varies |
The Centers for Medicare & Medicaid Services (CMS) indicated Alaska would receive $58.5 million for CY2018 and $68.7 million for CY2019. |
CY2018-CY2022 |
|
Colorado |
May 20, 2019 |
Approved—July 31, 2019 |
Colorado established a state-based reinsurance program. From CY2020 through CY2021, the program will reimburse issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap. The reimbursement percentage will vary across geographic rating areas in the state.
CY2021.c The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Colorado.
Delaware
July 10, 2019
Approved—
Delaware established a state-based reinsurance program, the Delaware Health Insurance
CMS indicated
CY2020-
Aug. 20, 2019
Individual Market Stabilization Reinsurance Program, which reimburses issuers sel ing coverage Delaware would
CY2024
in the state’s individual market for a percentage of enrol ees’ claims between an attachment
receive $21.7 mil ion
point and a cap.
for CY2020.
Delaware’s approved waiver is similar to other reinsurance-type waivers in that the ACA
provision requiring issuers to consider al enrol ees in individual plans offered by the issuer to be members of a single risk pool is waived,b which al ows issuers to consider Delaware
reinsurance program payments when setting market-wide index rates. The expected effect is
that individual market premiums wil decrease and federal spending on premium tax credits
for residents of Delaware wil decrease. The state is to receive the resulting reductions in federal spending as pass-through funding. Under the waiver, Delaware is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuers
beginning in CY2020 and continuing through CY2024. The approved waiver does not modify the eligibility criteria for premium tax credits for residents of Delaware.
CRS-11
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Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Georgia
December
Approved—
Georgia’s approved waiver has two parts: a reinsurance program scheduled to begin in
Georgia estimated it
CY2022-
23, 2019,
Nov. 1, 2020
CY2022 and the Georgia Access Model, which is to begin in CY2023.
would receive $306
CY2026
application
With respect to first part of the waiver, Georgia established a state-based reinsurance
mil ion for CY2022
was updated
program. Starting in 2022, the program is to reimburse issuers sel ing coverage in the state’s
and $1.6 bil ion over
on July 31,
individual market for a percentage of enrol ees’ |
Colorado estimated it would receive $162.8 million for CY2020 and $337 million over the CY2020-CY2021 period. |
CY2020-CY2021 |
|
Delaware |
July 10, 2019 |
Approved—August 20, 2019 |
Delaware established a state-based reinsurance program, the Delaware Health Insurance Individual Market Stabilization Reinsurance Program. Starting in 2020, the program will reimburse issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
CY2022 and continuing through CY2026. With respect to the second part of the waiver, Georgia is shifting its individual market
exchange enrol ment to the Georgia Access Model beginning in CY2023. Under the Georgia
Access Model, residents would no longer be able to enrol in individual market coverage through the federal y facilitated exchange and would instead only be able to utilize commercial
market web brokers or buy directly from issuers. Residents are stil to be eligible for premium
tax credits while enrol ing in coverage through the Georgia Access Model. Under the approved waiver, ACA requirements relating to the state establishment of health
insurance exchanges are waived to the extent they are inconsistent with the Georgia Access Model.d As a result, Georgia is able to implement the Georgia Access Model. Georgia
anticipates web brokers wil be incentivized to bring in new consumers, and, when combined with other outreach and support, there wil be increased enrol ment in the individual market.
Georgia anticipates the net effect of these new enrol ees wil be an increase in the amount of
premium tax credits received by residents. Georgia requested to reduce the pass-through
funding that would be provided in accordance with the reinsurance program aspect of the waiver to account for these costs. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Georgia.
CRS-12
link to page 25 link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Hawai
Aug. 10,
Approved—
|
Delaware estimated it would receive $20 million for CY2020 and $122.2 million over the period CY2020-CY2024. |
CY2020-CY2024 |
|
Hawaii |
June 16, 2016 |
Approved—December 30, 2016 |
Under the approved waiver, multiple ACA provisions relating to the establishment and
CMS indicated
CY2017-
2016
Dec. 30, 2016 operation of a Smal |
|
CY2017-CY2021 |
|
Maine |
May 9, 2018 |
Approved—July 30, 2018 |
Maine established a hybrid state-based reinsurance/invisible high-risk pool program
CMS indicated Maine CY2019-
July 30, 2018
administered by the Maine Guaranteed Access Reinsurance Association (MGARA), which
would receive $62.3
CY2023
helps health insurance issuers offering plans in the individual market offset the cost of covering Maine and continuing
through CY2023. The approved waiver does not modify the eligibility criteria for premium tax credits for residents of Maine.
CRS-13
link to page 25 link to page 25 link to page 25 link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Maryland
May 31, 2018 Approved—
|
|
CY2019-CY2023 |
|
Maryland |
May 31, 2018 |
Approved—August 22, 2018 |
Maryland established a state-based reinsurance program administered by the Maryland Health
CMS indicated
CY2019-
Aug. 22, 2018
Benefit Exchange, which reimburses issuers
available.h The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Maryland.
Minnesota
May 30, 2017 Approvedi—
|
CMS indicated Maryland would receive $373.4 million for CY2019. |
|
|
Minnesota |
May 5, 2017 |
| Minnesota established a state-based reinsurance program, the Minnesota Premium Security
CMS indicated
CY2018-
Sept. 22, 2017 Plan (MSPS), which reimburses issuers
and continuing through CY2022. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Minnesota.
CRS-14
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Montana
June 19, 2019 Approved—
Montana established a state-based reinsurance program, the Montana Reinsurance Program,
CMS indicated
CY2020-
Aug. 16, 2019
which reimburses issuers sel ing coverage in the state’s individual market for a percentage of
Montana would
CY2024
enrol ees’ |
CMS indicated Minnesota would receive $130.7 million for CY2018 and $84.8 million for CY2019. |
CY2018-CY2022 |
|
Montana |
June 19, 2019 |
Approved—August 16, 2019 |
Montana established a state-based reinsurance program administered by the Montana Reinsurance Association Board of Directors and the Montana Commissioner of Securities and Insurance. Starting in 2020, the program will reimburse issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
CY2020 and continuing through CY2024. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Montana.
New
Apr. 23,
Approved—
New Hampshire established a state-based reinsurance program, which reimburses issuers
New Hampshire
CY2021-
Hampshire
2020
Aug. 5, 2020
sel ing coverage in the state’s individual market for a percentage of enrol ees’ claims between
estimated it would
CY2025
an attachment point and a cap.
receive $32.9 mil ion
New Hampshire’s approved waiver is similar to other reinsurance-type waivers in that the
for CY2021 and
ACA provision requiring issuers to consider al enrol ees in individual plans offered by the
$180.9 mil ion over
issuer to be members of a single risk pool is waived,b which al ows issuers to consider
the period CY2021-
reinsurance program payments when setting market-wide index rates. The expected effect is
CY2025.
that individual market premiums wil decrease and federal spending on premium tax credits
for residents of New Hampshire wil decrease. The state is to receive the resulting reductions
in federal spending as pass-through funding. Under the waiver, New Hampshire is to use the pass-through funding to support the reinsurance program and corresponding payments to
issuers beginning in CY2021 and continuing through CY2025. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of New Hampshire.
CRS-15
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
New Jersey
July 2, 2018
Approved—
|
Montana estimated it would receive $22.1 million for CY2020 and $123.5 million over the period CY2020-CY2024. |
CY2020-CY2024 |
|
New Jersey |
July 2, 2018 |
Approved—August 16, 2018 |
New Jersey established a state-based reinsurance program, the Health Insurance Premium
CMS indicated New
CY2019-
Aug. 16, 2018
Security Plan, which reimburses issuers
$180.2 mil ion for
New Jersey and continuing through CY2023. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of New Jersey.
North Dakota May 10, 2019 Approved—
North Dakota established a state-based reinsurance program, the Reinsurance Association of
CMS indicated
CY2020-
July 31, 2019
North Dakota (RAND), which reimburses issuers sel ing coverage in the state’ |
CMS indicated New Jersey would receive $180.2 million for CY2019. |
CY2019-CY2023 |
|
North Dakota |
May 10, 2019 |
Approved—July 31, 2019 |
receive $21.5 mil ion
North Dakota CY2020 and continuing through
CY2024. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of North Dakota.
CRS-16
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Oregon
Aug. 31,
Approved—
Oregon established a state-based reinsurance program, the Oregon Reinsurance Program
CMS indicated that
CY2018-
2017
Oct. 18, 2017
(ORP), which reimburses issuers sel ing coverage in the state’s individual market for a
Oregon would
CY2022
percentage of enrol ees’ claims between an attachment point and a cap.
receive $54.5 mil ion
Oregon’s approved waiver |
North Dakota estimated it would receive $26.1 million for CY2020 and $144.1 million over the period CY2020-CY2024. |
CY2020-CY2024 |
|
Oregon |
August 31, 2017 |
Approved—October 18, 2017 |
Oregon established a state-based reinsurance program, the Oregon Reinsurance Program (ORP), which reimburses issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Oregon.
Pennsylvania
Feb. 11, 2020 Approved—
Pennsylvania established a state-based reinsurance program, which reimburses issuers sel ing
Pennsylvania
CY2021-
July 24, 2020
coverage in the state’s individual market for a percentage of enrol ees’ claims between an
estimated it would
CY2025
attachment point and a cap.
receive $95.1 mil ion
Pennsylvania’s approved waiver is similar to other reinsurance-type waivers in that the ACA
for CY2021 and
provision requiring issuers to consider al enrol ees in individual plans offered by the issuer to
$547.5 mil ion over
be members of a single risk pool is waived,b which al ows issuers to consider reinsurance
the period CY2021-
program payments when setting market-wide index rates. The expected effect is that
CY2025.
individual market premiums wil decrease and federal spending on premium tax credits for residents of Pennsylvania wil decrease. The state is to receive the resulting reductions in
federal spending as pass-through funding. Under the waiver, Pennsylvania is to use the pass-
through funding to support the reinsurance program and corresponding payments to issuers beginning in CY2021 and continuing through CY2025. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Pennsylvania.
CRS-17
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Rhode Island
July 8, 2019
Approved—
Rhode Island established a state-based reinsurance program, the Rhode Island Reinsurance
CMS indicated
CY2020-
Aug. 26, 2019
Program, which reimburses issuers sel ing coverage in the state’s individual market for a
Rhode Island would
CY2024
percentage of enrol ees’ |
|
CY2018-CY2022 |
|
Rhode Island |
July 8, 2019 |
Approved—August 26, 2019 |
Rhode Island established a state-based reinsurance program. Starting in 2020, the program will reimburse issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
and continuing through CY2024. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Rhode Island.
Wisconsin
Apr. 18,
Approved—
Wisconsin established a state-based reinsurance program, the Wisconsin Healthcare Stability
CMS indicated
CY2019-
2018
July 29, 2018
Plan (WIHSP), which reimburses issuers sel ing coverage in the state’s individual market for a
Wisconsin would
CY2023
percentage of enrol ees’ claims between an attachment point and a cap.
receive $127.7
Wisconsin’s approved waiver |
Rhode Island estimated it would receive $6.4 million for CY2020 and $35.3 million over the period CY2020-CY2024. |
CY2020-CY2024 |
|
Wisconsin |
April 18, 2018 |
Approved—July 29, 2018 |
Wisconsin established a state-based reinsurance program, the Wisconsin Healthcare Stability Plan (WIHSP), which reimburses issuers selling coverage in the state's individual market for a percentage of enrollees' claims between an attachment point and a cap.
and continuing through CY2023. The approved waiver does not modify the eligibility criteria for premium tax credits for
residents of Wisconsin.
CRS-18
link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Pending Applications
Idaho
July 15, 2019
Received
|
CMS indicated Wisconsin would receive $127.7 million for CY2019. |
CY2019-CY2023 |
|
Pending Applications |
|||||
|
Idaho |
July 15, 2019 |
Received notification of incomplete application—August 29, 2019 |
Idaho is seeking to waive the requirements that prevent individuals purchasing health
Idaho is not
N.A.
notification of
insurance through an exchange from being eligible to claim premium tax credits and cost
requesting pass-
incomplete
sharing reductions if they are eligible for other types of qualifying coverage (e.g., Medicaid).j
through funding.
application—
At the time the application was submitted, Idaho residents with incomes between 100% and Aug. 29, 2019 138% of the federal poverty level (FPL) who purchased health insurance through the individual exchange were eligible for premium tax credits and cost-sharing reductions (assuming other eligibility criteria also were met). However, Idaho was in the process of expanding Medicaid eligibility to individuals with incomes between 100% and 138% of the FPL, which was assumed by Idaho to be effective beginning CY2020. Once the Medicaid expansion went into effect, those who were newly eligible for Medicaid would no longer be eligible for premium tax credits and cost-sharing reductions through the exchange. By waiving the specified provisions, Idaho indicates that individuals with incomes between 100% and 138% of the FPL would be able to choose between subsidized exchange coverage
and Medicaid.
Massachusetts Sept. 8, 2017 Received
|
Idaho is not requesting pass-through funding. |
N.A. |
|
Massachusetts |
September 8, 2017 |
Received notification of incomplete application—October 23, 2017 |
Massachusetts is seeking to create a Premium Stabilization Fund (PSF), which would be used
Massachusetts
N.A.
notification of
to reimburse issuers amounts equal to what would have been provided by cost-sharing
estimated it would
incomplete
reduction payments. At the time the application was submitted, cost-sharing reduction
receive between
application—
payments were Under the proposed waiver, the ACA provision that provides for cost-sharing subsidy payments to issuers from HHS would be Under the proposed waiver, Massachusetts would use the pass-through funding for PSF
payments to issuers for an initial period of one year, beginning in CY2018, and the state would
request the opportunity to renew the waiver through CY2022.
CRS-19
link to page 25 link to page 25 link to page 25 link to page 25 link to page 25
Application Information
Waiver Information
Estimated
Pass-Through
Effective
State
Submitted
Status
Overview
Fundinga
Period
Ohio
Mar. 30,
Received
Ohio is seeking to waive the requirement that individuals must maintain minimum essential
Ohio is not
N.A.
2018
notification of
coverage, as established under the ACA’s individual mandate provision. | Massachusetts estimated it would receive between $143 and $146 million for CY2018. |
N.A. |
|
Ohio |
March 30, 2018 |
Received notification of incomplete application—May 17, 2018 |
|
Ohio is not requesting pass-through funding. |
N.A. |
|
Vermont |
March 15, 2016 |
Received notification of incomplete application—June 9, 2016 |
Vermont is seeking an exemption from the requirement that a state must establish a SHOP exchange for small employers. Under the proposed waiver, Vermont seeks to waive multiple ACA provisions relating to the
through funding.
application—
establishment and operation of a SHOP |
Vermont is not requesting pass-through funding. |
N.A. |
|
Withdrawn Applications |
|||||
|
California |
December 6, 2016 |
Withdrawn—January 18, 2017 |
California sought to provide undocumented immigrants with the ability to purchase unsubsidized insurance through its exchange. Under this waiver, the ACA provision that prohibits the marketing of nonqualified health plans |
California did not request pass-through funding. |
N.A. |
|
Iowa |
August 21, 2017 |
Withdrawn—October 23, 2017 |
$422 mil ion for
Under this waiver, Iowa sought to waive the
The Iowa waiver would have begun in CY2018 and would have |
Iowa estimated it would have received $422 million for CY2018. |
N.A. |
|
Oklahoma |
August 16, 2017 |
Withdrawn—September 29, 2017 |
and $1,395 mil ion Oklahoma |
Oklahoma estimated it would have received $309 million for CY2018 and $1,395 million over the period CY2018-CY2022. |
N.A. |
in CY2018.
Source: Various documents available on the CMS website, " “Section 1332: State Innovation Waivers," ” at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html, viewed November 1, 2019.
, viewed January 25, 2021.
CRS-21
Notes: Estimated pass-through funding describes either the amount of pass-through funding that a state estimates it will receive it wil receive in its waiver application or, when available, the amount of pass-through funding CMS estimates it will it wil provide to the state as determined annually annual y by the Secretary of the Department of HealthHealt h and Human Services Services and/or the Secretary of the Department of the Treasury (as appropriate). For more information on reinsurance, see CRS In Focus IF10707, Reinsurance in Health Insurance.
a. a. At the time of this report’s publication, CMS has not communicated the amount of pass-through funding for approved waivers in CY2020.
b. Specifically, CY2021. b. Specifical y, ACA §1312(c)(1).
c. c. Although waivers can be approved for a period of up to five years, the Colorado application requested, and was approved for, an effective period from CY2020
through CY2021.
d. Specifically, the following ACA §§: 1301(a)(1)(C)(ii
d. Specifical y, ACA §1311(b), (c), (d), (e), and (i) only to the extent that it is inconsistent with the Georgia Access Model. e. Specifical y, the fol owing ACA §§: 1301(a)(1)(C)(i ); 1301(a)(2); 1304(b)(4)(D)(i) and (iii ); 1311(b)(1)(B); 1312(a)(2); 1312(f)(2)(A); and 1321(c)(1).
ef.
The final amounts of pass-through funding received by Hawaii Hawai account for budget sequestration.
f. The final amount of pass-through funding to be received by Maine in 2019 by Hawai in 2021 is subject to a final administrative determination determination by the Department of the Treasury and any changes in Maine law or regulations that would affect the waiver (e.g., Medicaid expansion).
g. Although Maryland'.
g. The final amount of pass-through funding to be received by Hawai in 2021 is subject to a final administrative determination by the Department of the Treasury. h. Although Maryland’s waiver application anticipated having enough funds to operate the Maryland State Reinsurance Program from CY2019 through CY2021, the
application requested, and was approved for, an effective period from CY2019 through CY2023.
h.
i.
In addition to what is described in the table about Minnesota'’s approved waiver, Minnesota' Minnesota’s waiver application also requested that the state receive, in pass-through funding, the amount that the federal government would save in payments to Minnesota'’s Basic Health Program because of premium premium reductions due to MSPS. This request was not granted under the approved waiver. For details, see Letter from Mark Dayton, Governor of Minnesota, et al. to Thomas Price, Secretary of the U.S. Department of Health and Human Services, September September 19, 2017, http://mn.gov/gov-stat/pdf/2017_09_19_Governor_Dayton_Letter_to_Secretary_Price_1332_Waiver.pdf, , and Letter from Mark Dayton, Governor of Minnesota, to Seema Verma, Administrator Administrator of the Centers for Medicare & Medicaid Services, October 16, 2017, https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Downloads/Approval-Letter-MN.pdf.
i. The final amount of pass-through funding received by Oregon in 2019 is subject to a final administrative determination by the Department of the Treasury.
j. Approval-Letter-MN.pdf.
j.
Idaho applied to waive ACA §1402 and 26 U.S.C. §36B(c)(2)(B), the latter of which was added to the Internal Revenue Code by ACA §1401.
k.
k. Massachusetts applied to waive ACA §1402(c)(3)(A).
l.
Ohio applied to waive 26 U.S.C. §5000A(a), which was added to the Internal Revenue Code by ACA §1501.
m. Ohio'
m. Ohio’s House Bill Bil 49 requires Ohio's ’s department of insurance to submit a 1332 waiver application that includes a request to waive the ACA's ’s individual and employer
employer mandates. In its waiver application, Ohio acknowledges that the 2017 tax revision ( (P.L. 115-97) effectively eliminates the penalty associated with the individual mandate beginning in CY2019 but points out that the law does not eliminate the individual mandate. As such, Ohio's ’s 1332 waiver application requests to waive the individual mandate (however, the application does not include a request to waive the employer mandate).
n.
n. Vermont applied to waive the followingfol owing ACA §§: 1311(b)(1)(B); 1311(c)(3); 1311(c)(4); 1311(c)(5); 1311(d)(1); 1311(d)(2); 1311(d)(4)(A); 1311(d)(4)(B);
1311(d)(4)(C); 1311(d)(4)(D); 1311(d)(4)(E); 1311(d)(4)(G); 1311(k); 1312(a)(2); 1312(f)(2)(A) .
o. .
o. California applied to waive ACA §1311(d)(2)(B)(i).
p. p. Iowa applied to waive ACA §§1402; 1401(a); 1302(d); and 1332(d).
Author Contact Information
Acknowledgments
Earlier versions of this report were authored by Annie Mach, former CRS Specialist in Health Care Financing.
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress. Information in a CRS Report should n ot be relied upon for purposes other than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you wish to copy or otherwise use copyrighted material.
Congressional Research Service
R44760 · VERSION 20 · UPDATED
23 Financing.
| 1. |
The requirements are not specified in regulations. Department of the Treasury, Department of Health and Human Services (HHS), "Waivers for State Innovation," 80 Federal Register 78131, December 16, 2015. Department of the Treasury, HHS, "State Relief and Empowerment Waivers," 83 Federal Register 53575, October 24, 2018 (Hereinafter "State Relief and Empowerment Waivers guidance"). |
| 2. |
42 U.S.C. §18052(a)(2). |
| 3. |
A qualified health plan (QHP) is a plan that meets certain requirements and is certified to be sold through a health insurance exchange (in the non-group or small-group market). Although QHPs are certified to be sold through exchanges, they also can be sold in the non-group or small-group market outside of exchanges. For more information, see CRS Report R44065, Overview of Health Insurance Exchanges. |
| 4. |
For more information about the current status of the cost-sharing subsidies, see archived CRS Insight IN10786, Payments for Affordable Care Act (ACA) Cost-Sharing Reductions. |
| 5. |
For more information about the employer mandate, see CRS Report R45455, The Affordable Care Act's (ACA's) Employer Shared Responsibility Provisions (ESRP). |
| 6. |
For more information about the individual mandate, see CRS Report R44438, The Individual Mandate for Health Insurance Coverage: In Brief. The 2017 tax revision, P.L. 115-97, effectively eliminates the individual mandate penalty beginning in 2019. |
| 7. |
For more information about the essential health benefits package, see CRS Report R44163, The Patient Protection and Affordable Care Act's Essential Health Benefits (EHB). |
| 8. |
42 U.S.C. §18052(a)(6). |
| 9. |
42 U.S.C. §18052(b)(1) and State Relief and Empowerment Waivers guidance. |
| 10. |
State Relief and Empowerment Waivers guidance. |
| 11. |
State Relief and Empowerment Waivers guidance. |
| 12. |
HHS administers all FFEs, and it operates the same infrastructure technology platform in each state that has an FFE. State Relief and Empowerment Waivers guidance. |
| 13. |
Specifically, CMS services covered under the Intergovernmental Cooperation Act (ICA) are not considered for deficit neutrality purposes. |
| 14. |
State Relief and Empowerment Waivers guidance. |
| 15. |
|
| 16. |
For more information about how household income is calculated to determine premium tax credit eligibility, see CRS Report R43861, The Use of Modified Adjusted Gross Income (MAGI) in Federal Health Programs. |
| 17. |
42 U.S.C. §18052(b)(2). |
| 18. |
State Relief and Empowerment Waivers guidance. |
| 19. |
The public notice and comment period is to be "sufficient to ensure a meaningful level of public input for the application for a section 1332 waiver." 45 C.F.R. §155.1312. |
| 20. |
45 C.F.R. §155.1308(f). |
| 21. |
The public notice and comment period is to be "sufficient to ensure a meaningful level of public input and does not impose requirements that are in addition to, or duplicative of, requirements imposed under the Administrative Procedures Act, or requirements that are unreasonable to unnecessarily burdensome with respect to state compliance." 45 C.F.R. §155.1316(b). |
| 22. |
42 U.S.C. §18052(d)(1) and 45 C.F.R. §155.1316(c). |
| 23. |
42 U.S.C. §18052(a)(3). |
| 24. |
42 U.S.C. §18052(a)(3). |
| 25. |
42 U.S.C. §18052(e). |
| 26. |
42 U.S.C. §18052(a)(5). |
| 27. |
45 C.F.R. §155.1302(a). |
| 28. |
For information about each state's application, see CMS, Center for Consumer Information and Insurance Oversight (CCIIO), "Section 1332: State Innovation Waivers," at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html. |
| 29. |
For more information on reinsurance, see CRS In Focus IF10707, Reinsurance in Health Insurance. |
| 30. |
To read the withdrawal letters, see CMS, CCIIO, "Section 1332: State Innovation Waivers," at https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html. |