Tag Archive for Health

Can Sports Teams Help Inform the Public About Health Exchanges?

It’s a Wednesday night in Boston, and Amy O’Leary is out at Fenway enjoying a Red Sox game and hoping for another year like 2007. That’s when the team won the World Series, sweeping the Colorado Rockies in four games.

It’s also the year that Massachusetts started requiring nearly all residents to have health insurance — and the Red Sox helped to get the word out about it. They let the state set up booths at games to explain the new law to fans, and the Massachusetts Health Connector ran ads on Red Sox broadcast networks.

O’Leary remembers it well. “I think it made sense. People feel like they know the players,” she says. “I think that sports teams in general can be messengers of good information to a wide variety of people.”

Now that other states are opening health insurance marketplaces, they’re trying the same strategy. Myung Kim is outreach director for Colorado’s new health insurance marketplace, Connect for Health Colorado.

“People who care about being healthy, our young adult population, are big watchers of the sports shows, and we know are going to be an important population for us to reach,” Kim says.

Colorado is targeting young people — many of whom are uninsured — to help balance the insurance pool under the Affordable Care Act. Young people generally use fewer health services so their premiums will help the insurance companies cover the medical needs of older, sicker beneficiaries.

So the state is running television ads during Rockies baseball games that show people buying a health policy and then celebrating as if they’d just won sporting event. The voiceover in the ads says, “Connect for Health Colorado, because when health insurance companies compete, there’s only one winner: You.”

But while Colorado follows Massachusetts’ lead on advertising its new insurance marketplace, it is one of only 15 states independently setting up its own exchange. The federal government is fully or partially at the helm of the insurance exchanges in all the other states.

Mandy Cohen, with the federal Department of Health and Human Services, says it can be tough to reach young people who may not currently value having health insurance.

“We also know that they’re most heavily marketed to, so it’s really hard to break through to this group,” Cohen says. “We know we had to put an extra emphasis on the 18-to-35 year old cohort.”

But when the White House reached out to pro baseball, NASCAR and other sports organizations to discuss marketing partnerships, some Republicans called a foul. Senate Minority Leader Mitch McConnell sent the leagues a letter saying they, “risk damaging (their) inclusive and apolitical brand(s)” by promoting the federal health care law.

That didn’t happen in Boston, says Red Sox Vice President Charles Steinberg.

“We didn’t have negative feedback,” says Steinberg. “In American democracy we debate issues and we come to resolution and we pass laws. And those laws are designed to benefit the people. So when you can be a communicator of the laws of the land, you believe that you’re helping people.”

Still, the White House as of now has cancelled at least some of its meetings with sports leagues about potential partnerships.

In Colorado, the ads running during Rockies TV broadcasts haven’t stirred up any controversy. But they might not be home runs either.

The same night O’Leary was in Boston, Joan Ringel was at the Rockies game. She’s seen the ads on TV and says it’s kind of hard to even tell what they are selling.

“You wouldn’t know that that is Colorado’s exchange for the Affordable [Care] Act,” Ringel says. “I didn’t think they explained clearly that people need to pay attention to the exchange when it’s time to sign up.”

Open enrollment for Obamacare insurance starts in October — World Series time. The White House is hoping sports fans will also think of it as a chance to benefit from the Affordable Care Act.

This story was originally published by Kaiser Health News.

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Health Insurance Marketplaces Delay Mobile Apps for Now

In October, state health insurance exchanges (HIX) will start enrolling Americans for coverage as required by the Affordable Care Act (ACA). That’s good news for people with computers and broadband connections, who should have an easy time accessing state exchange portals to compare offerings, determine eligibility, enroll in plans and pay premiums.

But many who rely on smartphones for Internet access will have to choose a different way to apply for coverage, at least this year.

“We did have an extensive discussion around mobility and mobile access to our exchange early on,” said Curtis Kwak, CIO of the Washington Health Benefit Exchange. “Because the timeline was engraved in concrete for Oct. 1, we didn’t get a chance to build that into our version one application. But it’s definitely queued up for version two, which is planned for an August 2014 launch.”

State leaders understand that smartphones play an important role as Internet access tools, but in the scramble to get their HIXes up and running by October, most states haven’t yet tackled the question of mobile access.  

But smartphone use for Internet access is particularly high among some of the groups most likely to look to HIXes for health coverage because they aren’t getting it through employers.

Of adults who use their cellphones to access the Internet, 45 percent of 18- to 29-year-olds, 51 percent of African Americans and 42 percent of Latinos do most of their online browsing that way, according to the Pew Research Center’s Internet & American Life Project. People in households that earn less than $50,000 a year and people who haven’t graduated from college also are likelier to rely on mobile phones to get online, Pew said.

“[States] are finding themselves behind the eight ball as far as being ready for the exchanges. So they’re not as focused on the newer technology,” said Jinnifer Wattum, director of eligibility and exchange solutions for Xerox Government Healthcare Solutions.

People who lack Internet access will be able to interact with HIXes in other ways like calling customer service centers or mailing paper forms. And smartphone users won’t be entirely out of luck either.

Citizens will be able to use their mobile phones to read material on state exchange portals and perhaps to conduct some transactions. But which functions they can use, and how easily, will vary by state.
Watch video (above): Massachusetts’ Health Insurance Exchange Focuses on Reusability

“The good news is that the health benefit exchange interface is not a very heavy interface,” said Manu Tandon, secretariat CIO at the Massachusetts Executive Office of Health and Human Services. “Our idea in general is to make the amount of information we ask of citizens, especially if we’re asking the second time around, as minimal as possible.”

The Massachusetts HIX interface will contain a minimal number of data fields, Tandon said. It could become even simpler as the state’s system starts to pull more data from a hub that the federal government is building to supply data to state exchanges in real time.

If citizens don’t need to enter a lot of information, they might be able to conduct transactions through the browsers on their smartphones, he said.  

Massachusetts comes to the ACA with a strong advantage: Most of its residents already have health insurance, thanks to legislation the state enacted in 2006. When its new ACA-compliant HIX opens for business, most residents will use it to renew or change their coverage, not to enroll for the first time, Tandon said. Massachusetts will need to collect less data than typical states, so more residents will be able to use their smartphones to complete the tasks.

But in most other states, residents seeking health coverage will need to complete a lengthy form. The “streamlined application” — a single form used to apply for Medicaid, the Children’s Health Insurance Program and health insurance plans offered on state exchanges — is complex, said Bruce Caswell, president and general manager of health services at Maximus, a Reston, Va.-based company that partners with local governments to provide health services for poor communities. “That might not make it suitable to be completed on a mobile device.”

So what will Americans be able to do on their smartphones when HIXes open in October?

Smartphones aren’t the only mobile devices citizens can use to access state health insurance exchanges. Nevada is working to accommodate tablet computer users to interact with its Silver State Health Insurance Exchange.

“Tablets have a screen size that will allow for the comparison of plans side by side, and all the things that go along with the plan,” said C.J. Bawden, communications officer of the Silver State Health Insurance Exchange. The much smaller screens on smartphones don’t easily allow for that kind of activity.

Nevada is designing its exchange’s interface to display well on standard computers and tablets, Bawden said. ”We are going to move forward into development of an app or development of a mobile site, in future years, to make it easier for a person with a tablet to walk through all of the steps.”

In the exchange’s early years, Nevada will analyze how long it takes to navigate the site and where users encounter problems to improve the site across various devices.

Tablets could also become an important tool for navigators, or people who, under provisions of the Affordable Care Act, will educate individuals and small employers about health plans and help qualified individuals enroll. In Nevada, many of the navigators who guide citizens through the exchanges carry tablets, Bawden said.

Bruce Caswell, president and general manager of health services at Maximus in Reston, Va., said that navigators might become the real force driving adoption of mobile technology for health insurance exchanges.

“”I think that an iPad or tablet-based, downloadable app that individuals in the field can use in a comfortable setting to educate, communicate and then help navigate the process is going to be critical,” he said.

In states like Nevada, where vast areas of sparsely populated territory lack broadband and wireless service, navigators who visit residents during open enrollment periods might need other mobile technologies as well, said Bawden. ”We’re looking at putting together a truly mobile system, possibly with a vehicle with a satellite uplink to drive out to these remote locations.”

If consumers are using an iPhone or Android phone with a larger screen, they’ll be able to navigate the exchange Web page, said C.J. Bawden, communications officer of Nevada’s Silver State Health Insurance Exchange.

In some states, including Nevada, users of both smartphones and feature phones will be able to get text messages reminding them about premium due dates, open enrollment windows and other important deadlines.

“You’re going to have the ability through the Web portal to choose your preferred method of contact, whether that’s by SMS [short message service], email, a telephone call or regular mail,” Bawden said.

Xerox is developing Nevada’s exchange and Web portal, and the company created a function that reminds consumers when a payment is due.

“As long as the client has given their authorization and mobile number, we can put it on their account that 10 days before their premium is due, a text message will go out,” said Wattum. “They would have to go into the website to pay their premium, but it does give them a reminder via text that they need to do that.”

Rather than make smartphone users fend for themselves on their full-blown HIX portals, some states will most likely build mobile-optimized versions of those sites with simplified interfaces, said Caswell. Smartphone users probably won’t be able to complete entire applications on those mobile sites, but they’ll be able to go through the preliminary eligibility screenings.

“You might even see a relatively straightforward way to do health plan comparisons, at least at a basic level of comparing product costs and features,” he said. “But with the expectation that for a lot more detail, you’d have to go to a bigger browser version.”

While Massachusetts won’t create a separate mobile site in the first incarnation of its new portal, the state is taking mobile browsers into account, along with popular big-screen browsers, as it designs the interface.

“You always have this problem that you want to have the same content be presentable using different presentation media,” Tandon said. “This is no different.”

States could make more specific accommodations for smartphones starting in the next year or two. “I think what you’ll see in the first quarter of next year are mobile applications for paying a premium and making simple changes,” Wattum said.

Based on her conversations with officials in various states, Wattum said it seems that most users won’t be able to shop or apply for plans entirely from their smartphones until late 2014 or 2015.

Massachusetts is still confirming plans to add mobile functionality, said Tandon. “Our current thinking is to develop a mobile Web application for the state-based exchange using Oracle’s ADF Mobile product, which would support the iOS and Android OS using the same code base.”

That application probably would work best for functions like calculating insurance subsidies, managing a user account and paying premiums, Tandon said.

“Other functions, such as applying for health insurance, would be a lengthy process and may not be a good fit for mobile apps,” he said.

In Washington, Kwak envisions someday offering a mobile app that users could download for free from the Washington Health Plan Finder website or a commercial app store. But it’s not yet clear whether downloadable apps are an effective way to reach the state exchange’s target market, he said.

State officials also must remember that mobile apps carry a cost, Kwak said.  “I think there’s some perception out there that mobile applications are a dime a dozen,” he said.

That might be true for users who download the software, but it’s not the case for the organization that has to develop, test and market the app. “I want to be sensitive to the fact that there is major work in developing even the simplest mobile application and making it available to the public,” he said.  

Smartphone interfaces for health and human services already exist outside the realm of HIXes. For example, Maximus has developed a downloadable app for people receiving Temporary Assistance for Needy Families benefits in Wisconsin to demonstrate that they are seeking employment.

“You can use this mobile app to submit time sheets, to document your job search activity — literally taking pictures of the business cards from in-person interviews you’ve had,” Caswell said.

On the health-care side, this year Maximus will pilot the use of a mobile-optimized Web browser in some of the states where it provides services for the Children’s Health Insurance Program and Medicaid programs. Beneficiaries with smartphones will be able to use this browser to perform some basic activities, such as looking up health-care providers, Caswell said.

However, mobility, in general, has been making its way into the health benefit market at a glacial pace, Caswell said. HIXes provide a chance for catch-up.

While states are busy just getting their HIXes and portals up and running, they also realize that many of the citizens they’re trying to bring onto the exchanges are people under 30 who rely heavily on their smartphones, Caswell said.

“You need to have those folks in the exchanges, because from an actuarial perspective they’re critical to ensuring that the exchanges are sustainable,” he said.

It’s certainly time for a greater emphasis on mobility, agreed Wattum. In the past, organizations providing services to low-income and uninsured populations assumed that those clients lacked access to computers or weren’t technically savvy.

“That’s just not the case,” said Wattum. “And especially in the last three years, mobile devices have become the norm for every population.”

States need to figure out how to provide services through mobile devices, she said.

Like Tandon in Massachusetts, Wattum looks to the federal health-care data hub to pave the way for better smartphone access in the future.

When an applicant enters basic information, such as a name, Social Security number and current address, the federal hub will use that to verify citizenship, pull income figures from the IRS and otherwise retrieve data needed to apply for insurance and government subsidies, she explained. If the hub supplies that data, states won’t need complex on-screen forms to capture the information from applicants.

At least, that’s the theory. “States are hesitant about whether or not that’s truly going to be real time and whether it will be ready for this fall,” Wattum said. “Once that automation is proven out, I think the states and the federal government will be more open to investing in technology such as a mobile app.”

Photo of Manu Tandon by David Kidd

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States to Offer Additional Subsidies on Health Exchanges

At least three states plan to offer additional subsidies next year for health coverage purchased on Obamacare’s health insurance marketplaces, on top of the federal tax subsidies offered as part of the health reform law.

Officials in Massachusetts, New York and Vermont are considering various state-funded subsidy packages, although they differ in their scope and generosity. It is yet another reminder that, while much of the debate over the Affordable Care Act (ACA) centers on states that are refusing to implement the law, some are going beyond what Congress prescribed back in 2010.

New York and Vermont have one thing in common: They both currently offer Medicaid coverage to people above 138 percent of the federal poverty level, the new Medicaid eligibility threshold under the ACA in states that decide to expand the program. So those people above that line who currently receive Medicaid will instead purchase health coverage through the marketplaces, also known as exchanges, starting next year. The additional state subsidies are intended to make sure that being insured isn’t more expensive for that population when they move to the exchange, state officials say.

Massachusetts is slightly different, though the principle is the same: That state’s 2006 health reform law, which served as a model for Obamacare, included more generous subsidies than the federal law. So the state-funded subsidies on the exchange will help offset any difference in cost once the federal subsidies kick in next year.

“The concern for some states is that the subsidies in the exchanges… just aren’t good enough to enable folks to enroll,” says Jennifer Tolbert, who tracks exchange implementation for the Kaiser Family Foundation. “These states are looking at ways to improve the affordability of that coverage so more people will enroll.”

Vermont is planning to provide state-based subsidies to people with incomes between 138 percent and 350 percent of the federal poverty level (the federal subsidies go to 400 percent of the poverty level, roughly $46,000 for an individual) because those people currently qualify for Medicaid. The subsidies would offset the cost of premiums by another 1.5 percent on top of the federal subsidies. About 40,500 Vermonters are expected to receive the additional assistance, at a cost of $2.9 million to the state in 2014.

The state would also pay insurers to reduce both the deductible and out-of-pocket maximums of exchange coverage for those people. For example: someone making between 200 and 250 percent of the poverty level currently has a deductible of $500 for Medicaid, but that would increase to $1,900 for a private plan under the ACA. The state would therefore pay the difference for someone to purchase a plan with a $700 deductible. For someone making between 300 and 350 percent of the poverty line, the state would pay to lower their deductible from $1,900 to $1,500.

“In our state, Medicaid expansion really means Medicaid contraction,” says Mark Larson, commissioner of the department of Vermont Health Access. “When we thought about transition to 2014, we had a question of how do we maintain an affordability standard that we’ve already achieved in Vermont. What we attempted to do was maintain as close to the standard that we already had.”

The proposal in New York would function similarly to Vermont’s plan for premiums, though it would apply to a narrower income bracket. New York currently covers working parents with incomes up to 150 percent of the poverty level under Medicaid, so the state subsidies would apply to people between 138 percent of the poverty level and 150 percent.

Massachusetts extended Medicaid coverage (administered through private managed care plans) to individuals and families making up to 300 percent of the poverty level under its 2006 law; about 200,000 people were insured as a result. The 2006 law’s subsidies for that coverage were more generous than what the ACA will provide next year, however, so the state plans to offer state-funded subsidies to keep the cost of coverage the same for people up to the 300 percent threshold. As in Vermont, the size of the additional subsidies will be based on a sliding scale. State officials expect 150,000 people to qualify for the state subsidies, which are estimated to cost $120 million.

“We had a lot of success in our state with our first reform, and we expect that this will maintain the coverage gains that we’ve gotten to date,” says Candace Reddy, Massachusetts’s assistant secretary for health care finance.

Similar proposals were weighed to some degree in Connecticut and Maryland before being discarded. Connecticut Gov. Dannel Malloy proposed sending parents currently enrolled in Medicaid with incomes between 138 and 185 percent of the poverty line to the exchange and then providing premium assistance for their new coverage. But the legislature rejected Malloy’s plan, opting instead to keep those people on Medicaid.

The idea of additional state-funded subsidies was also floated briefly in Maryland, though nothing formal was ever introduced.

“I would say it would be a possible consideration for the future, but we’re locked into what we’re doing for year one,” says Joshua Sharfstein, Maryland Secretary of Health and Mental Hygiene.

The approach Massachusetts, New York and Vermont are taking makes some sense because concerns about the affordability of exchange coverage are very real, says Caroline Pearson, who tracks state ACA implementation for Avalere Health, an independent consulting firm.

According to a recent Avalere analysis, patients with incomes of 350 percent of the poverty level and below who reach the out-of-pocket maximum allowed under the ACA would be considered “underinsured” based on the percentage of their income that they could end up spending on medical costs, even with the available federal subsidies. For example: the study found that people making 300 percent of the poverty level could still spend up to 20 percent of their income on health care, while the underinsured threshold is 10 percent.

Therefore, the additional subsidies that these states are considering could help offset those costs and make it more affordable for people to enroll in the exchanges and purchase coverage, Pearson says.

“The subsidies still leave a bit to be desired. They still leave a lot of out-of-pocket costs,” she says. “It’s a pretty big deal for patients in these states if they get additional subsidies, but the question is: Can they sustain it?”

This story was originally published by GOVERNING.com. Photo courtesy of Shutterstock.

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Federal Data Hub Hobbling Health Exchange Implementation

The federal data hub intended to connect state health exchanges with federal agencies appears to be the most significant hurdle for a timely launch of the insurance marketplaces, according to a new Government Accountability Office (GAO) report.

Seven surveyed states identified the hub as “the major operational challenge” that they face, according to the GAO. Whether that challenge is resolved could determine whether the exchanges are ready to open on Oct. 1, 2013, the date set for their launch by the Affordable Care Act.

“States said, by and large: We’re doing the best we can. We’ve been doing this a while. We think we’re going to be ready, but it’s anybody’s guess because it’s so evolving, especially with the data services hub,” says Stan Czerwinski, who headed the group that authored the GAO report. “State systems have to connect with federal systems, which are still being developed. The challenge is hooking into these systems without knowing what they will look like.”

The data hub — in laymen’s terms, a huge digital warehouse capable of sending information to other online servers — plays a crucial role in the exchanges, which are websites that will allow the uninsured to shop for health coverage and access federal tax subsidies to help them purchase it. The tax subsidies, for example, are supposed to be based on a person’s income; the lower your income, the higher your subsidy.

The exchange is supposed to transmit the income information entered by an applicant to the hub, which will then verify the information with the Internal Revenue Service. That verification is then transmitted back to the exchange, so the person can access their subsidy. The hub will also relay information between the exchanges and other federal agencies, such as the U.S. Citizenship and Immigration Service and the U.S. Department of Homeland Security.

It sounds simple, but it’s a significant headache for the 17 states that, so far, are building their own exchanges. For starters, the hub hasn’t been completely built yet, nor have the rules that will govern its use been finalized. Because tax information will be exchanged through the hub, there is a laundry list of privacy and security standards that must be met. In addition, the IRS is accustomed to receiving and then processing this kind of information over long periods of time, up to a month, while the exchange is supposed to provide verification in almost real-time. Nobody is sure if and how the hub will be equipped to handle that workload.

All the while, states are already building the technical infrastructure for their exchanges, which includes a website and an eligibility system, without knowing exactly how their exchange is supposed to connect with the hub. It’s a major problem with four months left until the exchanges are supposed to be operational, and Czerwinski believes “this is going to go way up until the very last day.”

One state was so pessimistic that officials told the GAO they expected to be still modifying their exchange’s IT infrastructure to connect with the hub into 2014. For its part, the Obama administration told the GAO that it had provided states with information on how to connect with the hub through webinars and conferences, though that apparently has not assuaged states’ concerns.

“Until they’re able to do this testing to make sure that all these points connect, it’s still unknown,” Czerwinski says. “I think they agree that it’s the biggest challenge area and will need adjusting from day one.”

Caroline Pearson, who tracks state ACA implementation at Avalere Health, a consulting firm, said the GAO report underlines an overarching problem with health exchange IT development: it’s hard to know how states are doing. Some steps, such as accepting applications for health plans to be sold on the exchanges, are public, but the GAO’s findings are one of the few public disclosures of progress on the IT side.

“This does feel like an area where there could be pitfalls in rollout. There are a million ways it could go poorly,” Pearson says. “We have touch points and checkpoints on so many other things. All of that is a little more public, but it is really hard for me to assess whether a state’s exchange is going to crash on Oct. 1.”

Officials at the U.S. Department of Health and Human Services did not immediately respond to requests for comment. GAO interviewed officials from the District of Columbia, Iowa, Minnesota, Nevada, New York, Oregon and Rhode Island for the report.

This story was originally published by GOVERNING magazine.

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States Prepare to Launch New Health Law

With the Affordable Care Act set to debut in January, state legislators debated dozens of measures related to the historic health care law—from overhauling insurance laws and designing health “exchanges,” to shoring up anti-fraud protections and increasing the ranks of doctors and nurses.

On top of that, the politically volatile question of Medicaid expansion grabbed headlines, especially in the five states that still haven’t decided whether to expand the program.

“It’s been an IT undertaking of Manhattan Project proportions,” says Matt Salo, director of the National Association of Medicaid Directors.

Salo was referring to the need to mesh Medicaid enrollment with the new health insurance exchanges, but he could have been talking about any of the dozens of technical and administrative changes state officials must make to prepare for the Affordable Care Act (ACA).

For example, state insurance regulators in nearly every state have been racing to approve hundreds of new insurance policies that will be offered on the exchanges starting Oct. 1. Meanwhile, the Medicaid expansion debate has highlighted longstanding problems with the federal-state health program for the poor, prompting many states to make changes.

Alabama Republican Rep. Greg Wren said the ACA “provided a real jolt to our governor and our legislative leadership to look at systemic reforms of our Medicaid program.” The result, Wren said, was the state’s first major Medicaid overhaul, designed to better coordinate patient care and reduce costs.

As of today, 21 states and the District of Columbia have decided to expand Medicaid. In at least five more states – Arizona, Florida, Michigan, New Hampshire and Ohio – governors support expansion but Republican-dominated legislatures continue to debate the issue. In Maine, Republican Gov. Paul LePage is threatening to veto an expansion passed by the majority Democratic legislature.

Under the current eligibility rules, Medicaid mostly covers pregnant women and young children, disabled adults and the elderly. Under the expansion envisioned in the ACA,  it also will cover adults, many of them childless, between the ages of 18 and 65 with incomes up to 138 percent of the federal poverty line—about $15,900 for an individual and $32,500 for a family of four.

Many states plan to extend their use of managed care to cover these new adults, aiming to add more primary care providers to their existing networks of obstetricians, pediatricians and other specialists.

To boost the ranks of primary care providers, more than a dozen states enacted laws this year expanding the so-called “scope of practice” for nurse practitioners. These nurses with advanced degrees are trained to provide the same care as primary care doctors, but are prevented from doing so by state medical licensing restrictions. The new laws put nurse practitioners on an even footing with primary care doctors.

States also expanded licensing of retail health clinics, which typically see patients in drug stores or big-box retail stores, and enacted reciprocal licensing laws that allow doctors in neighboring states to care for out-of-state patients in rural areas through the use of telemedicine technology.

Even in states that choose not to broaden Medicaid under ACA, 2014 is likely to bring a substantial increase in state Medicaid rolls: The Congressional Budget Office predicts that millions of Americans who already qualify for Medicaid will enroll for the first time once national ad campaigns publicize the new health law’s individual insurance requirement.

Texas, for example, has firmly opposed Medicaid expansion under the ACA, but the state is expecting 555,000 people to sign up for Medicaid in the next nine years, growth that may cost the state nearly $4 billion.

Nationwide, the total cost of covering a projected 5.7 million people who are already eligible for the program but have never enrolled is estimated at $68 billion for states and $152 billion for the federal government, according to a study by the Kaiser Family Foundation and the Urban Institute.

Meanwhile, some GOP governors and lawmakers who are reluctant to expand Medicaid under the ACA are mulling alternative ways to expand coverage. One plan, referred to as “the Arkansas model,” would cover newly eligible adults through private insurance policies available on the health insurance exchanges. But the federal government has yet to approve that approach.

The health insurance exchanges will be online marketplaces where uninsured people can compare insurance policies, find out whether they qualify for either Medicaid or federal tax subsidies, and purchase insurance. The ACA allows states to either run their own health insurance exchanges, partner with the federal government, or let Washington run an exchange for them.

Insurance regulators in nearly every state began qualifying participating insurance companies and the policies they plan to offer starting in April. The process must be completed by July 31.

So far, California, Colorado, Maryland, Oregon, Rhode Island, Vermont and Washington have made public the names of the companies that have applied and their proposed policy prices. In every state, the new rates for individual and family policies on the exchange are expected to be higher than existing individual insurance policies. But because of new insurance company requirements in the ACA, the benefits for exchange plans in 2014 will be broader and there will be no caps on claims, making it difficult to compare them to today’s policies.

Stateline’s Legislative Review looks at policy and politics in the states since legislatures began their work in January. The five-part series will include analytical articles, infographics and interactives.

Every year, unscrupulous health care providers squander billions of state dollars by overbilling, filing claims for services that were never provided, or otherwise cheating the system. With millions of newly eligible beneficiaries and billions of federal dollars coming into state Medicaid programs next year, the authors of the ACA reasoned that opportunities for criminal activity would surge unless states increased fraud prevention efforts.

In addition to federal requirements, lawmakers in several states voted for additional anti-fraud measures this year. “Fraud fighters have to keep investing in new tactics and technology to stay one step ahead of the bad guys,” said Megan Comlossy, health expert with the NCSL.

Under the ACA, states are required to ramp up background checks on new health care providers and immediately suspend claims payments when there is a “credible allegation” of fraud. Arkansas, Florida, Iowa and Texas enacted laws defining what type of evidence is needed to make such a credible allegation.

The federal health law also calls on states to report doctors and other providers they have kicked out of their Medicaid programs. The list will be kept in a national database that includes the names of providers who have been terminated from Medicare. The database is intended to prevent crooked health care providers from simply moving from state to state or from Medicare to Medicaid.

In addition, the law provides federal money to states that invest in new technology designed to spot criminal activity before claims are paid. Arkansas, Colorado, Massachusetts and Texas this year approved new laws calling for investment in so-called “predictive modeling” software similar to what credit companies use to reveal patterns of illegal activity, according to NCSL.

Whether states can stop more criminals from siphoning money from Medicaid remains to be seen. The same goes for state efforts to attract more primary care providers to serve the newly insured and educational campaigns aimed at convincing low-income adults to sign up for tax credits.

One thing is certain: Though most state legislative sessions will be over by July, the work of implementing the ACA will go on for years.

This article originally appeared on Stateline, a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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