Background The State of Maine has had two particularly significant health care policy developments since Governor Mills took office: the implementation of Medicaid expansion in 2019, and the ongoing transition towards an SBM. Both developments stem from the flexibilities granted to states in the passage of the ACA ten years ago. By financing state expansions of Medicaid eligibility, establishing health insurance marketplaces, and providing subsidies for individuals with qualifying incomes seeking health insurance on those marketplaces, the ACA’s implementation has had a significant impact on the accessibility of health insurance for millions of Americans.
In March 2020, Governor Mills signed legislation that formally established the Maine Health Insurance Marketplace, enabling the State to transition to an SBM-FP and to explore the feasibility of establishing its own SBM.5 DHHS is responsible for leading this exploration phase and would oversee SBM operations.
The ACA presents states with a number of decisions around marketplace structure and oversight of Qualified Health Plans (QHPs). In essence, states can decide between operating and overseeing their own SBM or relying on the federal marketplace and its rules governing QHPs. SBMs provide states with significantly greater flexibility and autonomy regarding health insurance marketplace management.
In October 2020, Maine issued a request for proposal (RFP) for technology and call center partners to set up and operate an SBM.7 At the time of this writing, Maine has identified vendors and is currently in negotiations to finalize contract terms.8
In August 2020, Maine submitted a blueprint application to the Centers for Medicare and Medicaid Services (CMS), confirming its goals to adopt an SBM-FP for plan year 2021 (i.e., by November 2020) and an SBM for plan year 2022 (i.e., by November 2021).6
In November 2020, the State officially transitioned to the SBM-FP. Like other states, Maine is funding these operations via 0.5% user fees charged on the premiums This section first presents an overview of the national of plans sold on the marketplace (in addition to the federal government charges context and recent developments for Maine’s market- 2.5% user fees which the 9 in partnership models). place and MaineCare. Next, we describe key demographic characteristics of Maine’s overall population Medicaid Expansion and of marketplace and MaineCare enrollees. Finally, Court rulings since the ACA’s implementation have furwe outline a number of the reasons that states pursue ther opened up state flexibilities in health care proviSBMs and the challenges that an SBM transition entails. sion. In particular, the Supreme Court’s ruling in NFIB v.
Marketplaces
Sebelius made Medicaid expansion optional for states.10 has been Fourteen states and Washington, DC currently operate As of November 2020, Medicaid expansion 11 SBMs. Thirty states remain on the FFM, and six states adopted by 38 states and Washington, DC. Oklahoma operate an SBM-FP—Maine being a recent addition to and Missouri plan to implement their adopted expanthis latter group, as of the OEP beginning November sion in July 2021. 2020. SBM-FP states continue to utilize HealthCare. After Maine voters approved Medicaid expansion by gov’s technology platform and call centers but assume ballot initiative in 2017, former Governor Paul LePage responsibility for certain marketplace activities, includ- refused to implement the expansion, which was set to ing plan management and oversight, consumer out- take effect in July 2018.12 In January 2019, Governor reach, and marketing. Mills instructed DHHS to implement Medicaid expan2018.13 As of December 2020, Nevada’s SBM launch in 2019 marked the first migra- sion, retroactive to July 14 tion of a state to an SBM from an SBM-FP or the FFM abouti 67,500 Mainers —one in four MaineCare memenrolled in since 2014.4 New Jersey and Pennsylvania have since bers, and one in twenty Mainers—were ii coverage through the expansion group. followed suit, launching SBMs in November 2020. i Nearly 237,000 individuals were enrolled in MaineCare or CHIP as of August 2020.That same month, DHHS estimated that nearly 60,000 were enrolled through expansion. Source for total enrollment: Center for Medicare and Medicaid Services.“August 2020 Medicaid & CHIP Enrollment Data Highlights.” https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html. Source for expansion enrollment: Maine Department of Health and Human Services. MaineCare (Medicaid) Update: August 3, 2020. https://www.maine.gov/tools/whatsnew/index.php?topic=DHHS-MAINECARE-UPDATES&id=3010756&v=article. ii Expansion increased the eligibility threshold for parents from 105% of the federal poverty level (FPL) to 138% FPL and made most other adults with incomes up to
8 | BACKGROUND
