A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 Insight on the Issues Health Insurance State Innovation Waivers and Older Adults: A Guide for States Olivia Dean and Jane Sung AARP Public Policy Institute Section 1332 State Innovation Waivers, named after the section of the Affordable Care Act that created them, are intended to allow states to implement innovative strategies to provide health coverage for their residents. This Insight on the Issues provides a guide for states to understand the landscape and history of these waivers and how they can impact older adults. Background Section 1332 of the Affordable Care Act (ACA) allows protect and improve coverage for older adults. The states to seek and receive approval to waive certain paper is divided into five overarching steps: parts of the ACA through State Innovation Waivers.1 These waivers were originally intended to give states 1. Learn How a State Innovation Waiver Works, flexibility to implement innovative or alternative 2. Recognize Opportunities to Improve Coverage: approaches to improve health insurance coverage for Reinsurance and Other State Waivers, their residents. As of September 2019, several states 3. Approach Recent Federal Guidance with Caution: have received federal approval for waivers. Protecting Older Adults, Acknowledging that states have unique health 4. Understand the Waiver Process and Public Input care markets and may be able to achieve the ACA’s Opportunities, and health reform goals through various means, the ACA included State Innovation Waivers as a way for 5. Keep an Eye on Federal Activity. states to implement different approaches to health coverage while maintaining the law’s core consumer protections. States have been able to apply for waivers since early 2017. The departments of Health and DIFFERENT NAMES, SAME MEANING Human Services (HHS) and Treasury approve or While this paper uses the term State reject waiver applications based on whether they meet Innovation Waivers, these waivers are also certain requirements, as discussed in the next section. commonly referred to as section 1332 Through this Insight on the Issues, we provide a waivers, 1332 waivers, or State Relief and guide to help states understand and evaluate State Empowerment Waivers (as renamed by the Innovation Waivers and their potential impact on Trump administration in October 2018). older adults, as well as recommend steps to help A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 1. Learn How a State Innovation Waiver Works What Can States Waive? What are the Protections in the Law? States can use State Innovation Waivers to remove While section 1332 of the ACA authorizes waivers or modify certain parts of the ACA (figure 1). that could potentially alter significant parts of the However, in order to ensure states do not weaken ACA, it also contains important safety mechanisms the core protections of the ACA, several ACA to ensure that waivers do not unravel or undermine provisions cannot be changed through a waiver. the ACA’s core reforms. To date, most states with approved waivers have Section 1332 established four “guardrails” that limit chosen to modify financial assistance provisions the way waivers may be used by states and are (which provide for premium tax credits and cost- designed to protect consumers. The departments of sharing reduction subsidies). HHS and Treasury may grant a waiver only if they determine that the state’s waiver plan meets these guardrails (figure 2). FIGURE 1 State Innovation Waivers Can be Used to Change Certain Affordable Care Act (ACA) Provisions Waivable Provisions Non-waivable Provisions Qualified Health Plans Guaranteed Issue These are requirements that health plans must This provision requires insurance companies meet in order to be offered, including Essential to offer coverage without regard to health or Health Benefit requirements to cover a specified set preexisting conditions. of minimum benefits and limits on cost sharing. Premium Rating Protections These include provisions that prohibit insurers from Health Insurance Marketplaces a) charging older adults more than three times the These requirements govern how plan choices are amount they charge younger people for the same plan offered to consumers. (“age rating”) and b) charging higher premiums on the basis of a person’s health or preexisting condition. Premium Tax Credit and Lifetime and Annual Limit Ban Cost-Sharing Reductions This provision ends the previous insurance This provision provides premium tax credits and cost- company practice of setting lifetime and annual sharing reductions to people with incomes between dollar caps on coverage. certain ranges to make coverage more affordable. Employer Shared Responsibility No Copays for Preventive Care This provision requires employers with 50 or more This provision requires insurers to cover preventive employees to offer affordable health coverage. care services without copayments. Individual Shared Responsibility Young Adult Coverage This provision requires individuals to maintain This provision requires insurers to allow children up minimum essential coverage.* to age 26 to remain on their parents’ plan. * While the individual shared responsibility provision remains in federal law, Congress eliminated penalties associated with the requirement in December 2017 as part of the Tax Cut and Jobs Act, effective January 2019. 2 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 FIGURE 2 State Innovation Waivers Must Meet Guardrails • Waiver provides coverage that is at least as comprehensive COMPREHENSIVENESS in covered benefts as would be provided without the waiver. • Waiver provides coverage that is at least as affordable AFFORDABILITY as would be provided without the waiver. • Waiver provides coverage to at least a comparable COVERAGE number of residents in the state as would be provided without the waiver. COST • Waiver does not increase the federal defcit. In summary, waivers must ensure the coverage provided in a state is at least as comprehensive 2018 FEDERAL GUIDANCE PRINCIPLES (as the ACA’s Essential Health Benefits), at least as affordable, and cover at least as many people The October 2018 guidance states that as would coverage without the waiver—without secretaries of HHS and Treasury will costing the federal government more. These “consider favorably” waivers that advance guardrails are meant to ensure waivers maintain some or all of the following principles: the ACA’s key objectives and protections. The ACA also establishes procedural requirements 1. Increase access to affordable to ensure strong state support and opportunity for private market coverage, including meaningful public input (discussed in step 4). To association health plans and short-term ensure accountability, the ACA also requires state limited-duration plans, rather than public reporting and periodic evaluation. coverage. 2. Restrain growth in federal spending, What Criteria Does the Federal Government including reducing state regulation that Use in Approving Waivers? While the guardrails are specified in the ACA may discourage insurers from entering federal statute, the departments of HHS and markets. Treasury have exercised discretion in how they 3. Foster innovative state approaches that implement the law and how they approve or reject meet local consumer and market needs. state waivers. The federal agencies in both the 4. Support and empower those in need, current and previous administration have issued such as people with low incomes and supplementary guidance to states about waiver those with high health costs. procedures and requirements. 5. Promote consumer-driven health care Previous guidance issued under the Obama administration in 2015 outlined criteria that the by including incentives to encourage federal agencies at that time would consider in consumers to seek higher value coverage. assessing whether a waiver application violated any 3 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 of the law’s guardrails.2 In October 2018, the Trump of four waiver concepts in November 2018 and administration released new guidance to replace detailed papers on these waiver concepts in July the previous guidance. The 2018 guidance made 2019, which provided some potential examples significant changes to the prior administration’s for states to consider in using the new federal interpretations of the law, with one of its goals to flexibility.4,5 Step 3 of this paper describes the give states greater flexibility to satisfy guardrails potential impact of this guidance on older adults in (table 1).3 This guidance was followed by the release more detail. TABLE 1 Past and Present State Innovation Waiver Guidance 2015 Waiver Guidance 2018 Waiver Guidance • Specified protection for vulnerable • No specified protection for vulnerable populations such as the elderly populations such as the elderly HHS and Treasury departments must take HHS and Treasury departments only consider into account a proposed waiver’s impact on the impact on the population of state residents different groups of state residents, including as a whole, and no longer have to consider vulnerable populations like the elderly, people impact on vulnerable populations. A waiver that with low incomes, and people at risk for provides less affordable or less comprehensive serious health problems. Waivers that reduce coverage for some groups, such as older comprehensiveness, affordability, or coverage adults, could still be approved so long as it is for vulnerable groups may not be approved. comprehensive or affordable for state residents as a whole. • Consideration of enrollment in affordable, • Consideration of availability of affordable, comprehensive coverage comprehensive coverage State waivers must show that a comparable State waivers need only show the availability of number of residents would be forecast to enroll comprehensive and affordable coverage but do in affordable, comprehensive coverage under not have to demonstrate predicted enrollment the waiver as would have without the waiver. in such coverage. As long as the coverage is available, it does not matter how many people are actually likely to enroll in it. • Comprehensive definition of coverage • Relaxed definition of coverage In estimating coverage, states cannot include In estimating coverage, states can include plans that do not meet the ACA’s minimum plans that do not meet the ACA’s minimum essential coverage standards, such as short- essential coverage standards, such as short- term limited-duration plans and association term limited-duration plans and association health plans. health plans. These plans are not required to cover people with preexisting conditions and can charge older adults more than three times what they charge younger adults for the same coverage. The guidance also allows tax credits to be used for purchasing these plans. 4 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 2. Recognize Opportunities to Improve Coverage: Reinsurance and Other State Waivers State Innovation Waivers can provide opportunities Hawaii became the first state to receive a waiver to improve access to and affordability of coverage, approval on December 30, 2016, but its waiver was including for older adults. While states may innovate limited to accommodating state-specific reforms and develop unique proposals, they can also learn (employer market) already in place prior to the ACA.7 from what other states have already done.6 All subsequent state waivers that have been approved to date have focused on establishing state reinsurance State Waiver Activity programs to help stabilize state individual health As of September 4, 2019, thirteen states have insurance markets (discussed later in Step 2). received State Innovation Waivers (figure 3). Seven have either received rejections or withdrawn the Only a few waivers have been proposed or explored waivers themselves. that would implement somewhat broader reforms, though none of these have been approved yet. State waivers approved so far have been relatively Some were withdrawn or not submitted for federal limited in scope, but that may change in the future approval. For example, in 2016 California submitted given the latest federal guidance. Even though a waiver to expand access to unsubsidized coverage waivers could conceivably make sweeping changes on the state Marketplace to undocumented to the ACA, states that have received approvals thus immigrants,8 but the state subsequently decided to far have pursued more targeted changes to their withdraw the waiver in January 2017. In July 2019, health insurance markets. FIGURE 3 Status of State Innovation Waivers as of September 4, 2019 5 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 Idaho submitted a waiver that would allow certain Medicaid-eligible residents to enroll in qualified DID YOU KNOW? health plan, but it was deemed incomplete in The ACA included a temporary federal reinsurance August 2019. program for three years: 2014, 2015, and 2016. It was created to provide premium stability while the new Waiver Opportunity: Implementing law was getting started and insurers had little-to-no Reinsurance history on which to base expectations about claims. One positive way states can use waivers to improve After those three years passed and the federal affordability of individual market premiums is to reinsurance program sunset, insurer uncertainty implement state reinsurance programs. To date, without the guarantee of a federal reinsurer led to the vast majority of approved waivers—twelve out premium increases, particularly in 2017 and 2018 as insurers adjusted assumptions. That proved to be a of thirteen—have focused on establishing such catalyst for waiver activity at the state level. state funds. Reinsurance protects health insurers from unpredictable and high health care claims, and thus (figure 4). These attachment points and caps often allows insurers to set lower premiums and helps vary widely by state. provide market stability. Reinsurance programs have been effective in reducing individual market For example, in Minnesota, the reinsurance premiums, increasing enrollment, and retaining program pays 80 percent of claims above an insurer participation.9 attachment point of $50,000, up to a cap of $250,000. In Oregon, the program will pay States’ reinsurance programs vary in their 50 percent of claims between an attachment point approach. In a traditional reinsurance program, a of $90,000 and a cap of $1 million. reinsurer (usually a third party) pays for a portion In a condition-based reinsurance program, also of the costs starting when an individual’s health sometimes referred to as an invisible high risk pool, insurance claims exceed a certain threshold, called a reinsurer pays an insurer’s claims for specified an attachment point, until the claims reach a cap health conditions rather than reimbursing based on a dollar threshold and cap. Enrollees with health FIGURE 4 conditions who insurers believe will be particularly Traditional Reinsurance Example expensive are “ceded” into these “invisible” high- risk pools, which pay the health care costs for these high-risk enrollees above a certain threshold. Some states, like Maine, combine a condition-based approach with a traditional approach. Reinsurance programs can be helpful in stabilizing health insurance markets in states experiencing unaffordable premiums or insurers dropping out of the market. Reinsurance programs have proven successful in several states and can help reduce premiums and improve access to coverage for enrollees, including older adults.10 An analysis by Avalere found that states with their own reinsurance programs see an average 19.9% drop in individual market premiums in their first year.11 One of the biggest challenges to implementing a state reinsurance program is securing and then 6 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 maintaining a state funding source. Although they can access pass-through of federal ACA tax credit LOOKING BACK: funds (see explanation of Alaska waiver), state WHICH STATE WAS FIRST? reinsurance waivers have generally also included a source of state funding,12 which can be challenging In July 2017, Alaska became the to identify and maintain. first state to get a State Innovation Waiver approved. Under the waiver, Alaska designed and implemented a reinsurance program to better distribute costs of high-cost enrollees 12 out of 13 approved and lower premiums. Alaska worked with the Centers for Medicare & Medicaid Services waivers have (CMS) to find a way to access pass-through established state federal funds, a critical piece of Alaska’s waiver and subsequent state waivers. The reinsurance funds. pass-through funding comes from the federal government and is equal to the amount of funds that would have otherwise been provided to consumers and businesses through tax credits and cost-sharing subsidies had the waiver not been implemented. Minnesota and Oregon soon followed Alaska’s lead and had waivers approved in September and October 2017, respectively, to implement state reinsurance programs. Several other states have recently had waivers approved to establish reinsurance. 7 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 3. Approach Recent Federal Guidance with Caution: Protecting Older Adults While State Innovation Waivers offer opportunities for subsidies and would have difficulty affording for states to make positive changes to their premiums if they increased. Older adults already individual health insurance markets, recent federal face premiums that are three times as high as those guidance also opens the door to allowing states for younger adults for the same coverage, and even to pursue new types of waivers that could have a higher premiums could be unaffordable. potentially harmful impact on older adults. When Waivers that promote non–ACA compliant plans evaluating new waiver proposals, states should be should be closely analyzed to assess impact on older aware of several potential areas for concern. adults who purchase coverage in the individual Concern 1: Weaker protections could market, including for those who do not qualify for negatively affect older adults. subsidies. New flexibilities under the recent federal guidance have the effect of weakening guardrail protections. States should be aware that new waivers that CONCERNS WITH SHORT-TERM negatively affect older adults could potentially be PLANS AND ASSOCIATION approved under the latest guidance. While states are HEALTH PLANS no longer required to evaluate the potential impact of a waiver on older adults and other vulnerable Both short-term plans and association groups, states that want to ensure protections for health plans are not required to comply older adults should continue to examine a waiver’s with the ACA, so they do not have to impact on such groups. cover essential benefits, protect people with preexisting conditions, or adhere to Concern 2: Waivers could encourage premium rating consumer protections. While proliferation of non–ACA compliant plans. healthier enrollees may be attracted to The new guidance could allow waivers that promote these plans because they are cheaper, they the purchase of non–ACA compliant insurance, may face high out-of-pocket health costs if such as short-term limited-duration health plans an unexpected health issue arises that is not and association health plans. The waiver concepts covered by their plan. Expansion of these released also encourage states to allow premium plans could also disrupt the market and tax credits to be used to purchase these types of raise premiums for those remaining in ACA- coverage, which could drive even more people compliant plans. towards non-compliant plans. Expansion of non-compliant plans could result in fewer healthy people buying coverage in the ACA- compliant individual health insurance market Concern 3: Waivers could make coverage less and could be disruptive to the market. As a result, affordable. costs could increase for people who remain in the As illustrated in waiver concepts released in individual market, including older adults and people November 2018,13 states could also use State with preexisting conditions seeking coverage with Innovation Waivers to propose alternative ways to ACA consumer protections. offer tax credit premium assistance, which under Higher costs for those remaining in the individual the ACA is available to help lower-income people market would make it particularly difficult for afford health insurance premiums. While not all moderate-income older adults who may be ineligible changes to ACA tax credits are necessarily harmful, some proposals in recent years would have reduced 8 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 tax credit assistance to many older adults had they In addition to these changes, the recent guidance been adopted. also relaxes an ACA requirement that states enact One of the waiver concepts encourages states to authorizing legislation before pursuing a State consider alternative subsidy structures, including Innovation Waiver. States can now use existing one suggestion of a fixed premium tax credit legislation in conjunction with enacted regulations based on age. A similar proposal was central to the or executive orders to enforce the ACA generally. 2017 federal “repeal and replace” debate, when the While this procedural change may make it easier proposed American Health Care Act would have and faster for states to submit waiver applications, replaced the ACA premium tax credit with a new states should still ensure that there is adequate age-adjusted flat tax credit.14 Such a proposal would opportunity for meaningful public input. have significantly reduced premium assistance for many older adults. 9 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 4. Understand the Waiver Process and Public Input Opportunities Prior to submitting an application to the departments of Treasury and HHS, the ACA requires that states enact authorizing legislation State Innovation Waiver allowing the waiver to be implemented. As applications must include mentioned earlier, the latest federal guidance makes the following:16 it easier for states to initiate the waiver process • Public notice and comment by allowing them to use existing legislation along period with an executive order or enacted regulations for • Enacted state legislation enforcing the ACA. Following the creation of an application comes a public notice and comment • List of provisions the state plans to waive (including public hearings) stage, which must • Information to determine the waiver ensure a “meaningful level of public input.”15 meets the 1332 guardrails with actuarial The ACA and its implementing regulations support and economic analysis have established a number of steps states need • 10-year budget plan to complete to gain federal approval for a State • Implementation plan Innovation Waiver (figure 5). • Reporting targets First, states draft a waiver in conjunction with or after ensuring legislative authority. The waiver • Principles discussion application must include several elements, including FIGURE 5 State Innovation Waiver Application Process 10 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 actuarial and economic analyses that support the Marketplace enrollees had the state not received a state’s finding that the waiver complies with the waiver. law’s guardrails. While no longer required under the Once the federal agencies deem a state’s application recent guidance, states should ensure older adults complete, they conduct a federal public notice and other vulnerable populations are included and comment period for the waiver. No more in the actuarial analyses and report the potential than 180 days after the application is determined impact on these populations in their applications. complete, the departments of Treasury and HHS States submit the waiver applications to the make a final decision, either approving or rejecting the waiver application. departments of Treasury and HHS, which conduct a preliminary review within the first 45 days Waivers are approved for periods of up to five of receiving the application to determine if the years and are renewable. States are required to application is complete. conduct periodic reviews of implementation of the waiver, and within six months of implementation While no additional federal funding is provided for must advertise and hold a public forum. States State Innovation Waivers, the ACA does allow the must also submit quarterly and annual reports federal government to provide pass-through funding to the departments of Treasury and HHS, and for the amount of tax credits or cost-sharing the departments will periodically evaluate the reductions that would have been paid on behalf of implementation of the waiver. 11 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 5. Keep an Eye on Federal Activity States should be sure to keep an eye on federal the departments of Treasury and HHS wrote to activity related to State Innovation Waivers, as state governors encouraging states to submit waiver changes to federal law or guidance could have big applications, focusing specifically on waivers that impacts on access to and affordability of health propose reinsurance programs.17 In May 2017, CMS coverage for older adults. Recently, policy makers released a checklist to help states complete such and stakeholders have considered and advocated waiver applications. In October 2018, CMS released for changes to increase state flexibility in health new guidance, intended to replace the 2015 guidance, insurance regulation, including promoting greater and changed the name of the waivers from State use of State Innovation Waivers. Innovation Waivers to State Relief and Empowerment Waivers. This was followed by the release of four What Has Happened? accompanying waiver concepts in November 2018. In recent years, federal agencies have issued In July 2019, CMS released detailed papers on the guidance to encourage states to submit State four waiver concepts plus waiver templates, along Innovation Waivers. For example, in March 2017, with an updated checklist for states.18 2017 PROPOSED FEDERAL LEGISLATION IMPACTING STATE INNOVATION WAIVERS • The Bipartisan Health Care Stabilization Act: This ACA stabilization legislation included several proposed changes to expedite the approval process for State Innovation Waivers. States would no longer need to enact legislation before submitting a waiver application, and the waiver period could be extended to six years. The language around affordability would have been relaxed, though the bill still specified that waivers must maintain affordability for people who are low-income or have serious health needs, as well as other vulnerable populations (such as older adults). The bill would also have allowed other federal program costs to be included when calculating a waiver’s impact on the federal deficit. • The Lower Premiums through Reinsurance Act: This ACA stabilization legislation would have added funding for reinsurance programs that were created through State Innovation Waivers and provided an expedited approval process for such waivers. • The Better Care Reconciliation Act: This ACA “repeal and replace” legislation, as introduced in the Senate, would have made major changes affecting State Innovation Waivers. It would have eliminated the section 1332 guardrails that require coverage to be as comprehensive and affordable and cover as many people as would have been covered without a waiver. The bill also proposed eliminating the HHS and Treasury secretaries’ discretion to reject waivers for any reason other than that they increase the federal deficit. It would also have expedited the approval process for waivers and extended the waiver period, while forbidding secretaries to revoke a waiver once it was granted for any reason. Finally, the bill would have provided funds for states to establish reinsurance without a waiver. • American Health Care Act: This ACA “repeal and replace” legislation, as introduced in the House of Representatives, would have provided funds for states to establish reinsurance without a waiver and would have established a federal invisible risk sharing program with funding made available for the period 2018–26. It would also have granted states new authority to waive the federal definition of Essential Health Benefits and specify their own definitions. 12 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 State Innovation Waivers were also a topic of raising the potential that the guidance could be consideration in 2017 as Congress debated ACA overturned.19 “repeal and replace” legislation. The major bills New legislation: The State Innovation Waiver considered at the time included provisions that guardrails are embedded in statute, so they cannot would have affected these waivers (see textbox). be wholly eliminated or changed without a change Other legislation was introduced in 2017 with the in federal law. If Congress considers legislation goal of stabilizing the individual health insurance to change or eliminate guardrails, it is critical market, and some of the provisions in those bills that they ensure coverage, affordability, and would have made changes to the waiver approval comprehensiveness of benefits are maintained. process. While none of these bills were ultimately Policy makers could also propose other legislation enacted, it is helpful for states to know what was that would allow states to waive other federal proposed in case similar proposals resurface in the health insurance requirements, such as essential future. health benefits and the age rating ratio limit (which What Could Happen? prevents insurers from charging older adults more New guidance: While the State Innovation Waiver than three times what they charge younger adults guardrails (discussed primarily in step 1) are for the same coverage). Under current law, State enshrined in federal law, interpretations of how they Innovation Waivers cannot alter certain provisions operate in practice may continue to be modified by and must abide by federal guardrails, but no such federal agencies. As discussed, recent administration limitations would exist under such a law change. guidance made changes to federal waiver guidance While there is potential to make improvements that weakened previous guardrail protections. to waiver authority, the types of changes to State However, the U.S. Government Accountability Innovation Waivers listed above could permit Office (GAO) stated in July 2019 that the guidance waivers to be used to decrease affordability constitutes a rule that must be reviewed by and comprehensiveness of health coverage for Congress under the Congressional Review Act, consumers, including older adults. 13 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 Summary States play a central role in providing access to All states, whether or not they plan to pursue affordable, comprehensive health coverage for waivers in the future, should have a sound people who purchase coverage on their own in the understanding of State Innovation Waivers and the individual health insurance market, including older implications of recent federal and state changes to Americans ages 50 to 64. They have a responsibility these waivers for consumers, including older adults. to ensure protection of their residents, including States considering waivers in the future can look older adults and other vulnerable groups. Through to other states that have successfully implemented State Innovation Waivers, states have the power to waivers for promising practices to improve access to make big changes to their health insurance markets. and affordability of coverage for older adults. In the These waivers can help improve state health coming months and years, states should keep an eye insurance markets and lower premiums, but they on state and federal activity around these waivers, can also cause harm if used the wrong way. as it is likely to continue evolving. 14 A ARP PUBLIC POLICY INSTITUTE SEPTEMBER 2019 1 42 U.S.C. § 18052. 2 “Waivers for State Innovation,” Federal Register 80 (2015): 78131. https://www.federalregister.gov/documents/2015/12/ 16/2015-31563/waivers-for-state-innovation. 3 “State Relief and Empowerment Waivers,” Federal Register 83 (2018): 53575. https://www.federalregister.gov/documents/ 2018/10/24/2018-23182/state-relief-and-empowerment-waivers 4 “Section 1332 State Relief and Empowerment Waiver Concepts,” Discussion Paper, Centers for Medicare & Medicaid Services, Washington D.C., November 2018, https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/ Downloads/Waiver-Concepts-Guidance.PDF 5 “Concept Papers and Application Templates,” Centers for Medicare & Medicaid Services, Washington D.C., July 2019, https://www.cms.gov/cciio/programs-and-initiatives/state-innovation-waivers/section_1332_state_innovation_waivers-.html 6 For short descriptions of approved state waivers, see: “Tracking Section 1332 State Innovation Waivers,” Kaiser Family Foundation, Washington D.C., July 2019, https://www.kff.org/health-reform/fact-sheet/tracking-section-1332-state- innovation-waivers/. 7 This Hawaii waiver relieved the state from implementing the ACA’s Small Business Health Options Program (known as SHOP) and related requirements, as Hawaii already had a law requiring employer coverage and small employer premium assistance known as the Prepaid Health Care Act. 8 Eligible individuals would not be eligible for premium tax credits or cost sharing reductions. 9 Rachel Schwab, Emily Curran, and Sabrina Corlette, “Assessing the Effectiveness of State-Based Reinsurance: Case Studies of Three States’ Efforts to Bolster Their Individual Markets,” Georgetown University Health Policy Institute, Washington D.C., November 2018, http://chirblog.org/new-georgetown-report-assessing-effectiveness-state-based-reinsurance/. 10 “Leveraging 1332 State Innovation Waivers to Stabilize Individual Health Insurance Markets: Experiences of Alaska, Minnesota, and Oregon,” State Health Access Data Assistance Center (SHADAC), Minneapolis, MN, February 5, 2019, https://www.shadac.org/ news/leveraging-1332-state-innovation-waivers-stabilize-individual-health-insurance-markets 11 “State-Run Reinsurance Programs Reduce ACA Premiums by 19.9% on Average,” Avalere, Washington D.C., March 13, 2019, https://avalere.com/press-releases/state-run-reinsurance-programs-reduce-aca-premiums-by-19-9-on-average 12 “Leveraging 1322 State Innovation Waivers,” SHADAC. 13 “Section 1332 State Relief and Empowerment Waiver Concepts,” Centers for Medicare & Medicaid Services. 14 Jane Sung, Lina Walker, and Olivia Dean, “Adequate Premium Tax Credits are Vital to Maintain Access to Affordable Health Coverage for Older Adults,” AARP Public Policy Institute, Washington D.C., March 22, 2017, https://www.aarp.org/ppi/info- 2017/adequate-premium-tax-credits-are-vital-to-maintain-access-to-affordable-health-coverage-for-older-adults.html 15 45 C.F.R. §155.1312 16 “Steps for States Considering a 1332 Waiver,” Centers for Medicare and Medicaid Services, Washington D.C., May 2019, https://www.cms.gov/CCIIO/ Programs-and-Initiatives/State-Innovation-Waivers/Downloads/Steps-for-States- Insight on the Issues 145, September 2019 Considering-A-1332-Waiver.pdf 17 “Offering States Flexibility to Increase Market Stability and Affordable Choice,” © AARP PUBLIC POLICY INSTITUTE US Department of Health and Human Services, Washington D.C., March 2017, 601 E Street, NW Washington DC 20049 https://www.hhs.gov/about/news/2017/03/13/offering-states-flexibility- increase-market-stability-and-affordable-choices.html Follow us on Twitter @AARPpolicy on facebook.com/AARPpolicy 18 “Checklist for Section 1332 State Relief and Empowerment Waivers (also called www.aarp.org/ppi section 1332 waivers or State Innovation Waivers) Applications,” Centers for Medicare & Medicaid Services (CMS), Washington D.C., July 2019, For more reports from the Public Policy https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation- Institute, visit http://www.aarp.org/ppi/. Waivers/Downloads/Checklist-for-Section-1332-State-Relief-and_Empowerment- https://doi.org/10.26419/ppi.00081.003 Waivers.pdf 19 “Department of Health and Human Services and Department of the Treasury— Applicability of the Congressional Review Act to State Relief and Empowerment Waivers,” U.S. Government Accountability Office, Washington D.C., July 2019, https://www.gao.gov/products/B-330811 15