ohio: individual state report · work in the executive branch of state government focused on policy...

OHIOINDIVIDUALSTATE REPORT

State-Level Field Network Studyof the Implementation of theAffordable Care Act

September 2015

Rockefeller Institute of Government

State University of New York

The Brookings Institution

Fels Institute of Government

University of Pennsylvania

The Public PolicyResearch Arm of theState Universityof New York

411 State StreetAlbany NY 12203-1003(518) 443-5522

wwwrockinstorg

ACA IMPLEMENTATION RESEARCH NETWORK

Field Research Associates

Amy Rohling McGee President Health Policy Institute of Ohio

arohlingmcgeehpionet 614-545-0750

Amy Rohling McGee has served as the president of the Health Policy Institute of Ohioa nonpartisan independent nonprofit organization that provides information andanalysis to state policymakers since 2010 Her prior public sector experience includeswork in the executive branch of state government focused on policy related to issuessuch as health insurance health system improvement health information technologyand Medicaid and service in the state legislature as a Legislative Service Commissionintern in the mid-1990s Private sector experience includes five years as the executivedirector of the Ohio Association of Free Clinics representing health clinics that servedthe uninsured primarily through volunteers and several years in a management posi-tion at FIRSTLINK (now HandsOn Central Ohio) McGee earned her bachelorrsquos andmasterrsquos degrees from The Ohio State University She has received the BusinessFirst ldquoForty Under Fortyrdquo award and The Ohio State University Alumni AssociationWilliam Oxley Thompson award

Reem Aly Director of Healthcare Payment and Innovation Policy Health PolicyInstitute of Ohio

ralyhpionet 614-545-0759

Reem Aly is the director of Healthcare Payment and Innovation Policy at the HealthPolicy Institute of Ohio (HPIO) Prior to joining HPIO in June 2011 Aly worked as aconsultant and administrative resident at Nationwide Childrenrsquos Hospital Aly alsoworked in the legal field at OCLC Online Computer Library Center Inc and Bricker ampEckler LLC Aly holds a law degree and master of health administration as well as abachelor of science in psychology and a bachelorrsquos of arts in international relationsfrom The Ohio State University Aly was named one of six inaugural recipients ofAcademyHealthrsquos 2013 Presidential Scholarship for the AcademyHealth Institute onAdvocacy and Public Policy

Stephanie Gilligan Director of Access and Coverage Policy Health Policy Instituteof Ohio

sgilliganhpionet 614-545-0762

Stephanie Gilligan is director of Access and Coverage Policy at the Health Policy Insti-tute of Ohio (HPIO) Before joining HPIO in January 2014 she spent seven years work-ing for the Ohio Legislative Service Commission (LSC) During her time at LSC sheworked on the fiscal staff in the health and human services subject area and later coor-dinated the LSC Fellowship Program She holds a bachelorrsquos degree in political scienceand a masterrsquos degree in public administration from The Ohio State University

Rockefeller Institute Page ii wwwrockinstorg

ACA Implementation Research Network Ohio Individual State Report

OHIO

INDIVIDUAL STATEREPORT

State-Level FieldNetwork Study of theImplementation of theAffordable Care Act

September 2015


Rockefeller Institute Page iii wwwrockinstorg

ContentsPart 1 ndash Setting the State Context 1

11 Decisions to Date 1

Health Insurance Marketplace 2010-14 1

Health Insurance Marketplace 2015 3

Medicaid Expansion in Ohio 2013-14 3

Medicaid Expansion in Ohio 2015 5

12 Goal Alignment 7

Part 2 ndash Implementation Tasks 9

21 Exchange Priorities 9

22 Leadership ndash Who Governs 10

Federal Leadership 10

State Leadership 10

24 Outreach and Consumer Education 11

Outreach and Consumer AssistanceOrganizations in Ohio 13

25 Navigational Assistance 15

27 QHP Availability and Program Articulation 17

Part 4 ndash Summary Analysis 17

42 Possible Management Changes andTheir Policy Consequences 17

Endnotes 19

Part 1 ndash Setting the State Context

11 Decisions to Date

Health Insurance Marketplace 2010-14

Governor John Kasich a Republican opted for a federallyrun health insurance marketplace for Ohio HoweverOhiorsquos deliberations regarding exchanges can be traced

back to Democratic Governor Ted Stricklandrsquos administration(2007-10)

In September 2010 just prior to the gubernatorial election theOhio Department of Insurance (ODI) received a $1 million federalexchange planning grant to assist in marketplace planning andimplementation Around that time ODI created a bipartisanHealth Benefits Exchange Task Force a subcommittee of the OhioHealth Care Coverage and Quality Council (HCCQC)1 The taskforce comprised of a number of healthcare-related stakeholderswas tasked with providing guidance to state government on keydecision points related to implementation of health insurancemarketplaces2

In December 2010 the task force provided consensus recom-mendations on establishing a state-based exchange toGovernor-Elect Kasich and his administration3 In March 2011ODI terminated the HCCQC including efforts underwaythrough the exchange task force stating that many HCCQCefforts would transition to the Office of Health Transformation

OHIOINDIVIDUALSTATE REPORTState-Level Field Network Studyof the Implementation of theAffordable Care Act

State University of NewYork411 State StreetAlbany New York 12203(518) 443-5522wwwrockinstorg

Carl HaydenChair Board of Overseers

Thomas GaisDirector

Robert BullockDeputy Director forOperations

Patricia StrachDeputy Director for Research

Michael CooperDirector of Publications

Michele CharbonneauStaff Assistant forPublications

Nancy L ZimpherChancellor

Rockefeller Institute wwwrockinstorg


(OHT) created by Governor Kasich through executive order inJanuary 2011

ODI used the federal exchange planning grant received in2010 to conduct analyses related to marketplace implementationODI contracted with Milliman a health actuarial consulting firmto conduct research and analysis of the Ohio health insurancemarket and its implications for health insurance marketplaces4

ODI also contracted with the auditing firm KPMG to perform aninformation technology ldquogap analysisrdquo related to the require-ments of a health insurance marketplace5 The analyses werereleased in August and September of 2011 respectively

Following the Milliman and KPMG analyses the state awaitedfurther information and guidelines from the federal governmentAs details regarding the parameters for exchanges began toemerge in early 2012 Ohiorsquos lieutenant governor and director ofODI Mary Taylor expressed concern that federal guidelines onhealth insurance marketplaces did not give states enough flexibil-ity In addition some policymakers doubted the ACA in itsentirety would survive A number of factors contributed to thisstance including the passage of an Ohio ballot initiative inNovember 2011 to opt out of the federal individual health insur-ance mandate the anticipated ruling from the US Supreme Courton the constitutionality of the ACA in June 2012 and the presi-dential election of 2012

On November 16 2012 in a letter to the director of the Centersfor Medicaid amp Medicare Services Center for Consumer Informa-tion and Insurance Oversight (CCIIO) Kasich announced thatOhio would not implement a state-based marketplace6 InsteadOhio opted for the federally run marketplace In his letter Kasichindicated that ODI would retain the right to regulate Ohiorsquoshealth insurance industry and that the state would retain its abil-ity to determine Medicaid and Childrenrsquos Health Insurance Pro-gram (CHIP) eligibility for Ohioans

Around the same time a group of Democratic lawmakers inOhio introduced legislation (HB 412) in December 2012 to estab-lish state-based marketplaces through the formation of the OhioHealth Benefit Exchange Agency7 The legislation was sponsoredby Democratic Representatives John Carney and Nickie Antonioand cosponsored by fourteen other Democrats Carney and Anto-nio engaged a multistakeholder group including brokers andagents providers payers and consumer advocacy groups inwriting their bill Democratic Sen Mike Skindell introduced acompanion bill in the Senate The bills made little movement inthe Republican-controlled Ohio House and Senate

On February 14 2013 Taylor added more specificity regard-ing Ohiorsquos intention to use the federally run marketplace and per-form plan management activities In a separate letter to CCIIOTaylor indicated that Ohio would retain its legal authority andoperational capacity to oversee certification of qualified healthplans collect review and approve plan rate and benefit


Rockefeller Institute Page 2 wwwrockinstorg

information and oversee plan compliance consumer complaintsand issuer decertification Notably Ohio did not opt to performany consumer assistance functions related to the marketplace

The first open enrollment period for the federal exchange wasOctober 1 2013 through March 31 2014 By April 2014 154668Ohioans had enrolled in coverage through the federalmarketplace

In the context of state government the policy landscaperemained much the same during the second open enrollmentperiod which ran from November 15 2014 through February 152015 By March 2015 234341 people in Ohio selected a planthrough the federal marketplace Ohio enrollment trends are dis-cussed in more detail in Section 27

Health Insurance Marketplace 2015

In early March 2015 the US Supreme Court heard oral argu-ments in King v Burwell a case assessing the legality of federalpremium subsidies in federally facilitated marketplace (FFM)states Also in 2015 Representatives Michael Stinziano and NickieAntonio both Democrats introduced legislation to establish anOhio Health Care Exchange HB 1098 Similar to HB 412 of the129th General Assembly the language would establish a statehealth care exchange replacing Ohiorsquos use of HealthCaregov

Kasich initially avoided answering questions about King v

Burwell or possible alternative scenarios to Ohiorsquos current arrange-ment However after attending an event in South Carolina in Feb-ruary 2015 Kasich responded to a reporterrsquos question about theSupreme Court case saying ldquoI donrsquot like to get ahead of ourselveson what the Supreme Court might do But if it threw a half a mil-lion people without insurance wersquod have to look at itrdquo9 A fewweeks later he commented that his health care and Medicaid cab-inet directors were working on a plan that could eventuallyreplace Obamacare10 In June 2015 the Supreme Court ruled infavor of Burwell upholding the availability of tax credits to indi-viduals in FFM states

Soon after the Supreme Court decision Ohio passed the bien-nial state budget for state fiscal years (SFYs) 2016-17 In additionto changes affecting the statersquos Medicaid program the budget billlanguage requires the superintendent of ODI to apply for a Sec-tion 1332 waiver The application is required to ldquoprovide for theestablishment of a system that provides access to affordablehealth insurance coveragerdquo and include a request for waivers ofthe ACArsquos federal employer and individual mandates11 Furtherinformation regarding decisions and changes to the statersquosMedicaid program over the past two years are discussed in moredetail in the following Medicaid expansion sections

Medicaid Expansion in Ohio 2013-14

As of October 22 2013 Ohio decided to move forward withthe decision to expand Medicaid eligibility to 138 percent FPL



The issue of Medicaid expansion in Ohio has been controversialand riddled with significant policy considerations including theimpact of an expansion on Ohiorsquos budget and economy impact oncoverage access and quality of care and the impact on Ohiorsquosprivate insurance market and providers Some of the discussionregarding whether or not to expand Medicaid in Ohio has beenrooted in partisan ideology making the decision to expandcontentious

In early 2013 Medicaid expansion gained the support ofKasich but many in the Republican-controlled General Assemblyexpressed opposition During Ohiorsquos 2014-15 biennial budget pro-cess Kasich included language to expand Medicaid to low-incomeOhioans in his initial budget proposal to the General AssemblyKasichrsquos decision was bolstered by his administrationrsquos efforts tomodernize and improve the statersquos Medicaid system The Gover-norrsquos Office of Health Transformation Director Greg Moody andthe statersquos Medicaid Director John McCarthy provided testimonyhighlighting efforts to reform Ohiorsquos Medicaid program How-ever many Republican members of the General Assembly citedconcerns about Ohio Medicaidrsquos current structure and cost per-ceived uncertainty in continued federal funding for expansionand the potential for Medicaid to be abused as a welfare program

In April 9 2013 the House Finance Committee revealed a sub-stitute biennial budget bill eliminating Medicaid expansion provi-sions from the governorrsquos proposed budget legislation Medicaidexpansion language was never restored to the Senate amendedversion of the budget bill In fact the House included languageexpressly prohibiting Ohio from expanding Medicaid to addi-tional low-income residents On June 30 2013 Kasich signed thefinal biennial budget bill but executed a line-item veto to removelanguage that would have prohibited Medicaid expansion

Notably there were three Medicaid reform proposals intro-duced during the biennial budget process Some were bipartisanefforts that called for Medicaid reforms but did not include lan-guage to expand Medicaid One of the proposals (HB 176)sponsored by Rep Barbara Sears a Republican called forMedicaid reforms as well as an expansion of Medicaid tolow-income Ohioans Although none of the bills were incorpo-rated into the statersquos biennial budget bill both the House andSenate created Medicaid Finance Subcommittees to review theproposed Medicaid legislation Throughout the summer andinto the fall of 2013 the Ohio legislature indicated interest incontinuing dialogue around Medicaid expansion and separatestandalone legislation to address Medicaid reforms

In September 2013 McCarthy submitted a State Plan Amend-ment (SPA) to the federal government requesting extension ofMedicaid coverage as provided for under the ACA The Centersfor Medicare amp Medicaid Services (CMS) approved Ohiorsquos SPA onOctober 10 2013 As a result of the approved SPA federal fundswere available to extend Medicaid coverage in Ohio beginning



January 1 201412 However under Ohio law the Ohio GeneralAssembly or the state Controlling Board13 which oversees appro-priations and adjustments to the state budget is required toauthorize the spending of federal funds prior to use14

Given that Ohiorsquos General Assembly had not appropriated forthe spending of federal funds in the statersquos biennial budget theOhio Medicaid director turned to the Ohio Controlling Board OnOctober 11 2013 the Medicaid director submitted a request to theControlling Board seeking authorization to spend federal fundsfor Medicaid expansion in Ohio The specific request increasedappropriation authority in the federal fund of the state budget by$562 million in SFY 2014 and $2 billion in SFY 2015

On October 21 2013 the Controlling Board voted 5-2 to autho-rize Ohio Medicaidrsquos spending of federal funds ControllingBoard President Randy Cole Reps Ross McGregor and Sen ChrisWidener both Republicans and Rep Chris Redfern and Sen TomSawyer both Democrats voted for the authorization to spend fed-eral funds towards Medicaid expansion Notably prior to the voteon the morning of October 21 2013 Ohio House Speaker BillBatchelder a Republican replaced Republican Rep CliffRosenberger who was on the Controlling Board with RepMcGregor Batchelder also replaced Republican Rep RonAmstutz with Republican Rep Jeff McClain who was known tobe opposed to expansion A complaint was filed on October 222013 with the Ohio Supreme Court by several legislators and twoRight to Life organizations challenging the legality of the Control-ling Board action The Ohio Supreme Court decided in favor ofthe state on December 20 201315 The approved appropriationremained in effect through June 30 2015 the end of Ohiorsquos budgetbiennium

As of December 2014 485462 Ohioans had enrolled in cover-age through the new Medicaid eligibility category16 Notably thisnumber far exceeded projections from the Governorrsquos Office ofHealth Transformation which predicted that 366000 Ohioanswould sign up for coverage by June 201517

Medicaid Expansion in Ohio 2015

In the months leading up to the introduction of the governorrsquosexecutive budget proposal for the 2016-17 biennium there wasspeculation about how the Medicaid expansion debate would pro-ceed legislatively Because the initial controlling board appropria-tion approval remained in effect only through the end of SFY 2015(June 30 2015) the issue would be before the General Assemblyagain Some predicted that the continuation of Medicaid extensionwould be dealt with in a bill separate from the main operatingbudget bill or that it would be addressed through the ControllingBoard again

In the days before the budget proposal was released newHouse Speaker Rosenberger a Republican indicated that hewould not actively seek to repeal extending Medicaid benefits He



was quoted in the Cleveland Plain Dealer saying ldquoThe truth of thematter is wersquore not talking about expansion anymoremdashwersquore talk-ing about reauthorizationrdquo18 Rosenbergerrsquos stance was notableboth as the newly named speaker (replacing the long-servingBatchelder) and in light of the fact that he was one of the Control-ling Board members who had been substituted in October 2013 toauthorize expenditure of Medicaid funds In Ohio budget billsare introduced in the House of Representatives and House com-mittee hearings are conducted by the Finance and Appropriationscommittee and its standing subcommittees first

Kasich introduced his budget proposal ldquoBlueprint for a NewOhiordquo on February 2 2015 As introduced the budget bill did notaddress Medicaid eligibility levels but included an appropriationsufficient to cover the expansion population Ohiorsquos existing SPAauthority does not expire so unless the Medicaid director submitsanother SPA to change Ohiorsquos policy the current Medicaid eligi-bility levels remain in effect

In addition to appropriation authority the executive budgetproposal would have made several other changes affecting theexpansion population and eligibility

Require premium payments for adults over 100 percent of thefederal poverty level (FPL) Ohio Medicaid currently requirescost sharing in the form of co-pays for some beneficiariesbut no premiums The executive budget proposed thatchildless nonpregnant adults with incomes between100-138 percent FPL pay a monthly premium expected tobe around $20 for most enrollees

Coverage for optional eligibility groups Ohio Medicaid cur-rently covers pregnant women Breast and Cervical CancerProject enrollees and the family planning group (whichcovers limited family planning services for enrollees) up to200 percent of the FPL The executive budget eliminatedMedicaid coverage for these groups above 138 percent ofthe FPL and directed them to the federal marketplace forsubsidized health insurance coverage

The final budget bill passed the Ohio legislature on June 25and was signed by the governor on June 30 2015 taking effect onJuly 1 2015 The bill includes several changes affecting the expan-sion population and eligibility

Healthy Ohio Program Instead of implementing premiumsfor adults over 100 percent of the FPL as proposed in theexecutive budget the final version of the bill added lan-guage requiring the Ohio Department of Medicaid to seeka federal waiver to create a modified health savings ac-count (HSA) program called the ldquoHealthy Ohio ProgramrdquoThis program would be mandatory for adults enrolled inthe covered families and children eligibility group (gener-ally parents pregnant women and Group 8 adults) in-cluding those below 100 percent of the FPL Participants



would be required to make a monthly contribution up to a$99 annual limit into an HSA administered by their healthplan Participants excluding pregnant women who fail topay will have their coverage terminated until payments re-sume Also included are voluntary referrals to workforceservices and yearly and lifetime limits on benefit payouts

Health and Human Services Fund The budget bill creates theHealth and Human Services Fund in the state treasury andprovides that the fund is to be used to pay any costs asso-ciated with ldquoprograms or services provided by the state toenhance the public health and overall health care qualityof Ohiorsquos citizensrdquo The director of the Office of Budgetand Management (OBM) is directed to transfer $200 mil-lion to the fund The legislative intent is that this fund willhold the state share of Medicaid expansion funding forSFY 2017 The Controlling Board will likely need to autho-rize the spending of these funds before they can be used

Coverage for optional eligibility groups The legislature re-stored coverage for pregnant women and the Breast andCervical Cancer Project up to 200 percent of the FPL Cov-erage was not restored for the limited family planningbenefits group

12 Goal Alignment

The federal policy goals of the ACA have encountered mixedsupport from Ohiorsquos state policymakers

Governor Kasich has been an outspoken supporter of provid-ing Medicaid coverage to more Ohioans in need He often uses hisreligious convictions to defend his position After a conference in2014 for example he responded to a question about his rationaleby saying ldquoI donrsquot know about you lady but when I get to thepearly gates Irsquom going to have an answer for what Irsquove done forthe poorrdquo19

Similarly a profile in a local newspaper the Columbus Dis-patch described the foundation of his support of Medicaidexpansion

While Kasich contends that the expansion is savingmoney by decreasing emergency-room visits he also jus-tifies it by scriptural references One is Jesusrsquo admonitionin Matthew 25 to care for ldquothe least of theserdquo followed bya warning that those who donrsquot will be sent to ldquoeternalfire prepared for the devil and his angelsrdquo20

However Kasich remains opposed to the ACA as a whole Infact the governor sparred with the Associated Press (AP) in Octo-ber 2014 after the AP reported that he said he did not believe law-makers in Washington should repeal the health care law ifRepublicans won control of the Senate in the upcoming midtermelections The story made national news and Kasich called the APafterwards to clarify that he was talking specifically about the



repeal of the expansion of Medicaid and not the Affordable CareAct more broadly saying ldquoFrom Day One and up until today andinto tomorrow I do not support Obamacarehellip I never have and Ibelieve it should be repealedrdquo He went on to say ldquoI have favoredexpanding Medicaid but I donrsquot really see expanding Medicaid asreally connected to Obamacarerdquo21

Kasich has received praise from many Ohio stakeholders forhis efforts to expand Medicaid Supporters include the OhioChamber of Commerce Ohio Hospital Association Ohio Associa-tion of Health Plans Ohio Council of Behavioral Health and Fam-ily Service Providers and the Ohio State Medical AssociationHowever some conservative legislators and other stakeholderssuch as leadership in the Ohio House and the conservative thinktank The Buckeye Institute remain vocally opposed to expansionand other steps to implement the ACA in Ohio As described ear-lier the lieutenant governor who is also the director of the OhioDepartment of Insurance was also a vocal opponent In June 2011before the statersquos decision to expand Medicaid she stated

Leave it to Washington DC to think they know besthow to insure Ohioans The federal healthcare law forcesmany new mandates onto states that are overly burden-some including a huge and costly Medicaid expansionthe creation of a new health insurance regulatory bureau-cracy and one-size-fits-all market reforms that limitstatesrsquo discretion to regulate health insurance It is con-cerning that even the less controversial parts of the newlaw come at a great cost and burden to Ohioans and ourjob creators22

Ohio has taken other steps to implement components of theACA For example the ACA required Medicaid programs to pro-vide online real-time web-based eligibility applications verifica-tions and determinations With funding from the federalgovernment Ohio designed and built an integrated eligibility sys-tem for all of the statersquos health and human services programs Akey component of the system is the Ohio Benefits website(benefitsohiogov) which went live in October 2013 allowing Ohioresidents to check eligibility and apply for benefits through anonline self-service portal

Ohio is also participating in the State Innovation Models (SIM)initiative which provides financial and technical support to statesto design or test innovative multipayer health care payment andservice delivery models with the goal of improving health systemperformance increasing quality of care and decreasing costs TheSIM initiative is a project of the ACA-established Center forMedicare amp Medicaid Innovation within CMS Ohio received a $3million SIM Design Award in February 2013 and a $75 millionSIM Model Test Award in December 201423



Part 2 mdash Implementation Tasks

21 Exchange Priorities

Since Ohio is participating in the federally facilitated market-place the federal government conducts many implementationtasks However Ohio received approval from the US Depart-ment of Health and Human Services to conduct plan managementactivities to support certification of qualified health plans in theFFM However the Ohio Department of Insurance continues toperform insurance regulatory functions while using theHealthCaregov platform for consumers By retaining its regula-tory authority over the business of insurance ODI oversees thecertification of qualified health plans Additionally ODI continuesto collect and analyze information on plan rates covered benefitscost-sharing requirements plan compliance consumer com-plaints technical assistance and other related duties Howeverthe federal government has final authority to approve qualifiedhealth plans (QHPs)

In early 2015 network transparency emerged as a key issuefor ODI In February the department released a proposed draftrule for stakeholder input The department cited an increase incomplaints related to consumersrsquo ability to identify which provid-ers were in insurersrsquo networks In testifying before the JointMedicaid Oversight Committee (JMOC) a representative fromODI stated ldquoWith more health insurance coverage requirementsas a result of the Affordable Care Act the Department has seenhealth insurers narrow their networks as a means to control costsand keep the price of health insurance downrdquo She also noted thatthe consumer services division saw a 30 percent increase in healthrelated complaints in 2014 as compared to the previous year24

Among the rulersquos provisions is a requirement that insurance com-panies maintain a provider directory made available on theirwebsite including contact information and indicating whether theprovider is accepting new patients25 The target implementationdate for the rule is January 1 2016

Ohio has also prioritized modernizing its Medicaid eligibilitysystem Previously eligibility determinations for health andhuman service programs in Ohio were conducted using differentpolicies and processes Kasichrsquos first budget enacted in 2011 initi-ated a project to replace Ohiorsquos Enhanced Client Registry Informa-tion System (CRIS-E) with an integrated eligibility system calledOhio Benefits The project has focused on Medicaid eligibility butwill eventually support all income-tested health and human ser-vice programs such as the Supplemental Nutrition AssistanceProgram (SNAP) and Temporary Assistance for Needy Families(TANF) The administration anticipates transitioning additionalprograms to Ohio Benefits during SFYs 2016-17

Ohio Benefits went live on October 1 2013 and allowed Ohio-ans to electronically check their eligibility and apply for Medicaidcoverage Among the technical problems with HealthCaregov



was the inability to automatically transfer Medicaid applicationsto states Instead batch files were sent from the federal govern-ment beginning in February 2014 The backlog of eligibility deter-mination processing continued in some counties through summer2014 By fall 2014 this process had been improved with file trans-fers from the FFM to the Ohio Department of Medicaid twice aweek

Most activities related to outreach education and enrollmentassistance have been performed by federally funded navigatororganizations community health centers and other entities out-side of state government as described in the ldquoNavigationalAssistancerdquo section

22 Leadership ndash Who Governs

Federal Leadership

Federal leadership comes from a number of entities mostwithin the Center for Medicare amp Medicaid Servicesrsquo Center forConsumer Information and Insurance Oversight (CCIIO) Centerfor Medicaid and Medicare Innovation (CMMI) and Center forMedicaid and CHIP Services (CMCS) The Ohio Department ofInsurance primarily interacts with CCIIO

The US Department of Health and Human Services (HHS)has ten regional offices that directly serve state and local organiza-tions Ohio is included in Region V and the regional office islocated in Chicago IL Kathleen Falk was appointed regionaldirector in September 2013 Falk traveled to Ohio during the firstand second open enrollment periods to speak at communityforums and meet with key consumer outreach and enrollmentassistance groups

State Leadership

Governor John Kasich was elected to a second term in Novem-ber 2014 As described above Kasich has been a proponent ofMedicaid expansion yet an opponent of the Affordable Care Act

Kasichrsquos running mate Lieutenant Governor Mary Tayloralso serves as director of the Department of Insurance and leadsOhiorsquos Common Sense Initiative an effort to reform Ohiorsquos regu-latory framework to facilitate economic growth Her professionalbackground includes working as a certified public accountant andserving as a state legislator

Key state agencies involved in the implementation of the ACAinclude the Ohio Department of Insurance the Ohio Departmentof Medicaid and the Governorrsquos Office of Health Transformation

Ohio Department of Insurance The Ohio Department of In-surance (ODI) is the state agency responsible for providingconsumer protection services and regulating the insurancemarket The agency regulates the activities of more than1600 insurance companies including those offering healthand managed care policies The department also monitors



the conduct of more than 196000 insurance agents includ-ing those offering products on the health insuranceexchange

Ohio Department of Medicaid The Ohio Department ofMedicaid (ODM) administers the statersquos Medicaid pro-gram with the assistance of other state agencies countydepartments of job and family services county boards ofdevelopmental disabilities community behavioral healthboards and area agencies on aging ODM became astandalone agency in July 2013 and is led by JohnMcCarthy

Governorrsquos Office of Health Transformation In January 2011shortly after he took office Kasich created the GovernorrsquosOffice of Health Transformation (OHT) with the objectivesto modernize Medicaid streamline health and human ser-vices and pay for value OHT is led by Greg Moody

24 Outreach and Consumer Education

Successful enrollment into coverage depends on the ability toraise awareness about new coverage opportunities and to guideconsumers through the application and enrollment processOhiorsquos outreach and consumer education efforts are influenced bythe statersquos geographic size mix of Appalachian counties and size-able metropolitan areas and diverse population These demo-graphic characteristics have proven challenging for assistanceorganizations since they necessitate wide distribution ofresources attention to multiple media markets and a focus onboth urban and rural audiences Many consumers are not awareof coverage options and available financial assistance

Ohio has not invested or engaged in outreach and consumereducation related to marketplace plans In fact Ohio returned a fed-eral Consumer Assistance Program grant after the 2010 gubernato-rial election Unlike some state departments of insurance withinfederally facilitated marketplaces the Ohio Department of Insur-ance does not provide consumer education on insurance optionsthrough the marketplace although it provides consumer educationon a variety of insurance issues including Medicare through itsOhio Senior Health Insurance Information Program (OSHIIP)

Other entities involved in outreach and consumer educationinclude health insurance issuers who offer qualified health plansthrough the marketplace Medicaid managed care plans agentsand brokers provider organizations and associations and com-munity-based organizations that do not provide consumer assis-tance Many of these organizations rely upon materials developedby HHS and CMS by their state or national association (if a mem-bership organization) or by Enroll America

Enroll America is a national nonprofit nonpartisan 501(c)(3)organization focused on maximizing the number of Americanswho are enrolled in and retain health coverage Because of thestatersquos large number of uninsured Enroll America has invested



significantly in Ohio including hiring a staff of fifteen who workthroughout the state The staff does not provide direct consumerenrollment assistance but instead identifies eligible uninsuredOhioans and helps connect them to sources of consumerassistance

During the first open enrollment period HHS invested inmedia buys in major Ohio markets including print radio andTV As part of its responsibility as a navigator grantee the OhioAssociation of Foodbanks led a robust media campaign in January2014 The campaign included TV commercials phone banksaudio bus advertisements and radio advertisements primarilyfocused on major metro areas

Ohio Network for Health Coverage and Enrollment BecauseOhio declined to operate a state-based health insurance market-place there is no state-led initiative to coordinate outreach enroll-ment and consumer assistance To fill this void the Ohio Net-work for Health Coverage and Enrollment or ONCE was formedin the summer of 2013

Sponsored and funded by the Philanthropy Ohio HealthInitiative (POHI) and managed through a subcontract with theHealth Policy Institute of Ohio (HPIO) ONCE was designed toensure that outreach education and enrollment efforts in Ohiowere coordinated and effective so that uninsured Ohioans under-stand and enroll in health care coverage ONCE was open to allOhio organizations with similar goals and its network includedover 360 individuals representing more than 250 organizationsThe ONCE network included navigators CACs communityorganizations providers (notably hospitals and community healthcenters) agents and brokers small business representativescommunity organizations and county departments of job andfamily services (the agencies that are responsible for Medicaid eli-gibility determination in Ohio)

ONCE met regularly to share information provide policyupdates identify best practices and network Several state agen-cies including the Governorrsquos Office of Health Transformationthe Ohio Department of Administrative Services and the OhioDepartment of Health were active partners and provided regularupdates to the group The ONCE network played an integral rolein the development of the Are You Covered communications cam-paign and helped disseminate information about the Get CoveredConnector

Two new initiatives were undertaken in Ohio for the secondopen enrollment period The first a communications campaignworked to develop a cohesive brand and marketing plan to sup-port awareness of and enrollment in health care coverage throughthe marketplace and expanded Medicaid It emphasizedhard-to-reach and underrepresented populations and engagedtrusted messengers in the community The campaign includedcollateral materials the website wwwareyoucoveredohioorg andother resources



Secondly the Ohio Association of Foodbanks Ohiorsquos leadnavigator organization (see below under ldquoNavigational Assis-tancerdquo) worked with Enroll America to implement the ldquoGetCovered Connectorrdquo across the state The Connector is a central-ized scheduler and online enrollment assister tool It allows assist-ers to post and manage appointments and consumers to searchand sign up for those appointments The connector is linked withthe Are You Covered website and other local organizations As ofJanuary 2015 more than 1900 appointments had been posted andmore than 230 assisters were using the tool POHI funding con-cluded in April 2015 Moving forward the Ohio Association ofFoodbanks Ohiorsquos lead navigator organization plans to continueconvening interested stakeholders HPIO will continue to engagein policy work related to coverage and enrollment

Outreach and Consumer Assistance

Organizations in Ohio

Certified Application Counselors (CACs) Federal codedefines the duties of CACs as ldquo(1) Provide information to indi-viduals and employees about the full range of QHP optionsand insurance affordability programs for which they are eligi-ble (2) Assist individuals and employees in applying for cover-age in a QHP through the Exchange and insurance affordabilityprogramsrdquo Unlike navigators CACs do not receive fundingfrom the marketplace In order to become a designated CACorganization an entity is required to submit an application tothe Centers for Medicare amp Medicaid Services After an organi-zation has been designated a ldquoCAC organizationrdquo individualsaffiliated with the organization can become certified applica-tion counselors by completing an online five-hour trainingcourse that covers the basics of health insurance the newhealth insurance marketplaces how to assist consumers andprivacy and security standards26 During the initial open enroll-ment period there were an estimated 450 CACs in Ohio How-ever experience suggests that only a small number wereactively working to provide assistance during that time

Community Health Centers as Certified Application Coun-selors Through the Health Center Outreach and EnrollmentAssistance Supplemental Funding Opportunity the HealthResources Services Administration (HRSA) has provided supple-mental funding awards to community health centers This fund-ing supports efforts to raise awareness of insurance options andprovide eligibility and enrollment assistance to eligible patientsand residents in their service areas27

As a result of this funding community health centers thatreceived the awards have applied to become CACs making com-munity health centers the only federally funded Certified Applica-tion Counselors In Ohio $59 million was awarded to communityhealth centers across the state ($39 million in FY2013 and $2 mil-lion in FY2014) This funding is expected to support thirty-six



health centers in Ohio including hiring seventy-five additionalworkers who will assist over 84000 people with enrollment intoaffordable health insurance coverage28 Throughout the state 189Certified Application Counselors provide services at 130 healthcommunity health center sites

Agents and Brokers Agents and brokers are also active inOhio enrolling individuals and small employers Recentlyenacted Ohio law requires insurance agents to complete trainingand obtain a license before being permitted to sell solicit or nego-tiate insurance through a health insurance marketplace As ofMay 2014 nearly 580 Ohio agents and brokers were certified tosell QHPs on the marketplace29

Other Consumer Assistance Recognizing the large number ofuninsured in Ohio CMS contracted with two information technol-ogy companies Cognosante and SRA to provide in-person con-sumer assistance in Cuyahoga Franklin and Hamilton countiesCognosante had twenty-six in-person assisters and SRA hasthirty-one in-person assisters By contract neither companyrsquosassisters can provide assistance with Medicaid enrollment whichcan create challenges for consumers

In addition to these categories of assisters regional assistancecoalitions have formed across the state to help coordinate enroll-ment efforts Six geographic areas are represented by such a coali-tion Center for Healthy Communities (Greater Dayton andMontgomery County) Healthcare Collaborative of GreaterColumbus (Franklin County and Greater Columbus) Get CoveredNW Ohio Coalition (Lucas Wood Sandusky and Erie counties)Northeast Ohio Outreach and Enrollment Council (northeastOhio) Southwest Ohio Marketplace Assister Workgroup (BrownButler Clermont Clinton Hamilton Highland and Warren coun-ties) and Summit County Public Health (Summit County)

Additional Needs Ohio consumer assistance organizationshave identified common themes from the initial open enrollmentperiod that can help inform future outreach education andenrollment efforts Consumer assistance organizations high-lighted the need for additional resources and training for assistersPost-enrollment surveys show that consumers who enrolled inmarketplace coverage knew more about coverage options thanthose who did not enroll Navigator and CAC organizationsacross the state also described the extensive time needed toanswer consumersrsquo questions and the reality that it often takesmore than one session to complete an application

Relatedly there is a need for general health literacy and insur-ance education within the uninsured population in Ohio andthose seeking new coverage options Oftentimes this educationtakes place during the enrollment process contributing to thelength of the process Reaching Ohiorsquos diverse population pres-ents unique challenges to outreach and education efforts In par-ticular assisters stressed the need for reaching rural populationsthose with limited English proficiency and racial and ethnic



communities There is also a demand for bilingual assisters andfor educational materials in languages other than English andSpanish

25 Navigational Assistance

Navigational assistance which we define as consumer enroll-ment assistance is available in all states The Affordable Care Actand related rules define several types of consumer assistanceentities

Navigators Federal code defines the duties of navigators asldquo(1) Maintain expertise in eligibility enrollment and programspecifications and conduct public education activities to raiseawareness about the Exchange (2) Provide information and ser-vices in a fair accurate and impartial manner Such informationmust acknowledge other health programs (3) Facilitate selectionof a QHP (4) Provide referrals to any applicable office of healthinsurance consumer assistance or health insurance ombudsmanor any other appropriate State agency or agencies for any enrolleewith a grievance complaint or question regarding their healthplan coverage or a determination under such plan or coverageand (5) Provide information in a manner that is culturally and lin-guistically appropriate to the needs of the population beingserved by the Exchange including individuals with limited Eng-lish proficiency and ensure accessibility and usability of Naviga-tor tools and functions for individuals with disabilitiesrdquo30

As a federally facilitated marketplace state the federal govern-ment funds Ohiorsquos navigator program During the first openenrollment period FFM states received less federal funding forconsumer assistance efforts than states with state-partnership(SPM) or state-based (SBM) marketplacesmdash about $2 per unin-sured person compared with about $16 per uninsured person inSPMs and about $11 per uninsured person in SBMs31

Despite funding disparities navigators are an integral part ofthe consumer assistance framework in Ohio Five organizationsinitially were awarded federal navigator grants in August 2013Ohio Association of Foodbanks Cincinnati Childrenrsquos HospitalMedical Center Clermont Recovery Center Helping Hands Com-munity Outreach Center in Dayton and Neighborhood HealthAssociation in Toledo32

However around this time HB 3 of the 130th GeneralAssembly (Ohiorsquos ldquonavigator billrdquo) sponsored by Rep Sears andfellow Republican Rep Stephanie Kunze became law and estab-lished additional state regulations for navigator organizations33 Afew months later the Ohio Department of Insurance promulgatedrule 3901-5-13 to implement the law34

There was vigorous testimony and public input on both thelegislation and agency rule Lawmakers and Lieutenant GovernorTaylor the statersquos insurance director who supported the restric-tions established in the legislation cited the need to have individ-uals who discuss insurance coverage with consumers be subject to



consumer-protection regulations Community groups and advo-cacy organizations criticized the law for unnecessarily shrinkingthe pool of people able to provide enrollment assistance

Ultimately as a result of HB 3 and the accompanying rulestwo organizations were forced to decline navigatorgrantsmdashCincinnati Childrenrsquos Hospital Medical Center andClermont Recovery Center In particular a specific provision inthe state law prohibits any ldquoentity that is receiving financial com-pensation including monetary and in-kind compensation gifts orgrants on or after October 1 2013 from an insurer offering a qual-ified health benefit plan through an exchange operating in thisstaterdquo from acting as a navigator As medical providersCincinnati Childrenrsquos Hospital Medical Center and ClermontRecovery Center receive payment from health insurers and wereunable to participate in the navigator program35

In May 2014 CMS issued a final rule that addresses a varietyof issues related to exchanges including the relationship betweenfederal and state navigator laws36 The rule provides more detailabout which types of state laws HHS considers to be overlyrestrictive to federal navigator and consumer assistance laws Pre-cedent set by federal court decisions in other states and the CMSrule suggest that Ohiorsquos rule prohibiting entities that receivefinancial compensation from an insurer offering plans on theexchange from acting as a navigator could be invalidated

Ohiorsquos final navigator grants totaled almost $3 million distrib-uted among three organizations The Ohio Association ofFoodbanks was the largest recipient with an award of $2014750Helping Hands Community Outreach Center received $230920and Neighborhood Health Association received $75326037 Toachieve statewide reach the association operates as a navigatorconsortium joining with six regional partners throughout thestate The association itself provides navigation services in Ohiocounties that do not have a navigator presence The Ohio Associa-tion of Foodbanks also has received foundation funding to recruitand support the work of six Certified Application Counselor orga-nizations The initial federal navigator grant awards continuedthrough August 2014

The second round of federal navigator funding wasannounced on September 8 2014 HHS awarded $60 million ingrants to ninety organizations in states with federally facili-tated and state partnership marketplaces As with the firstround of funding these awards are intended to support enroll-ment and outreach activities during the second year of themarketplace

Three Ohio organizations were awarded navigator grants dur-ing the second round of funding The Ohio Association ofFoodbanks was again the largest recipient with an award of$2188846 Two new organizations also received awards MidwestAsian Health Association ($149397) and HRSErase Inc($275000)38



Funding for 2015 navigator grant recipients was announcedon September 2nd Two previous navigator organizationsreceived federal funding to operate in Ohio HRSErase Inc($274392) and the Ohio Association of Foodbanks ($2000000)

27 QHP Availability and Program Articulation

27(a) Qualified Health Plans (QHPs) Ohio is one of the fed-erally facilitated marketplace states with the greatest number ofQHP issuers In 2014 twelve issuers offered marketplace plans In2015 sixteen issuers are offering marketplace plans (one 2014issuer exited and five new issuers entered the marketplace)39

In 2014 Ohio had an average of thirty QHPs offered percounty and in 2015 there is an average of fifty-four QHPs offeredper county40

Ohio has seventeen geographic rating areas and each of theserating areas has several health plans offering several choices in thecatastrophic bronze silver and gold metal tiers A few areas alsooffer platinum plans41

During the first open enrollment period 154668 Ohioansselected a marketplace plan Of those who selected a plan 85 per-cent received financial assistance Most chose a silver plan (59 per-cent) followed by bronze (25 percent) and gold (12 percent)42

During the second open enrollment period 234000 Ohioansselected or were reenrolled in a marketplace plan Of those thatselected a plan 84 percent received financial assistance Mostchose a silver plan (67 percent) followed by bronze (22 percent)and then gold (7 percent)43

Ohiorsquos enrollment as of March 31 2015 is 18886744 whichrepresents only about 20 percent of the estimated potential marketsize for marketplace coverage45 Compared with all other statesand the District of Columbia Ohio ranks forty-seventh in per-centage of potential market enrolled

Ohio enrollment in the federally facilitated marketplace hasoccurred at a slower rate than Medicaid expansion enrollmentOhio expanded Medicaid in October 2013 with coverage begin-ning in January 2014 By December 2014 more than 500000 Ohio-ans had coverage through the new eligibility category Enrollmentquickly outpaced state administration estimates and assisters fre-quently reported helping more Medicaid-eligible consumers

Part 4 ndash Summary Analysis

42 Possible Management Changes and

Their Policy Consequences

Governor Kasich announced his 2016 presidential campaignon Tuesday July 21 2015 His decision related to Medicaid cover-age has already emerged as a key issue on the national stage In aspring 2015 profile of Kasich before his campaign announcementone national magazine described his decision to expand Medicaidand how it has been viewed by the national Republican party



ldquoConservativesrsquo primary complaint is that Kasich single-handedlyaccepted the Obamacare-Medicaid expansion for his state thusmaking him complicit in the most loathed policy of the loathedDemocratic presidentrdquo46 However others view his moderate pol-icy positions as an advantage among the broader electorate

It is unclear what effect his candidacy will have on state poli-tics or the policy landscape around ACA implementation in Ohio

Over the past year state agency leadership and some mem-bers of the legislature have taken an interest in exploring varioushealthcare reforms in Ohio that address rising healthcare costsand identifying ways to improve healthcare quality efficiencyand improve overall health outcomes for Ohioans For examplethe legislature included language around healthcare price trans-parency in the most recent state budget and formed a study com-mittee for the summer of 2015 with the purpose of examininghealthcare efficiencies that lead to better health outcomes at alower cost to Ohioans

As Governor Kasich continues his campaign for the USpresidency and enters the latter years of his second termadministration staff in Ohio indicate they will remain focused onfurthering the initiatives described in this report such asimplementing the State Innovation Model (SIM) test grant

The General Assembly will resume legislative sessions in fall2015 and will likely continue work on previous areas of interestsuch as monitoring spending growth in the Medicaid program inaddition to other health-related issues of concern such as infantmortality and opioid use

Management changes with policy implications also may belikely after House of Representatives elections in 2016 and thenext gubernatorial election in 2018 While Republicans have hadmajorities in both chambers for several years future elections willdetermine whether the political ideology of the members becomesmore conservative

Ohio like many other states has implemented a number ofhealth-related reforms in recent years Tracking the outcomesrelated to these reforms will be a critical component of developingpolicy options for the future





Endnotes1 The Health Care Coverage and Quality Council was established in Ohiorsquos biennial budget passed in July

2009 The Council was comprised of more than thirty public and private health care stakeholders taskedwith implementing strategies to improve the quality and control the cost of Ohiorsquos health care and coveragesystems

2 Ohio Health Care Coverage and Quality Council and Health Benefits Exchange Planning Task Force(HBETF) ldquoHBETF Chargerdquo nd accessed July 2015httpwwwhealthcarereformohiogovDocumentsHBETF20Charge20(2)pdf

3 Memorandum from Doug Anderson and Tracy Plouck Co-Chairs of Ohiorsquos Health Benefit ExchangePlanning Task Force to the Kasich Administration ldquoTransition of Health Exchange Planning to the NewAdministrationrdquo December 27 2010

4 Jeremy D Palmer Jill S Herbold and Paul R Houchens Assist with the first year of planning for design andimplementation of a federally mandated American Health Benefit Exchange Milliman Client Report prepared forthe Ohio Department of Insurance (Indianapolis Milliman Inc August 312011)httpwwwinsuranceohiogovConsumerDocumentsMilliman_Reportpdf

5 State of Ohio Health Insurance Exchange Planning Strategic Architecture Roadmap and Budget Report (ColumbusOH KPMG LLP September 14 2011httpwwwhealthtransformationohiogovLinkClickaspxfileticket=8SDAQ4Y-enE3damptabid=150 Seealso State of Ohio Health Insurance Exchange Planning Strategic Architecture Blueprints Report (ColumbusKPMG LLP September 13 2011)httpwwwhealthtransformationohiogovLinkClickaspxfileticket=O46c4hg0AQM3damptabid=150

6 Memorandum from Governor John Kasich to Director Gary Cohen Centers for Medicare amp MedicaidServices Center for Consumer Information and Insurance Oversight November 16 2012httpwwwhealthtransformationohiogovLinkClickaspxfileticket=d0RkDcUwCeo3damptabid=150

7 Ohio House Bill 412 129th General Assembly See also Ohio Senate Bill 277 129th General Assembly

8 Ohio House Bill 109 131st General Assembly

9 Chrissie Thompson ldquoKasich in SC Whatrsquos wrong with Common Coreldquo Cincinnaticom June 4 2015httpwwwcincinnaticomstorynews20150218john-kasich-ohio-governor-south-carolina-gop-201623627115

10 Darrel Rowland ldquoGov Kasich adds New York Detroit South Carolina to travel plansrdquo Columbus DispatchMarch 7 2015httpwwwdispatchcomcontentstorieslocal20150307govmdashkasich-adds-new-york-detroit-south-carolina-to-travel-planshtml

11 Ohio House Bill 64 131st General Assembly Ohio Revised Code (ORC) Section 3901052

12 Ohio Office of Health Transformation ldquoMedicaid Controlling Board Requestrdquo nd accessed July 2015httpwwwhealthtransformationohiogovLinkClickaspxfileticket=3L86BOjkGgE3damptabid=160

13 The Ohio Controlling Board is comprised of seven voting members Members include an individualappointed by the Ohio Office of Budget and Management (OBM) three representatives from the OhioHouse appointed by the House Speaker and three representatives from the Ohio Senate appointed by theSenate President Appointments must represent two members from the majority and one member from theminority of each of the legislative chambers

14 ORC 13135 Spending federal and certain nonfederal funds

15 State ex rel Cleveland Right to Life v State of Ohio Controlling Bd 138 Ohio St3d 57 2013-Ohio-5632

16 Ohio Department of Medicaid ldquoOhio Medicaid Enrollment Caseload Reportrdquo Updated February 11 2015

httpmedicaidohiogovPortals0ResourcesReportsCaseload201501-Caseloadpdf

17 Ohio Office of Health Transformation ldquoMedicaid Applications in Ohio Benefitsrdquo Updated July 31 2014httpwwwhealthtransformationohiogovLinkClickaspxfileticket=8ojC1suorRg3damptabid=117



18 Jeremy Pelzer ldquoOhio House Speaker Cliff Rosenberger says he wonrsquot press to repeal Medicaid expansionrdquoCleveland Plain Dealer January 26 2015httpwwwclevelandcomopenindexssf201501ohio_house_speaker_says_he_wonhtmlincart_river

19 Alex Isenstadt ldquoOperation Replace Jebrdquo Politico Updated June 21 2015httpwwwpoliticocomstory201506john-kasich-replace-jeb-bush-2016-candidate-119191

20 Darrel Rowland ldquoConservatives question Kasichrsquos support of Medicaid expansion in NYCrdquo ColumbusDispatch March 26 2015httpwwwdispatchcomcontentstorieslocal20150326kasich-four-seasons-meetinghtml

21 Sarah Wheaton ldquoGov John Kasich Repeal Obamacare but not all of itrdquo Politico October 20 2014httpwwwpoliticocomstory201410john-kasich-obamacare-repeal-112048html In March 2015 theAssociation Press (AP) published a correction to the story ldquoThe APrsquos story should have made clear thatKasich often discusses Medicaid expansion separately from the law as a whole and that the governor didnot backtrack from his earlier statement in the second interview The APrsquos initial versions of the storyshould have said Kasich believes the health care law should be repealedrdquo Associated Press ldquoClarificationHealth Overhaul-Republicans storyrdquo March 4 2015httpbigstoryaporgarticlecde18743641f4aadaf817b8d03fced20gop-governors-dont-see-obamacare-going-away

22 Mary Taylor ldquoGuest Column Presidentrsquos Healthcare Plan is Bad for Ohio and our State Insurance MarketrdquoOhio Department of Insurance Communications Office Press Release June 24 2011httpswwwinsuranceohiogovNewsroomPages06242011HealthcarePlanaspx

23 Eric Polkar ldquoOhio Receives Federal Grant to Advance Health Care Payment Innovationrdquo Governorrsquos Officeof Health Transformation Press Release February 21 2013httpwwwhealthtransformationohiogovLinkClickaspxfileticket=r2b-iXyOqCA3damptabid=138

24 Carrie Haughawout Ohio Department of Insurance ldquoNetwork Transparencyrdquo Testimony Before the JointMedicaid Oversight Committee July 16 2015httpjmocstateohusAssetsdocumentsODI_Testimony_July_16_2015pdf

25 Ohio Department of Insurance ldquoProposed Rule 3901-8-16 Required Provider Network Disclosures forConsumersrdquo nd accessed July 2015httpinsuranceohiogovConsumerDocuments3901-8-16_DRAFTpdf

26 ldquoThe Certified Application Counselor (CAC) Program Facts about the CAC Designation for OrganizationsrdquoEnroll America September 2013httpwwwenrollamericaorgthe-certified-application-counselor-cac-program-facts-about-the-cac-designation-for-organizations

27 ldquoThe Affordable Care Act and Health Centersrdquo US Department of Health and Human Services HealthResources and Services Administration nd accessed July 2015httpbphchrsagovabouthealthcenterfactsheetpdf

28 ldquoOhio Health Center Outreach amp Enrollment Assistancerdquo US Department of Health and Human ServicesHealth Resources and Services Administration nd accessed July 2015httpwwwhrsagovaboutnews2013tablesoutreachandenrollmentohhtml See also Affordable CareAct Consumer Assistance Resources by StateTerritory for State and Local Partners (Washington DC WhiteHouse Initiative on Asian Americans and Pacific Islanders Updated October 31 2013)httpwwwedgovedblogsaapifiles201303Affordable-Care-Act-Resources-for-State-and-Local-Partners-103113pdf

29 ldquoFind an Agentrdquo Ohio Association of Health Underwriters nd Accessed April 1 2014httphealthbenefitsohiocomconsumerphp

30 79 FR 30342 sect155206 Civil money penalties for violations of applicable Exchange standards by consumerassistance entities in Federally-facilitated Exchanges May 27 2014httpwwwecfrgovcgi-bintext-idxSID=3611e39d4cf54c4dacaf149bc871971eampnode=451012703273amprgn=div8

31 Helping Hands A Look at State Consumer Assistance Programs under the Affordable Care Act (Menlo Park HenryJ Kaiser Family Foundation September 2013)httpkaiserfamilyfoundationfileswordpresscom2013098486-helping-handspdf

32 Natalie Villacorta ldquoOhio receives $3 million for health insurance outreachrdquo Cleveland Plain Dealer August15 2013httpwwwclevelandcomhealthfitindexssf2013083_million_awarded_to_ohio_forhtmlincart_river

33 Ohio House Bill 3 130th General Assembly

34 Ohio Administrative Code 3901-5-13 Insurance navigator certification and agent exchange requirementsJuly 22 2013httpwwwregisterofohiostateohuspdfs3901053901-5-13_PH_RV_N_RU_20130722_1317pdf

35 ORC 3905471 (F)(3)(a) Insurance Navigator Certification httpcodesohiogovorc3905471

36 US Department of Health and Human Services ldquoPatient Protection and Affordable Care Act Exchangeand Insurance Market Standards for 2015 and Beyondrdquo 45 CFR Parts 144 146 147 et al May 27 2014httpsfederalregistergova2014-11657

37 Centers for Medicare amp Medicaid Services ldquoNavigator Grant Recipientsrdquo October 18 2013httpwwwcmsgovCCIIOPrograms-and-InitiativesHealth-Insurance-MarketplacesDownloadsnavigator-list-10-18-2013pdf

38 Centers for Medicare amp Medicaid Services ldquoNavigator Grant Recipients for States with aFederally-facilitated or State Partnership Marketplacerdquo nd Accessed August 26 2015httpswwwcmsgovCCIIOPrograms-and-InitiativesHealth-Insurance-MarketplacesDownloadsnavigator-list-09-08-2014pdf

39 ldquoIn-Person Assistance in the Health Insurance Marketplacesrdquo Centers for Medicare amp Medicaid ServicesCenter for Consumer Information amp Insurance Oversight nd accessed September 15 2015httpswwwcmsgovCCIIOPrograms-and-InitiativesHealth-Insurance-Marketplacesassistancehtml

40 Munira Z Gunja and Emily R Gee Health Insurance Issuer Participation and New Entrants in the HealthInsurance Marketplace in 2015 (Washington DC US Department of Health and Human ServicesSeptember 23 2014) httpaspehhsgovsitesdefaultfilespdf77051ib_NewEntrantspdf

41 Health Plan Choice and Premiums in the 2015 Health Insurance Marketplace APSE Research Brief (WashingtonDC US Department of Health and Human Services Updated January 8 2015)httpaspehhsgovhealthreports2015premiumreporthealthpremium2015pdf

42 ldquoMarketplace Premiums Ohiordquo Office of the Assistant Secretary for Planning and Evaluation AccessedJuly 2015 httpaspehhsgovhealthreports2013MarketplacePremiumslongdescohcfm

43 Health Insurance Marketplace Summary Enrollment Report for the Initial Annual Open Enrollment Period ASPEIssue Brief (Washington DC US Department of Health and Human Services May 1 2014)httpaspehhsgovexecsumhealth-insurance-marketplace-summary-enrollment-report-initial-annual-open-enrollment-period

44 Health Insurance Marketplaces 2015 Open Enrollment Period March Enrollment Report ASPE Issue Brief(Washington DC US Department of Health and Human Services March 10 2015)httpaspehhsgovhealthreports2015MarketPlaceEnrollmentMar2015ib_2015mar_enrollmentpdf

45 ldquoMarch 31 2015 Effectuated Enrollment Snapshotrdquo CMS fact sheet Centers for Medicare amp MedicaidServices June 2 2015httpwwwcmsgovNewsroomMediaReleaseDatabaseFact-sheets2015-Fact-sheets-items2015-06-02html

46 ldquoMarketplace Enrollment as a Share of the Potential Marketplace Populationrdquo Henry J Kaiser FamilyFoundation State Health Facts As of March 31 2015httpkfforghealth-reformstate-indicatormarketplace-enrollment-as-a-share-of-the-potential-marketplace-population-2015table

47 Molly Ball ldquoJohn Kasich Barges Inrdquo The Atlantic July 21 2015httpwwwtheatlanticcompoliticsarchive201507what-john-kasich-believes399044

Field Research Associates

Amy Rohling McGee President Health Policy Institute of Ohio

arohlingmcgeehpionet 614-545-0750

Amy Rohling McGee has served as the president of the Health Policy Institute of Ohioa nonpartisan independent nonprofit organization that provides information andanalysis to state policymakers since 2010 Her prior public sector experience includeswork in the executive branch of state government focused on policy related to issuessuch as health insurance health system improvement health information technologyand Medicaid and service in the state legislature as a Legislative Service Commissionintern in the mid-1990s Private sector experience includes five years as the executivedirector of the Ohio Association of Free Clinics representing health clinics that servedthe uninsured primarily through volunteers and several years in a management posi-tion at FIRSTLINK (now HandsOn Central Ohio) McGee earned her bachelorrsquos andmasterrsquos degrees from The Ohio State University She has received the BusinessFirst ldquoForty Under Fortyrdquo award and The Ohio State University Alumni AssociationWilliam Oxley Thompson award

Reem Aly Director of Healthcare Payment and Innovation Policy Health PolicyInstitute of Ohio

ralyhpionet 614-545-0759

Reem Aly is the director of Healthcare Payment and Innovation Policy at the HealthPolicy Institute of Ohio (HPIO) Prior to joining HPIO in June 2011 Aly worked as aconsultant and administrative resident at Nationwide Childrenrsquos Hospital Aly alsoworked in the legal field at OCLC Online Computer Library Center Inc and Bricker ampEckler LLC Aly holds a law degree and master of health administration as well as abachelor of science in psychology and a bachelorrsquos of arts in international relationsfrom The Ohio State University Aly was named one of six inaugural recipients ofAcademyHealthrsquos 2013 Presidential Scholarship for the AcademyHealth Institute onAdvocacy and Public Policy

Stephanie Gilligan Director of Access and Coverage Policy Health Policy Instituteof Ohio

sgilliganhpionet 614-545-0762

Stephanie Gilligan is director of Access and Coverage Policy at the Health Policy Insti-tute of Ohio (HPIO) Before joining HPIO in January 2014 she spent seven years work-ing for the Ohio Legislative Service Commission (LSC) During her time at LSC sheworked on the fiscal staff in the health and human services subject area and later coor-dinated the LSC Fellowship Program She holds a bachelorrsquos degree in political scienceand a masterrsquos degree in public administration from The Ohio State University

Rockefeller Institute Page ii wwwrockinstorg


OHIO



September 2015









12 Goal Alignment 7





State Leadership 10







Endnotes 19











Thomas GaisDirector

























































12 Goal Alignment



























Federal Leadership



State Leadership








































































































































OHIO



September 2015









12 Goal Alignment 7





State Leadership 10







Endnotes 19











Thomas GaisDirector

























































12 Goal Alignment



























Federal Leadership



State Leadership


















































































































































Thomas GaisDirector

























































12 Goal Alignment



























Federal Leadership



State Leadership

























































































































































































12 Goal Alignment



























Federal Leadership



State Leadership



























































































































































Federal Leadership



State Leadership






































































































































