Since the Affordable Care Act (ACA) was signed into law six years ago, section 1332 waivers have existed. The 1332 waivers offer States the opportunity to design a new coverage system customized for local needs and preferences while still fulfilling the aims of the ACA.  As States have begun to put enrollment seasons under their belts and are seeing how certain modifications could benefit their residents and their health insurance markets, waiver applications have begun. (The process is detailed as authorized by the United States Secretary of HHS pursuant to 42 U.S.C. § 18052.)

The content and proposed State changes vary widely, from minor fixes to substantial redirections. The most substantive changes sought by the States are related to reinsurance pools, which were successfully implemented by Alaska and Minnesota resulting in lower premiums in both states since the programs were implemented. Some states have undertaken initial steps to either take more control or transition fully from

In order to transition to a State-Based Marketplace from Federally Facilitated Marketplace (FFM or, all the State has to do is to follow in Idaho and Nevada’s footsteps, formally notify CMS of its intent, scale (i.e. full SBM implementation or, say, taking over plan management first, as New Jersey did recently, and timing), and work through the logistics of the transition with CMS. As of February 2019, 14 States have considered legislation to initiate the 1332 waiver application process. The list of state actions and waivers granted, as well as additional resources, can be found at the National Conference of State Legislature (NCSL) and at Centers for Medicare and Medicaid Services (CMS).