Q. What type of health insurance exchange/marketplace does my state have?
A. For the 2024 plan year, there are 19 fully state-run health insurance marketplaces (SBMs), three state-based marketplaces that use the federal platform (SBM-FP), 23 fully federally-run marketplaces (FFMs), and six state-federal partnership marketplaces, which are a type of FFM. So in reality, there are 29 FFMs, 19 SBMs, and three SBM-FPs.
Note that the federal platform is HealthCare.gov. And “Exchange” and “Marketplace” mean the same thing, so you’ll also see people use the acronyms SBE, SBE-FP, and FFE.
Three of the states that now have SBMs (Kentucky, Maine, and New Mexico) had SBM-FPs as of 2021, but created their own state-run exchange platforms that were up and running as of the fall of 2021. Virginia has joined them as of November 2023, so people enrolling in 2024 coverage are using Virginia’s new Marketplace platform to sign up (Virginia residents who are enrolling in December coverage using a special enrollment period are using HealthCare.gov, but will need to renew their coverage for 2024 using the state’s new Marketplace platform).
Georgia had also intended to have an SBM by the fall of 2023, but CMS has delayed Georgia’s transition, clarifying that the state will need to use an SBM-FP starting in the fall of 2023 and then transition to an SBM in the fall of 2024. Illinois has enacted legislation that calls for the state to have an SBM-FP by the fall of 2024 (for the 2025 plan year) and an SBM by the fall of 2025. And Oregon, which currently has an SBM-FP, has enacted legislation that calls for the state to transition to an SBM by the fall of 2026.
Texas was also considering legislation (HB700, HB2554, and SB344) to create a state-run exchange, but the bills died in committee during the 2023 session. Similar legislation was considered in Michigan in 2022, but did not advance to a vote.
Rules states must follow when transitioning to a state-run exchange
In the rulemaking process for 2024 coverage, HHS finalized a more lenient approval process timeline for states that are transitioning away from the federally-run exchange in order to establish their own exchange and/or exchange platform. However, some additional rules have since been proposed for the transition, effective in 2025 and future years.
The previous rules (pre-2024) required a state to have federal approval or conditional approval at least 14 months before the start of open enrollment if they were transitioning from an SBM-FP to an SBM, and at least three months before the start of open enrollment if they were transitioning from the FFM to an SBM-FP.
Under the new rules, the approval or conditional approval simply has to be received before the start of open enrollment. States will continue to go through the same intensive process of working with HHS to ensure a smooth transition and well-functioning exchange, but no longer have to obtain approval more than a year in advance in order to establish an SBM.
However, HHS has proposed a rule change for 2025 and future years that would require a state to operate an SBM-FP for at least one year (including the open enrollment period for that year) before operating a new SBM. If finalized, this would prohibit a state from transitioning directly from the FFM to an SBM.1
Here’s how each state’s exchange operates, as of the 2024 plan year (for enrollments that began in November 2023):
SBMs: State-run marketplaces (these states have their own enrollment websites)
- District of Columbia
- New Jersey
- New Mexico
- New York
- Rhode Island
- Virginia (effective as of plan year 2024; Virginia previously used the federally-run exchange and then had an SBM-FP for 2023)
SBM-FPs: State-based marketplaces that use the federal enrollment platform (HealthCare.gov)
- Georgia (effective as of plan year 2024; Georgia previously had a federally-run exchange, and will have an SBM by the fall of 2024)
- Oregon (Oregon plans to operate a state-run exchange platform starting in the fall of 2026, per legislation enacted in 2023)2
Partnership exchanges (these states use the federal HealthCare.gov enrollment platform)
- Illinois (legislation enacted in 2023 calls for the creation of an SBM-FP by 2025 and an SBM by 2026)
- New Hampshire
- West Virginia
Federally-run marketplace (these states rely entirely on HealthCare.gov)
- North Carolina
- North Dakota
- South Carolina
- South Dakota*
- Texas (legislation was introduced in 2023 to create a state-run exchange, but it was unsuccessful)
(States with an asterisk have a marketplace plan management exchange. Their exchanges are federally-run, but the state retains oversight of the plans, and is active in certifying QHPs for sale in the exchange.)
How does a state's exchange model affect the open enrollment schedule?
States that use the federally-run marketplace – including SBM-FPs and partnership marketplaces – have to follow the open enrollment schedule set by HHS. The current enrollment schedule in these states is November 1 through January 15, although the enrollment period for 2024 coverage has been extended through January 16 on HealthCare.gov, due to the federal holiday on the 15th of January.
States that run their own exchange platforms can set their own open enrollment schedules, as long as the final deadline isn’t earlier than December 15. But most of them have opted for an enrollment window that’s at least as long as the enrollment window being used by HealthCare.gov. For 2022, 2023, and 2024 coverage, Idaho is the only state-run exchange that has chosen to have an earlier deadline (December 15).
How has management of the marketplaces changed over time?
The exchanges/marketplaces debuted in the fall of 2013, providing coverage for the 2014 plan year. Since then, several states have made changes to their marketplace management. There was initially a trend of states abandoning their own enrollment platforms and opting for HealthCare.gov instead. But we’re seeing the opposite happening in the 2020s, with a growing number of states choosing to leave HealthCare.gov and operate their own exchanges with their own enrollment platforms. This gives a state added flexibility (for example, the opportunity to extend open enrollment) and control, and states are also finding that it’s less costly to operate their own exchanges. Here’s an overview of the states that have made changes to their marketplace management over the years:
For the 2015 plan year:
- Idaho used HealthCare.gov for enrollment in 2014, but switched to being a fully state-run exchange prior to the 2015 open enrollment period.
- Nevada and Oregon both had state-run exchanges in 2014, but due to technical difficulties, they both opted to become federally-supported state-based exchanges (SBM-FPs) prior to the 2015 open enrollment period (Nevada has since switched back to having a fully state-run exchange).
For the 2016 plan year:
- Hawaii opted to transition to an SBM-FP, abandoning its state-run enrollment platform (as noted below, Hawaii dropped the state-run aspect altogether the following year).
For the 2017 plan year:
- Arkansas switched from having a state-federal partnership exchange to an SBM-FP (enrollment continued to be via HealthCare.gov, so there was no change from a consumer perspective).
- Hawaii switched from an SBM-FP to the federally-run exchange (enrollment continued to be via HealthCare.gov, so there was no change from a consumer perspective).
- Kentucky switched from a state-based exchange to an SBM-FP (Kentucky is planning to revive its fully state-run exchange and Kynect enrollment platform in time for the 2022 plan year).
For the 2020 plan year:
Exchange management stayed unchanged for a few years. But several changes took effect in the fall of 2019, for the 2020 plan year:
- Nevada switched to a fully state-run exchange, after having an SBM-FP since 2015. Nevada enrollees now use Nevada Health Link instead of HealthCare.gov.
- New Jersey transitioned to an SBM-FP, after having a federally-run marketplace since 2014 (federal approval for this was granted in October 2019; enrollees continued using HealthCare.gov, but as described below, the state will no longer use HealthCare.gov as of the 2021 plan year).
- Pennsylvania also transitioned to an SBM-FP, after having a fully federally-run marketplace in previous years. And just like New Jersey, Pennsylvania will stop using HealthCare.gov in the fall of 2020.
For the 2021 plan year:
The following changes occurred in the fall of 2020:
- Pennsylvania transitioned to a fully state-run exchange, called Pennie (residents no longer use HealthCare.gov).
- New Jersey transitioned to a fully state-run exchange, utilizing the GetCoveredNJ platform (residents no longer use HealthCare.gov).
- Virginia transitioned to an SBE-FP (residents continue to use HealthCare.gov for enrollment at this point, but Virginia plans to transition to a fully state-run exchange with its own enrollment platform in the fall of 2023, and residents will use the state-run platform to enroll in 2024 coverage).
- Maine transitioned to an SBM-FP, and plans to have a fully state-run exchange by the fall of 2021. Legislation was enacted in Maine in 2020 to move forward with the process of creating a state-run exchange. Maine did not receive federal Navigator funding in August 2020, because the state was going to be operating its own state-run exchange (albeit with the HealthCare.gov platform used for enrollment) by the time open enrollment began in November 2020, meaning that Maine became responsible for its own Navigator program funding.
For the 2022 plan year:
New Mexico, Maine, and Kentucky transitioned away from HealthCare.gov as of November 1, 2021, for people enrolling in coverage with a 2022 effective date. All three states used the SBM-FPs for the 2021 plan year.
For the 2024 plan year:
Virginia has a fully state-run exchange that became operational in the fall of 2023.
Anticipated changes for future years:
- Georgia had intended to run its own exchange starting in the fall of 2023, but CMS clarified that Georgia will need to run an SBM-FP for the 2024 plan year and then begin operating a state-run enrollment platform in the fall of 2024.
- Illinois plans to have an SBM-FP by the 2025 plan year, and an SBM by the 2026 plan year (under the terms of legislation that the state enacted in 2023).
- Oregon has an SBM-FP and plans to have a state-run exchange platform starting in the fall of 2026, for coverage effective in 2027 (under the terms of legislation enacted in 2023).2
Change to SHOP (small business) exchange management
Arkansas, Mississippi, and Utah were all running their own SHOP exchange (the platform for small businesses to enroll in coverage), but switched to using the federal platform or a direct-to-carrier process by 2018. But by that point, even the federal platform for small business enrollment was no longer functioning as it had in past years, and small group enrollment had switched to a direct-to-carrier process in nearly every state. New Mexico was still running its own SHOP exchange platform as of early 2023, but switched to a direct-to-carrier system in mid-2023.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health insurance marketplace updates are regularly cited by media who cover health reform and by other health insurance experts.
- Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2025; Updating Section 1332 Waiver Public Notice Procedures; Medicaid; Consumer Operated and Oriented Plan (CO-OP) Program; and Basic Health Program. Centers for Medicare and Medicaid Services. November 2023.
- Oregon Senate Bill 972. BillTrack50. Enacted August 2023.