Roundup of Selected State Health Developments — Second-Quarter 2019 

29 July 2019

While federal debate over “surprise” medical bills and drug costs continues, some states have already begun to tackle balance-billing practices, overall drug spending, prescription importation and regulation of pharmacy benefit managers (PBMs). To increase access to healthcare, a number of states are pursuing telehealth expansion. Other jurisdictions, like Nevada and San Francisco, are continuing to implement existing healthcare initiatives or considering whether to pursue Affordable Care Act (ACA) innovation waivers. Several states have also enacted individual coverage mandates to prevent a spike in uninsured residents after rollback of federal mandate’s penalty. Other state activity in the second quarter focused on various insurance laws, as well as paid or unpaid leave and pregnancy accommodation mandates. 

Here are highlights of some key state health, leave and related employment activity in Q2 2019. Download the full 21-page print-friendly GRIST to find detailed coverage, including links to related resources.

Balance Bills

As Congress considers how to protect patients from costly, unexpected balance bills from out-of-network healthcare providers, states are acting to reduce the impact of these surprise bills. Five states — Colorado, Nevada, New Mexico, Texas and Washington — have enacted balance-billing laws that take effect for healthcare services delivered on or after January 2020. Some of these states are setting price guidelines and arbitration provisions, while most include patient disclosure obligations. Because states generally can’t regulate self-insured ERISA plans, these laws primarily protect patients covered by insured plans.

Prescription Drugs

The escalating prices of prescription drugs and the role of PBMs in delivery and management have spurred cost-control efforts by the Trump administration, Congress and state lawmakers. At least 10 states have recently taken action to lower prescription drug prices. Colorado and Maryland have enacted legislation to directly reduce consumer costs. Florida will ask the US Department of Health & Human Services (HHS) to let the state import drugs from Canada. Louisiana, Minnesota, Oklahoma, South Carolina, Texas and Washington state will begin or increase PBM regulation. Maine has enacted a package that will take all three approaches.


Improved technology and an expanded need for healthcare access — particularly in rural areas — and for mental health treatment have inspired greater use of telehealth services. Five states took steps in the second quarter to expand telehealth. Florida is expanding state residents’ access to telehealth providers licensed in other states. Hawaii’s advisory council will review telehealth obstacles, with the aim of recommending legislative proposals. Oklahoma has joined a multistate telehealth psychology compact to facilitate mental health treatment across state lines. Maine and Texas have added telehealth coverage mandates for insured health coverage.

State Health Coverage Initiatives

States are continuing their efforts to expand comprehensive healthcare with new or updated programs. A recent study reviews states’ public health coverage proposals that use a Medicaid buy-in option. One state, Washington, will develop its public option beginning 2021, without seeking federal funds through an ACA innovation waiver. But other states are tempted by the Trump administration’s efforts to broaden waiver availability. In California and Nevada, existing employer-based coverage initiatives have received updates. San Francisco has amended its health coverage and wage requirements for city contractors. Nevada has raised its two-tiered minimum wage rates and established new health coverage standards for employers paying the lower rate.

Individual Mandates

State lawmakers apprehensive of declining coverage now that individuals without health insurance face no ACA penalty have taken varying approaches to protect the individual market. California and Rhode Island have joined Massachusetts, New Jersey, Vermont and the District of Columbia in enacting individual coverage mandates. California and Rhode Island include employer reporting requirements similar to those in other jurisdictions, while Vermont places the reporting onus on individual taxpayer payers.


A number of states have modified their insurance laws and regulations, which don’t apply to self-insured ERISA plans. Arizona plans to allow small employers to form association health plans (AHPs) that conform to the Trump administration’s 2018 rule, parts of which are on hold pending litigation. Maine will ban discretionary clauses in insured health and disability policies. Maryland has added a special enrollment period for pregnant women to get small-group or individual policies. New Jersey has aligned its insurance mandates with the federal Mental Health Parity and Addiction Equity Act (MHPAEA). New York has strengthened women’s health provisions in two areas: Regulatory guidance confirms the state’s contraceptive mandate isn’t preempted by federal moral and religious exemption regulations (currently on hold due to litigation), and a new law mandates coverage for in vitro fertilization in New York insured plans.

Leave and Employment

Leave — paid and unpaid — and employment accommodations have drawn considerable attention in recent months. In the second quarter, state lawmakers considered new and expanded leave programs, and state regulators moved ahead to implement existing laws. In California, the Los Angeles City Council is looking at options to require employers to subsidize the portion of parental leave not covered by state law. Meanwhile, the state has expanded its family leave program from six to eight weeks and is considering increasing the program’s wage replacement to 100% of base pay.

Connecticut and Oregon will add new paid family and medical leave (PFML) programs similar to those enacted in Massachusetts, Washington state and Washington DC. Programs in those three jurisdictions have begun collecting contributions, despite some implementation delays. Vermont and New Hampshire lawmakers passed PFML programs, but both states’ governors vetoed (or have promised to veto) the bills.

Aside from PFML initiatives, two states — Maine and Nevada — have enacted accrued paid time off (PTO) laws. Unlike PFML programs, these laws require employers administer leave-accrual programs and pay full wages during accrued time off. Unlike other states with paid sick and safe accrued leave laws, the Maine and Nevada laws allow employees to use accrued leave for any purpose, including vacation.

Narrower mandates enacted in Maryland and Oregon require employers to grant unpaid job-protected leave for organ donation. In addition, Kentucky now requires pregnancy-related job accommodations.

About the author(s)
Related solutions
Related insights