Rhode Island being the smallest state, you might think word would travel faster there. But according to a recent survey commissioned by the Rhode Island Health Benefits Exchange, four out of five state residents have never heard of the exchange. So much for brand awareness. Regardless, Rhode Islanders and consumers across the nation best do their homework as the October 2013 exchange launch date, for coverage effective Jan. 1, 2014, rapidly approaches. The structure of state exchanges, including participating health plans, is taking shape, and there are developments worth noting in one of the bellwether exchange regions New England.

In Connecticut, Aetna, Anthem, ConnectiCare and HealthyCT (a Consumer Operated and Oriented Plan, or CO-OP) have applied to offer products in the state-run health insurance exchange, and it appeared Massachusetts-based nonprofit Harvard Pilgrim Health Care would be joining the lineup as well. The insurer, which also operates in Maine and New Hampshire, had set its sights on expanding to Connecticut, and saw the exchange as the perfect entryway for the launch of its brand in the state.

However, in its bid to secure a state license and build out its provider network while also implementing a companywide IT conversion, Harvard Pilgrim simply ran out of time. The insurer has delayed its debut in the Connecticut market until at least April 2014, but possibly as late as July 2014. Harvard Pilgrim has been cautious about expansion in recent years, and knows full well the challenges it will face gaining a foothold in Connecticut.

Harvard Pilgrim also appears to have opted out of exchanges in Maine and New Hampshire, two states it already competes in. Both states are dominated by Anthem Blue Cross and Blue Shield plans, and Harvard Pilgrim execs previously said the insurer was in favor of state-run exchanges, which is not the case in Maine (federally administrated) or New Hampshire (a state-federal partnership).

Anthem BCBS is the only insurer planning to take part in New Hampshire's exchange, while in Maine, Anthem and a state CO-OP, Maine Community Health Options, have publicly announced their intent. Anthem is planning to team with MaineHealth, the largest integrated healthcare network in the state, to offer a lower-cost, narrow network option in the exchange, pending regulatory approval. The Anthem/MaineHealth narrow network product should prove to be attractive, as individuals buying through the exchange will be cost-conscious, and as self-insured employers become more active in containing costs.

Cigna, active in both Maine and New Hampshire, opted out of those states exchanges, not surprising considering it doesn't focus heavily on the small-group market.

Vermont made news 11 months ago when the Vermont Health CO-OP, fresh off a $33.8 million federal startup loan, announced its formation and plans to offer products in the state's health insurance exchange. Vermont made news again May 22, 2013, when the state in effect issued a thanks, but no thanks decree. Vermont's commissioner of the Department of Financial Regulation denied the CO-OP's request for a license to offer insurance products in the state, pointing to a laundry list of concerns including unaffordable rates and unrealistically high enrollment projections. This leaves dominant market leader Blue Cross Blue Shield of Vermont and MVP Health Care as the two plans that will be operating in the exchange.

In Rhode Island, market-leader Blue Cross & Blue Shield and UnitedHealthcare of New England are participating in the exchange, as is the state's largest Medicaid HMO, Neighborhood Health Plan. Though it has not offered a commercial product in Rhode Island before, the move makes sense for Neighborhood Health Plan. The ACA calls for Medicaid expansion for those up to 138 percent of the federal poverty level, and Rhode Island will be among the states expanding its program. The ACA also requires state exchanges to offer a seamless transition as people migrate between Medicaid and the exchanges. By having a Medicaid plan and health insurance exchange plans in the same state, Neighborhood Health Plan can provide that transition for those whose incomes change and cause them to lose or gain Medicaid eligibility.

Massachusetts-based Tufts Health Plan, a distant No. 3 commercial player in Rhode Island, is delaying entry in Rhode Island's exchange until 2015. In all, Rhode Island's exchange will include 28 different plan options, 16 for small businesses and 12 for individuals.

Now if the state can just get those four out of five people to pay attention, January of 2014 could dawn with some people enrolled in its exchange.

Follow Ric Gross on Twitter at @RicGrossHLI

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