(Bloomberg) — U.S. health insurers will face a fragmented regulatory landscape in 2014 under the first state insurance marketplaces approved as part of the Patient Protection and Affordable Care Act.

Rules for the six state insurance exchanges that won conditional approval from the Obama administration Monday are split evenly between those with strict criteria for companies that want to participate and states that have opened their exchanges to all comers, a scenario supported by the insurance industry. A high bar for inclusion could limit the number of insurers offering health plans in some states.

The exchanges, the heart of PPACA, have less than a year to open online platforms where local residents, with the help of federal tax credits, can shop online for insurance. The approved states are Connecticut, Maryland, Colorado, Oregon, Massachusetts and Washington.

“The challenge is it’s all new,” says Kim Holland, executive director for state affairs at the Blue Cross Blue Shield Association, a Washington-based trade group that represents 38 state insurance plans. “We have a really, really short period of time in order to get everything done.”

Enrollment in the exchanges must begin by Oct. 1, 2013, for plans that will take effect Jan. 1, 2014. The U.S. government plans to give states that run their own exchanges a share of about $2 billion to help get them started.

In Connecticut, regulators are taking a strict approach by making insurers meet requirements for patient access to doctors that exceed those of federal PPACA guidelines. Insurers will have to make two-year commitments to participate in the Connecticut Health Insurance Exchange, and include almost all of the state’s U.S.-funded health clinics in their networks.

“The board saw its role as being very, I’d say, passionate about supporting consumers and trying to establish standards where health plans could reach to a slightly higher bar than required in the ACA,” says Kevin Counihan, CEO of the Connecticut exchange.

At the same time, Maryland said it’s letting any plan that meets federal standards sell coverage at the start as the state rushes to craft a marketplace that will be popular with both consumers and insurers.

“What we’re focused on in the initial couple of years is really getting as many people enrolled on the exchange as possible,” says Rebecca Pearce, executive director of the Maryland Health Benefit Exchange. “To do that we need to make sure we have as many carriers as possible.”

‘Unlevel field’

Insurers are worried about measures that might create “an unlevel playing field,” according to Holland, a former Oklahoma insurance commissioner, speaking in a telephone interview. “Anything that would create market variation or lack of consistency would be problematic.”

Daryl Richard, a UnitedHealthcare spokesman, says the Minnetonka, Minn.-based company is in the process of researching how each of the state’s exchanges may be structured.

“Given the regulatory variation from state to state — and many states have not yet formalized their exchange models — we have not yet made any decisions about where we will be offering our health plans through the exchanges,” Richard says.

UnitedHealthcare is not the only for-profit insurer looking at the exchanges warily, says Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the industry’s lobbying group in Washington.

The group has generally opposed practices like those of Connecticut, a model called “active purchasing” through which some insurers may be excluded from selling their plans, he says.

“There’s already variation in how health insurance is regulated state by state,” Zirkelbach says. “The important thing is how the exchanges are structured, ensuring they’re done in a way that will maximize choice and competition for consumers and employers.”

States with extra rules run the risk that insurers won’t participate in their exchanges, says Ana Gupte, an analyst with Sanford C. Bernstein & Co. in New York.

“I’m sure the insurance industry will go in with good faith of wanting to play everywhere they possibly can, but they can always reduce their effort and involvement over time,” she says. “It’s a balance, because you do want the large publicly traded players and the big Blue Cross Blue Shield to of course all be there, in addition to the smaller not-for-profits.”

Friday deadline

A majority of the remaining 50 states may let the federal government run the markets or choose to provide services such as consumer assistance in a partnership with the federal government.

Twenty-two governors already have sent notice that they won’t build their own exchanges. The rest have until Friday to decide.

No more than three or four additional states are expected to build exchanges themselves, according to estimates made by Bryce Williams, a managing director at the consulting company Towers Watson.

Nationwide, health plans will be required to meet certain minimum qualifications for participating in the exchanges, such as offering sufficient networks of doctors and hospitals and meeting federal limits on out-of-pocket costs. The law lets states set additional rules.

In states that already have many competing health plans, “the exchange can afford to be a little more selective, versus a state where there aren’t that many health plans, or the politics are such that they don’t believe in as active a state role,” says Jon Kingsdale, a former executive director at the Massachusetts’ health exchange and a managing director at Wakely Consulting Group, an adviser for five of the six states that won approval.

Maryland may establish stricter rules aimed at driving down health care costs, “at the point we have the market behind us,” Pearce says. The state’s marketplace has already drawn interest from 10 companies, including UnitedHealth and Aetna Inc., and will be open to any plan that meets the federal minimum rules, with a few technical modifications, until at least 2016, she says.

Connecticut will require all health plans to commit to sell plans in its exchange for at least two years, and they face a two-year “lockout” period if they exit the exchange, says Counihan, the CEO of the state’s exchange. Plans will also have to include at least 90% of the state’s federally funded health clinics in their networks, a rule aimed at protecting low-income people, he says.

Massachusetts’s Health Connector, the exchange that has operated in that state since 2006, has added carriers even as it imposed rules that include requiring insurers to offer standard benefit packages, says Glen Shor, the executive director.

“We work very closely with all of our insurers to structure rules that empower consumers but make it as easy as possible for insurers to work with us,” Shor says. “It is a delicate balance to strike.”

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