The NAIC, referenced heavily throughout the act, has by all accounts been working exhaustively to implement the reforms while the states have been working overtime on medical loss ratios (MLRs).

MLRs are proving to be the stickiest wicket in implementing the early provisions act thus far, according to comments made by commissioners at a press conference after the meeting. Most provisions will not take effect until Jan. 1, 2014.

The PPACA requires insurers to meet minimum medical loss ratios–the percentage of premiums collected by insurers actually spent on care that is not administrative costs or profits.

The states want to be able to write the law so it doesn't disrupt the marketplace and force out insurers, but not so broadly that it doesn't conform to the law, Ms. Cline said.

At the same time, commissioners have been hearing from a slew of companies writing in the individual health insurance marketplace–where the new MLR will be 80 percent–threatening to drop out of the marketplace as they won't be able meet the minimum.

Some states have MLRs in the 60s embedded in existing law, [while the law calls for no more than 80-85], Ms. Cline noted. Iowa and Maine have already or will be asking HHS for a waiver for compliance, according to Iowa Commissioner Susan Voss. It was unclear how many other states may follow suit.

Florida Commissioner and NAIC Vice President Kevin McCarty said he will hold a hearing in his state Friday to gather evidence of the disruptions, as requested during the meeting by HHS, and detail precise concerns in a few weeks. Mr. McCarty said HHS' Jay Angoff needs something more evidentiary than to hear about "amorphous displeasures" in the marketplace.

"We might lose some of those players," Mr. McCarty said he had expressed to Secretary Sebelius, noting that "there is a paradigm shift" with the passage of this law–some business plans won't be successful at adapting.

Ms. Sebelius knows the territory well. She served as NAIC president and insurance commissioner of Kansas before being elected governor of Kansas in 2003.

Commissioners said HHS was not thrilled with a phase-in of MLR to 2014, as was discussed, but Kansas Commissioner Sandy Praeger, who chairs the NAIC Health Insurance Committee, said the law does give latitude for phase-in on a state-by-state basis to HHS. She said, however, that she can't imagine Ms. Sebelius spending time reviewing every states' progress, and so she is looking for flexibility from HHS.

The NAIC and some commissioners have a weekly call with HHS, so dialogue on implementation will be ongoing and more detailed guidance will be forthcoming from HHS.