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ACA’s Next Challenge: United States House of Representatives v. Burwell
As we head back to court, what does a challenge to the ACA mean for the country’s Health Insurance Marketplaces?
Over the past five years, the Affordable Care Act (ACA) has withstood challenges to the constitutionality of its insurance mandate, Medicaid expansion, birth control-related provisions, and questions about who can receive premium reducing tax credits. In 2016, the law will once again be put to the test as a federal District Court judge reviews a legal challenge related to yet another portion of its cost-related provisions.
What is this latest challenge? In the summer of 2014, the US House of Representatives voted along party lines to file a case against the Obama Administration, arguing that top staff in the President’s cabinet had acted illegally in implementing portions of the ACA. The original documents filed with the US District Court of the District of Columbia contend that the administration subverted Congressional authority and violated the Constitution’s separation of powers in two ways:
- the Administration illegally delayed the implementation of the law’s employer mandate, and
- the Administration illegally authorized $175 million dollars in payments to insurance companies as part of a cost-sharing program in the law.
In September 2015, Judge Rosemary M. Colleyer ruled that while the House did not have standing to bring a claim related to the employer mandate, the case could go forward on the issue of whether the President violated the Constitution by directing federal appropriations.
What is the cost-sharing program referred to in the lawsuit? There are two types of federal financial assistance provided through the ACA that reduce the cost of insurance for low-income people enrolled in qualified health plans (QHPs). The first, and more commonly known, is the Advanced Premium Tax Credit (APTC), which is a subsidy provided directly to insurers to lower an individual’s monthly premium. The second, at center of this case, is the Cost Sharing Reduction subsidy (CSR), which reduces out-of-pocket expenses for health care utilization for enrollees who are below 250 percent of the federal poverty level. CSRs are critical, as these subsidies allow the lowest-income QHP purchasers to not only maintain health insurance coverage but also to afford to use their insurance when they need it. Unlike APTCs, these subsidies do not have to be reconciled against an individual’s earnings at tax time. As of June 2015, over 5.5 million marketplace enrollees (more than half of all total enrollees at that time) were in plans that included cost-sharing subsidies.[i]
How do the CSRs work? Individuals qualify for a CSR when they have income between 100-250 percent of the federal poverty level and purchase a silver-tier plan on a state or federal marketplace. These subsidies reduce the portion of health care coverage paid for by the consumer by increasing the actuarial value of the silver plan selected by the consumer. Actuarial value, which is represented as a percentage, reflects how much of a plan’s covered benefits are being paid for by the insurance company. The higher the actuarial value, the more a company bears the responsibility for the enrollee’s covered health care costs and the less the enrollee pays out of pocket.
How were these CSRs funded through the ACA? Under the ACA, insurance companies are required to adjust the actuarial value of silver plans for all individuals with incomes between 100-250 percent of the federal poverty level. The government is then expected to provide periodic payments to make companies whole for any loss accrued from the increased actuarial value of their plans.
At issue in this case is whether in setting up a set of complementary subsidy programs to support low-income enrollees, the bill crafted by the House of Representatives creates a permanent appropriation for CSRs. The Plaintiffs argue that there is not an explicitly stated appropriation for CSRs that parallels language included in Section 1324 of the law for APTCs. A brief filed by Democratic leadership states that in fact it was always intended for the APTC and CSR funding to come from the same permanent funding source contained in 1324, and in support cites analyses developed by the non-partisan Congressional Budget Office which assumed that that this was the case.
It should be noted that Congress retains the discretion to resolve any uncertainties in this case by adding a line item for CSRs in upcoming budgets. Given the current tensions over the law, it is unlikely that this will happen before a decision is issued in this case.
What is the likely outcome in this case? It is unclear. A court review of a legislative challenge to an executive branch decision is unprecedented, particularly given the authority of the executive branch to administer laws and interpret them as needed. In the past, the Supreme Court has held that Congress does not have the ability to bring suit to force an administration to execute laws consistent with Congressional interpretation of the law’s meaning. Given the new territory this case is covering, it is difficult to predict what the outcome may be. Any appeal of this case may result in a higher court deciding that the District Court had no authority to review this case in the first place. The resolution of this dispute, and the understanding of the precedent it sets, could take years to unravel.
Would the loss of the CSRs mark the end of the ACA’s Marketplaces? The answer is probably not. The most likely scenario is a significant increase in premiums for the silver-tier plans offered through the marketplaces and a dip in enrollment. As described above, plans being sold on a federal or state marketplace must provide increased actuarial value plans to very low-income enrollees even without an appropriation. Without being made whole through government subsidies, the plans will in all likelihood significantly increase their premiums to make up the difference. Alternatively, insurance companies could decide to remove themselves from the marketplaces altogether. A recent report published by the Urban Institute estimates that silver plan premiums could increase an average of $1,040 per person and overall enrollment could drop by 400,000 if a court decision eliminates the CSR payments to insurance companies.[ii]
The significant increase in silver plan premiums would also result in substantial increases to the amount of money expended by the federal government on the APTC subsidies, as the amount of these subsidies are directly tied to the premium costs of silver plans. In the same report mentioned above, the Urban Institute estimated that the increased APTC subsidy to offset the loss of CSR would cost the federal government an additional $47 billion over the next 10 years.
What should states be on the look out for? A decision in this case is expected from DC’s District Court by spring of 2016. This decision will almost certainly be appealed by the losing side, and will move to the District’s federal Appellate Circuit, and then possibly the Supreme Court. Most observers doubt that decision by the District Court will change the CSR program while an appeal is pending. This means it would be at least another year before the program is truly in jeopardy – however, with over half of marketplace enrollees in limbo and another potential blow to the predictability of the insurance marketplace, this is definitely a dispute to watch.
[i] https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-09-08.html
[ii] https://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000590-The-Implications-of-a-Finding-for-the-Plaintiffs-in-House-v-Burwell.pdf
Rounding the Bend: Enrollment and Outreach Updates from the State-based Marketplaces
B2015 has drawn to a close, and with it deadlines for consumers to have coverage on January 1. The Department of Health and Human Services has recently released an enrollment update, citing that over 11.2 million individuals have enrolled in plans through the marketplace, 2.7 million of which have come through the 13 states operating as State-based Marketplaces (SBMs).
In December, we provided an early account of enrollment across the SBMs. As states head toward the finish line of open enrollment they continue to ramp up their efforts to enroll individuals in coverage, including targeted outreach to the hard-to-reach and a ramp up of community events and in-person support. Below, we provide updates on activities and enrollment across the SBMs.
California
California chose to extend its enrollment deadline from December 15 to December 17 after receiving more than 55,000 applications during the final 48-hours of sign-up for January coverage—an increase of 23,000 applications from the same two- day period in 2014. As of January 2, Covered California reported more than 238,000 new consumers had signed up for coverage, which puts it ahead of projections. In addition, the most recent HHS data showed Covered California with 1.41 million consumers, including 1.18 million who were set to re-enroll, which is an increase of 210,000 over the previous year.
To target its enrollment efforts, Covered California used new maps that highlight neighborhood “hotspots” with high concentrations of uninsured, subsidy-eligible populations. The maps were developed using U.S. Census data and estimates of eligibility for coverage from a model of California insurance markets developed by the University of California, Los Angeles. Once regions of high uninsurance were identified, Covered California expanded the number of storefronts and community partners available in these neighborhoods and targeted local media in the preferred language of residents.
Covered California also teamed with community partners and insurance companies to open an enrollment center in the Los Angeles area, where consumers can immediately enroll in coverage. This enrollment center is the first of its kind in establishing regular hours, having prominent signage and having health insurance companies on site to provide information about benefits. Other targeted efforts included deployment of outreach teams to businesses frequented by targeted populations and a branded Covered California van (“Van with a Plan”).
In addition, Covered California reached out to new members by using “The Force” on social media prior to the opening of a new movie that seems to be pretty popular with the kids. May the coverage be with you.
Colorado
Connect for Health Colorado reports an all time high enrollment with more than 145,000 Coloradans enrolling in coverage between November 1 and December 15 (including over 116,000 enrolled in QHPs). On December 22 Connect for Health Colorado chose to extend its deadline for a second time to December 26. This followed an initial 48-hour deadline extension that generated increased interest and a snowstorm on December 17, which affected the ability of consumers to enroll. Based on the later deadline, additional enrollments for January 1 will likely be reported in the coming weeks.
Connecticut
Access Health CT (AHCT) has reported higher enrollment rates for 2016 over previous open enrollment periods. As of January 5 there are 104,363 consumers enrolled in a QHP. Of these customers, 22 percent are new to the marketplace.
AHCT has focused on reaching consumers on their electronic devices and in their communities. Through its “Get Covered CT” campaign (also available in Spanish at “Asegurate CT”), individuals can share their coverage status through text messages and opt in to text and/or email messages tailored to the registrant. AHCT has also increased the number of community events, called “Community Chats” which are hosted at places of worship, libraries, and schools in the communities where the uninsured work and live. AHCT reports it has developed 100 new organizational contacts through attendees at these chats.
District of Columbia
The DC Health Benefit Exchange Authority publicly releases enrollment information at its monthly Executive Board meetings. The latest numbers were released January 13. Since opening for business October 1, 2013 through January 11, 2016, 31,188 people have enrolled in individual market coverage through DC Health Link; 25,657 employees have obtained Small Business Health Options Program or SHOP coverage through DC Health Link; and 144,329 people have received Medicaid eligibility determinations through DC Health Link. DC Health Link also reported that to date 3,831 new customers have enrolled for 2016 coverage; 2,594 renewing customers had changed their health plans for 2016; and that DC Health Link had auto-renewed 14,108 individual market customers for 2016 coverage.
DC Health Link has focused on outreach events that attract the District’s young adult population. DC Health Link had major enrollment efforts tied in with the recent release of the newest Star Wars movie and on December 15 the SBM hosted a coverage “café crawl”, where teams of assisters and navigators with internet-ready laptops were stationed at three of DC’s most popular coffee shops..
Idaho
On December 18, Your Health Idaho reported that over 93,000 individuals had selected a QHP for 2016 through Your Health Idaho. This is a significant increase over the approximately 86,000 Idahoans enrolled in coverage for 2015. Your Health Idaho continues to strengthen its partnership with agents and brokers including the statewide enrollment event “Super Sign-Up Saturday” on January 16th.
Kentucky
Enrollment continues through Kentucky’s marketplace, kynect, although newly inaugurated Governor Bevin may propose changes. In a recent report, the United Health Foundation moved Kentucky up three spots in its annual ranking of state health – from 47th to 44th. A significant factor in the move was increased access to insurance, over the past two years the report found a 24 percent decrease in the uninsured across Kentucky. kynect has been continuing to use their successful “kynect stores,” which had extended hours over the holiday season.
Maryland
Similar to its counterpart in DC, the Maryland Health Connection (MHC) has also decided to increase its focus on the sometimes hard to reach “young invincible” population. The state launched the #HealthYeah campaign that stresses free, local, in-person enrollment assistance and financial assistance for most enrollees.
MHC is also trying to reach other more difficult to engage populations. Outreach activities include 16 weekend enrollment fairs, including on December 13 in Baltimore where Meredith Hurston, who blogs on health care resources geared to the African-American community hosted a live Periscope video stream / Q&A for consumers. Other events include a statewide “Library Enrollment Day” on January 9 where enrollment navigators staffed public libraries; a Hispanic-oriented enrollment fair on January 13 which included radio station “El Zol,” and “Super Health Sunday” on January 24 where navigators will be on hand to assist with enrollments at several predominantly black churches.
Enrollment numbers demonstrate the success of these efforts. As of December 28, 71,055 Marylanders have enrolled in a new Qualified Health Plan, and an additional 79,238 people have already renewed their plan for 2016.
Massachusetts
As of January 1, the Massachusetts Health Connector reported a total enrollment of 189,700 individuals, with more than 27,600 representing enrollees new to the marketplace. Reports from the state highlight that the open enrollment period has been smooth, with low wait times for its call center (average of 9 seconds) and an increased availability of in-person assistance.
For this open enrollment period, the Connector focused its outreach and education campaign on 10 priority communities with higher rates of uninsured residents. Messaging was delivered predominantly through spots on Hispanic TV and radio, as well as a significant investment in digital outreach, and was focused on benefits of coverage and the availability of support to both pick the right plan and complete the application.
Minnesota
Enrollment figures released by MNsure on January 4 showed 67,680 Minnesotans enrolled in a qualified health plan(QHP) by December 28. Of those QHP enrollees, approximately 40 percent are new to the exchange. This is in comparison to last year, where total QHP enrollment was 60,092 after the end of OE2.
Minnesota’s broker enrollment center initiative also continues to gain momentum in its second year of operation. To date, the 20 walk-in broker enrollment centers statewide have enrolled more than 3,160 Minnesotans in a QHP. That’s more than twice the number of QHP enrollments by the same group compared to this time last year. MNsure offers matching marketing funds to these brokers to help promote their business across the state, and uses them for earned media opportunities where appropriate.
New Mexico
beWellnm hit the ground running on November 1 with a robust schedule of events, a new consumer centric website, and advertising that targeted the rural and remote communities in the state. The exchange has hosted more than 249 outreach activities with 15,671 attendees since the launch of open enrollment.
Exchange outreach efforts have focused on reaching the Hispanic/Latino, Native American, and urban and rural communities by hosting scheduled events at Hispanic marketplace locations, in outlying rural communities, urban centers and pueblo communities. Additional efforts included bilingual town hall radio calls that feature a local celebrity who is highly regarded by the community, partnering with advocacy groups that work with the hard to reach communities, as well as presentations to civic organizations. beWellnm engaged outreach partners located throughout the state to focus on their communities and identified unique language and messaging to help them understand the benefits of having insurance and moving them to enrollment.
These efforts have led to a 47 percent increase of traffic to the call center from the first week of December to two weeks prior to the December 15 deadline. Additionally, the exchange moved from a referral – only call center to a certified application counselor or CAC certified call center, which may have increased enrollment and provided a better consumer experience. As of December 26, 46,816 individuals are enrolled for 2016 coverage.
New York
In recent weeks, New York State of Health has reported significant activity on its website (43 million page views, 1.8 million individuals using the anonymous shopping tool) and at its call center (averaging over 34,000 calls a day leading up to December 15). Based on this interest, the state pushed back its deadline for January enrollment from December 15 to December 19.
New to the market this year is the state’s Basic Health Plan, called the Essential Health Plan, which provides low- to almost no-cost coverage to individuals with incomes between 138% and 200% of the federal poverty level. New York State of Health has developed a marketing campaign promoting the plan, with a digital spokesperson named “Essie”, targeted at young New York residents.
Rhode Island
On January 6, Health Source RI reported that 34,627 individuals have enrolled in a QHP for 2016. Of these enrollees, 4,462 represent individuals who are new this year.
Rhode Island extended its January enrollment deadline to December 29 to accommodate the surge of calls received by the SBM leading up to its previous December 23 deadline. To help drive enrollment, HealthSource RI has continued to offer a significant number of in-person assistance events (with over 20 scheduled for OEIII), including an Enrollment Fair with all the participating insurers that took place on December 1.
Vermont
In mid-December, Vermont Health Connect launched a new plan comparison feature on its website that will allow potential enrollees to review costs across different health care plans. The tool allows individuals to compare the costs of major medical procedures, premiums, and out-of-pocket costs in various plans and is designed to give consumers an educated look into their potential health care spending for 2016. Vermont Health Connect is hopeful the tool will help Vermonters make more informed choices when selecting a plan for the upcoming year.
Washington
As of January 6, the Washington Healthplan Finder reported that it had 173,947 individuals enrolled in QHP coverage for January 1. During OE3, Washington Healthplan Finder has worked on its partnerships with small local businesses and the broker community through its events, storefront, and referrals.
The exchange has been particularly successful at reaching the young, “invisible” population. More the 50,000 residents under the age of 35 signed up for insurance through the exchange in the first weeks of open enrollment, representing a 66 percent increase in young adult enrollment over last year.
NASHP will continue to update the progress during this open enrollment period as we move towards the January 31 deadline. We encourage you to check back on the blog for the latest.
Will There Be State Innovation Under Section 1332 Waivers?
Will there be state innovation under Section 1332 Waivers?
Since the ACA was enacted in 2010, a number of states have been looking at the law’s State Innovation Waiver, also known as Section 1332, as a way to reimagine the ACA’s approach to health insurance coverage. Apart from final rules issued in 2012 that focused on the process for application, timing and content of any waiver application, CMS had released little information about how Section 1332 would be interpreted, leading a number of states to dream big. However, the new guidance released on December 12 by the Departments of HHS and Treasury suggests states may have a harder time hitching their grand plans to Section 1332 waivers and leaves us wondering: will there be state innovation under Section 1332?
As a reminder for those who haven’t followed this as closely, Section 1332 allows states to request a waiver from any of the following four ACA coverage requirements: 1) the individual health coverage mandate; 2) the employer mandate; 3) benefit and subsidy requirements; or 4) use of exchanges and qualified health plans (QHPs) to enroll consumers into coverage. However, any waiver application must guarantee that the scope, comprehensiveness, and affordability of coverage will be comparable to that provided under current ACA rules and cannot increase the federal deficit. In addition, states are barred from waiving insurance market guaranteed issue or related rating rules. States are permitted to submit a single application for waiver of Medicaid, Medicare or other tax rules and the ACA requires the HHS and Treasury Secretaries to coordinate Section 1332 review with other waivers.
NASHP hosted a session on 1332 waivers at its annual conference in Dallas in October 2015. At the session, Deborah Bachrach of Manatt Health Solutions provided a detailed overview of 1332 waivers and offered some helpful hints for states considering them. State officials that participated on the NASHP panel illustrated the wide continuum of approaches states are considering, from precise changes to tinker and adapt the ACA coverage model to ideas that entirely reimagine coverage.
For example, Minnesota’s Medicaid agency and the Governor’s Health Care Finance Task Force has been considering Section 1332 as an option to help the state simplify the ACA’s eligibility requirements, increase volume for value-based purchasing approaches, provide additional subsidies to smooth premium and cost sharing cliffs between programs, align requirements for Medicaid and private managed care entities, or support financial sustainability of their state-based marketplace. By contrast, another state panelist suggested that 1332 waivers could allow states to access tax and Medicaid funds to support private, defined-contribution models of coverage. One example envisioned a state developing a new coverage model relying on Medicaid to fund the purchase of either employer-sponsored coverage (where offered) or individual market plans, with defined contribution health savings account or high-deductible health plan options to control costs. While not actively under consideration, the panelist suggested this more expansive approach to Section 1332 might appeal to some states that have not otherwise embraced the Medicaid expansion.
The new HHS and Treasury guidance may deter many states from pursuing more expansive ideas for Section 1332. By establishing a series of high benchmarks states must meet to get waiver approval, with a strong emphasis on ensuring that the vulnerable, low-income populations the ACA supported are protected, the guidance hews closely to the letter and spirit of the ACA but may make it harder for states to demonstrate compliance with new, innovative ideas. In brief, the rule creates three important hurdles for states seeking 1332 waivers: (1) substantive comparability standards; (2) deficit neutrality requirements; and (3) administrative capacity. (For a more detailed review of the new requirements, see Tim Jost’s excellent Health Affairs blog.)
Substantive Comparability. The new guidance sets minimum thresholds to determine whether the proposed 1332 waivers provide coverage that is comparable, affordable, and as comprehensive as that otherwise available under the ACA. For example, to meet the comparability requirement, states will have to demonstrate that they are covering a comparable number of individuals, that the coverage they are providing meets the minimum essential coverage (or an alternate standard), and ensure there is no adverse impact for all residents including the most vulnerable. To show affordability, states will need to demonstrate there’s no adverse impact on all forms of individual cost-sharing and that coverage meets an actuarial value of 60 percent, complies with ACA out-of-pocket limits, and meets Medicaid affordability requirements, taking into account employer contributions toward coverage and wages. Comprehensiveness of coverage will be measured by whether the benefits provided under a waiver program meet the essential health benefits (or Medicaid/CHIP, if appropriate) requirements, with focus on benefits provided to vulnerable groups. By sticking to the letter and spirit of the ACA’s requirements, the guidance ensures that state 1332 waiver proposals will need to mirror the ACA’s coverage footprint, which may be challenging for states to demonstrate prospectively for entirely new coverage arrangements.
Deficit Neutrality. The deficit neutrality test in the guidance requires states to take into account the full range of federal spending, including federal premium tax credits, cost-sharing reductions, small business tax credits, revenues from tax penalties on individuals or employers, the “Cadillac tax” on employers for high-cost plans and any changes in employment income or payroll that affect federal tax revenues. Federal spending for Medicaid will also be considered, but any cost-savings included in a Section 1115 waiver submitted as part of a 1332 waiver request will not count toward the deficit neutrality analysis (although Medicaid savings in a 1332 waiver can be considered). Pass-through funds that the state can use to fund its 1332 waiver will include federal spending for subsidies that would have otherwise been spent, but cannot access federal administrative cost savings. Also, the guidance states that any necessary waivers submitted with 1332 waivers will be considered “independently” by respective agencies, which also dashes states’ hopes for a more combined, coordinated approach that ensures a more holistic review at the federal level. Is is also unclear how and whether states will be able to make calculations about the prospective impact of their 1332 proposal on whether employers offer coverage or choose to alter the scope of benefits or wages.
Administrative Oversight. The guidance also clarifies that federal administrative support for state 1332 waiver implementation will be limited. Because the FFM and the IRS have limited capacity to administer customized approaches for calculating federal assistance, enrollment periods, and plan options, states seeking to implement 1332 waivers that want customization will have to use or build their own exchanges and tax systems to administer them. This sets a high bar for states that have not built their own exchanges already, given that they need to provide 21 months notice before implementing and that there are no longer federal funds available to support implementation of a state-based marketplace. For these reasons, this new guidance appears to reduce the likelihood that states participating in the federally facilitated marketplace (FFM) will be able to consider 1332 waivers.
The new federal guidance on Section 1332 waivers sets the bar high for states seeking to make changes. While consistent with ACA-supported policy, the new, more stringent standards for comparability and the administrative complexities of proving deficit neutrality and administering a new program may deter states with grand coverage plans from seeking 1332 waivers in the near term. At the same time, states with more modest administrative goals that fit within the ACA framework and already have administrative structures in place (e.g., Minnesota, Massachusetts, possibly Hawaii) may not be deterred.
Section 1332 remains an option and opportunity for state innovations to improve on the ACA. Whether and how more states will use this option in 2016 is still an open question. NASHP will continue to track and report on this as state innovation unfolds.
An Update on Open Enrollment in the State-Based Marketplaces
The winter holiday season is in full swing and as many people are counting down to their celebrations, the health insurance marketplaces are counting down to their December enrollment deadlines to ensure consumers are covered by January 1.
To date, the marketplaces have reported steady progress on enrollment. As of November 28, CMS reported that over two million individuals selected plans in the 38 states using Healthcare.gov, inclusive of individuals who will automatically be reenrolled in their coverage in December. Enrollments in the federal marketplace states, including federally-facilitated marketplace states and states that share the federal technology platform,[1] range from 4,356 qualified health plan (QHP) selections in Alaska to 444,711 QHP selections in Florida.
State-based Marketplaces (SBMs) have different methods to count and manage enrollment, reflecting the variety of strategies in which SBMs are engaging to monitor enrollment priorities. Below, we share enrollment updates from the SBMs as they wrap-up the first month of open enrollment.
CALIFORNIA
As of December 7, California reported that more than 78,000 new marketplace consumers had selected QHPs through Covered California—an average of 2,000 individuals per day since the launch of open enrollment. Individuals renewing their enrollment will be auto-renewed, unless they revise their plan selections prior to the end of open enrollment. After the first few weeks of open enrollment, California reported enrollment of more than 33,000 individuals in its family dental plan offerings, new for 2016. Learn more about dental coverage and the marketplaces in Dental Benefits and Health Insurance Marketplaces: An Update on Policy Considerations.
One draw for consumers has been Covered California’s focus on eliminating consumer confusion while shopping for health insurance. Consumer Reports recently honored Covered California on its 2015 Nice List for these efforts, including the marketplace with companies such as jetBlue, Target, and Chipotle.
COLORADO
More than 46,000 enrollees have obtained coverage through Connect for Health Colorado inclusive of QHP, Medicaid, and Child Health Plan Plus (CHIP) enrollees through November 29. Colorado reports early significant gains, resulting from the many system improvements it implemented for this year. Colorado also focused on improved outreach resources, including the launch of a new tool to connect consumers directly with brokers for enrollment assistance. This tool yielded 622 leads within the first week of open enrollment. Similarly, a new tool to support in-person assistance accounted for more than 800 appointments scheduled with consumers by the end of week one.
CONNECTICUT
Connecticut reported more than 99,100 enrollments in QHPs, inclusive of 5,400 new enrollees, as of November 17. In addition, nearly 24,000 individuals had been determined eligible for Medicaid through Access Health CT. The state revamped its marketing and outreach strategy for this open enrollment season, focusing on reaching “community influencers,” and identifying many unique target segments including African Americans, Polish, Asians, French/Creole, Brazilians, and Hispanics. To draw in broker assistance, Connecticut launched a new broker-focused mobile app that has been billed as a “game changer.” Moving into the holidays, Connecticut is partnering with many local charity initiatives to spread the news about coverage, while also supporting a cause. This includes participating in NBC’s Joy of Sharing Food and Toy Drives and volunteering its enrollment centers as drop-off locations for the Gr8 Holiday Give benefiting Toys for Tots.
DISTRICT OF COLUMBIA
At 5.3 percent, the District of Columbia boasts the third lowest uninsured rate in the country after two years of marketplace operation. Based on the most recent Census data, the District of Columbia achieved a 20 percent drop in the rate of uninsured in 2014. For this open enrollment period, DC Health Link has committed to a citywide call to action to “Each One, Link One” to reach universal coverage in the District. Target populations include African Americans, Hispanics, Asian-Pacific Islanders, LGBTQ communities, and millennials. Enrollment campaigns encourage individuals and communities to “be the link” to coverage for the uninsured. DC Health Link officials have also been very active in community engagement and outreach work from participation in local community fests, to Spanish language Sunday masses, to posting a table at concession stands during blockbuster movies, such as the “Hunger Game’s Mockingjay Part II” the upcoming opening of “Star Wars: The Force Awakens”. DC Health Link is also experiencing benefits from system enhancements made for this year, including reductions in average call times and increased active shopping for plan renewals.
IDAHO
Idaho has successfully completed automatic renewals for all of its 86,000 QHP enrollees. Your Health Idaho (YHI) reports that this year they are offering consumers more plan choices than ever before, including the addition of adult dental coverage. Additionally, YHI has trained and certified more than a thousand agents and brokers to act as personal shoppers for consumers. In January, agents across the state will host a Super Sign Up Saturday for consumers.
Affordability remains a key message in Idaho and YHI is driving awareness of the tools and resources that are available to help Idahoans find the plan that is best for them and their families.
KENTUCKY
Much attention has focused on the implications of the most recent gubernatorial election on the future of kynect, Kentucky’s marketplace. Potential changes to the marketplace are unlikely to occur until next year; meanwhile open enrollment is in full swing with the marketplace. Kentucky has experienced the highest reduction in its uninsured rate of any state, with more than half a million consumers finding coverage through the marketplace. For this open enrollment period, kynect has been equipped with even more tools to assist consumers including an updated mobile app, and a new cost-calculator. Kynect is also continuing use of its “kynect stores;” last year, one store welcomed 7,600 visitors and processed 6,000 applications. Consumers can use kynect’s “power towers” (pictured) to charge their cell phone while checking their eligibility or applying for coverage.
MARYLAND
Maryland has enrolled 36,483 individuals in qualified health plans through Maryland Health Connection through Dec. 6, and an additional 130,505 in Medicaid for a total of 166,988 individuals since open enrollment for 2016 began on Nov. 1. An additional 100,000 individuals who enrolled for 2015 are eligible for “passive renewal” into their same or comparable plans in January. Like California and Idaho, Maryland is offering adult dental for the first time and 9,853 have enrolled in a dental plan for 2016 as of Dec. 6. A “Health Yeah!” marketing campaign was launched to help drive more young people to enroll. The Maryland Health Benefit exchange has also launched the “BATphone” (Broker Assistance Transfer) that enables “warm handoffs” of a customer from the call center to a participating broker. The pilot program has resulted in 490 enrollments from 887 calls so far.
MASSACHUSETTS
Massachusetts has reported a much smoother enrollment process with 2,645 eligibility determinations reported through the Health Connector after (approximately) the first two weeks of the enrollment season. Expanded in-person service centers have been a key part of consumer assistance, serving more than 800 customers at the time of their report. Also noted were improvements to the Connector’s call centers, which have reduced both wait times and total call times in this year. This is in part likely attributed to extended call center hours and increased call center staffing implemented for this year.
MINNESOTA
Minnesota reports 23,181 enrollments through MNsure, as of November 17, inclusive of 6,864 QHP enrollees, 11,226 enrollees in Medical Assistance (Minnesota’s Medicaid program), and 5,091 enrollees in MinnesotaCare (Minnesota’s Basic Health Plan). In addition, 363 Minnesotans have enrolled in a qualified dental plan. Responding to high growth in premium rates, MNsure has strongly encouraged consumers to take advantage of the tax-credits and cost saving reductions available to consumers through MNsure. MNsure reports that more than 70 percent of customers have qualified for financial assistance so far this open enrollment season, a 20 percent increase over previous enrollment years Beyond implementation of new plan comparison tools and increased call center staff to support consumers, MNsure has also touted the importance of local partnership to reach consumers, such as connections with local brokers for personal assistance to connecting with programs that assist specific populations, such as those with mental illness.
NEW YORK
Aiming for a “Marvel-ous” open enrollment season-New York included Marvel comic charters as spokespeople during a statewide mall tour—the state’s coverage strategy is focused on achieving a statewide goal of one-million fewer uninsured individuals by the end of 2016. Beyond its statewide mall tour, NY State of Health has partnered with pharmacies to host over 100 educational events across the state. In the spirit of the holidays, the marketplace partnered with Equinox, a local non-profit serving homeless, behavioral health, and domestic abuse populations, to share Thanksgiving meals while also sharing information about coverage availability.
RHODE ISLAND
As of November 28, HealthSource RI reports 31,238 QHP enrollments, with over 85 percent of enrollees qualifying for financial assistance. Addressing limitations imposed by reductions in the marketplace’s budget, HealthSource RI is focused on continuing to improve consumer service for marketplace customers, including a ramp-up of call center staff and encouragement for consumers to use various tools available through the marketplace website.
VERMONT
After two weeks of open enrollment, Vermont has completed automatic processing of over 18,000 QHP renewals. Last year, the state conducted renewals manually—a process not completed until more than three months into open enrollment. Vermont’s efforts leading up to open enrollment concentrated on system improvements to ensure smoother experiences for consumers such as new self-service features that enable customers to complete changes and updates online, rather than through the call center. Officials anticipate a “surge” in enrollments during this year, and while the state is still working out some fixes, it has committed that “we owe [it] to Vermonters” to fix any problems found.
WASHINGTON
On November 19, Washington reported approximatley 150,000 QHP enrollees through the Washington Healthplanfinder, putting the state within 90 percent of its projected enrollment figure of 165,000 individuals by the end of the enrollment period. Washington has identified three Cs important for consumer consideration when selecting plans: cost, coverage, and convenience, encouraging consumers to spend some time shopping its “new, better, and more affordable” options. Washington is also encouraging consumer education about coverage through the “know your plan” resources available on the Healthplanfinder website. The Healthplanfinder is also hosting a series of Facebook “office hours” to enable consumers to get real time responses to questions from enrollment specialists.
Enrollment deadlines are December 15 for most marketplaces (December 23 in Massachusetts, Rhode Island, and Washington) to receive coverage by January 1. This report reflects a point-in-time summary; we encourage you to stay tuned for more analyses throughout open enrollment as states continue to report on their progress.
[1] FFM: Federally-facilitated marketplace states; SPM: state-partnership marketplace states; SBM-FP: state-based marketplace states using the federal technology platform.
Dental Benefits and Health Insurance Marketplaces: An Update on Policy Considerations
The Affordable Care Act (ACA) includes pediatric dental services as one of ten Essential Health Benefits that health plans in the small group and individual markets must cover. Adult dental services are not required, but are being offered by marketplace plans as well. However, the way that the ACA structures dental coverage has created a number of implementation challenges relating to affordability, benefit design, and consumer experience.
In 2014, the National Academy for State Health Policy (NASHP) examined these issues in a comprehensive report. In early 2015, NASHP convened a follow-up call with marketplace and dental leaders to discuss progress on addressing these issues.
This brief provides an update of current activity across the marketplaces. Key issues addressed include:
- Impact of decisions to offer pediatric dental coverage through medical plans or stand-alone dental products on affordability and implementation of marketplace systems;
- State interest in offering optional adult dental coverage;
- Enhancing data and reporting on access to and purchase of dental coverage;
- Improving outreach, enrollment, and dental plan quality;
- Impact of future state and federal decisions about coverage programs on dental coverage through marketplaces, including decisions about federal funding for the Children’s Health Insurance Program (CHIP).
| Read full brief here |
And They’re Off: New State-based Marketplace Consumer Services and Supports Launch for OE3
On November 1, health insurance marketplaces officially opened to millions of individuals for 2016 enrollment. Early reports indicate a smooth launch of the open enrollment season, partially due to several new tools to ease enrollment and renewal processes for marketplace consumers.
Smarter Plan Comparison Tools
Recent articles have featured the many new shopping tools available on healthcare.gov, the health insurance marketplace used by the 38 states opting to use the federal platform. Similarly, many states operating their own marketplaces are launching a slew of new tools that will enable consumers to make smarter choices across their coverage options. New or enhanced “shop-and-compare” tools in California, Connecticut, Massachusetts, Minnesota, and the District of Columbia will enable consumers to make informed comparisons across their plan choices. Kentucky’s tool allows consumers to enter basic information about health conditions, medications, and frequency of doctors’ visits to generate plan recommendations and costs. Similarly, Connecticut’s tool allows consumers to select from a list of common medical conditions, which they can also rate by severity, to calculate costs. Furthermore, the tool is connected to the state’s all-payer claims database (APCD) to draw in more accurate and real-time data on costs.
Smoother Enrollment and Renewal Experiences
Improved system performance was the focus of several states, including Rhode Island and Vermont, which installed major systems upgrades to fix enrollment glitches from prior years. The District of Columbia has streamlined its online application; reducing the number of screens a consumer will “touch” to complete his or her application from 28 to eight. To ease traffic, which can slow systems, Idaho and Maryland enabled advanced plan browsing, encouraging consumers to educate themselves early about their plan options. California allowed current enrollees to come in as early as October 12 to renew plans, or shop for a new one.
Improved Provider Directories
States are easing consumers’ ability to find information about provider networks through marketplaces plans. The District of Columbia’s new Doctor Directory allows consumers to search for providers by name, location, specialty, and language(s) spoken (English or Spanish). To ensure accuracy of information, the District has also implemented a monthly reporting mechanism to inform both health plans and the marketplace about inconsistencies in Directory information. Massachusetts’ provider search can provide information about which plans include inputted physicians, and acute-care hospitals. In the future, the state is considering adding community health centers, mental health providers, and social workers to the searchable list. Maryland will continue to have its provider search tool managed by the state health information exchange, known as CRISP, which enables real-time information sharing about providers in both commercial and Medicaid coverage.
Enriched Customer Service and Support
Adapting to reach both the remaining uninsured as well as the evolving needs of current consumers, states have revamped their consumer support strategies to serve their target consumers. California is doubling the number of “storefronts” it will open during this enrollment period to provide consumers with in-person support services. Minnesota is tripling the number of enrollment centers it will open to allow consumers to get assistance from certified brokers and navigators as well as piloting a new portal to facilitate the ability of assisters to complete applications on behalf of enrollees. Massachusetts has opened four new walk-in centers, including three at community health centers, to offer expanded face-to-face assistance to applicants. Maryland is launching a pilot that will enable its call center to transfer applicants directly to brokers to complete enrollment—giving consumers access to enrollment experts while reducing the burden on its main call center staff. Washington has updated its online consumer resources including a new enrollment guide and glossary of key terms.
Open enrollment runs from November 1, 2015 through January 31, 2016. Over that time, we will monitor enrollment activity across all marketplaces and share updates about how states are working to bring new consumers to their doors including targeted marketing and use of data and surveys to direct outreach work.
Keeping a Focus on Children During Open Enrollment
The Affordable Care Act’s (ACA) third annual open enrollment period kicked off November 1st and continues through January 31, 2016. During this time, individuals can enroll or renew coverage in qualified health plans through state and federal exchanges. The ACA’s open enrollment period is a great time to focus on reaching and enrolling children as well as their parents and other eligible adults. Research shows that parents who are enrolled in health coverage are more likely to enroll their children in coverage.
Although, very few children obtain their coverage through exchanges, as they are predominately enrolled in employer sponsored insurance or are eligible for Medicaid and CHIP, the Children’s Health Insurance Program (for which enrollment is open year round), open enrollment is a good time to remind families about the public and publicly subsidized coverage available for their children. By capitalizing on the current increased attention on health coverage, there are steps states can take to make sure children are part of outreach, enrollment and retention efforts.
NASHP recently published an issue brief that shares state strategies for reaching, enrolling, and retaining children in coverage during early implementation of the ACA. The promising practices discussed in the brief were surfaced during work with NASHP’s Children in the Vanguard network which, since 2011, has brought together teams of state Medicaid and CHIP officials with child health advocates to work together to advance child’s coverage. Many of the promising practices included in the paper are the direct result of the strong working relationships established between state officials and advocates.
State teams took creative approaches to maintain a focus on children’s coverage, and their strategies emerged in themes:
- Targeting outreach efforts to specific populations
In Ohio, Medicaid officials engaged underserved minority communities to reduce enrollment barriers.
- Engaging and educating new partners
Rhode Island child health advocates developed a business process plan to engage partners, such as WIC offices, in a new Medicaid and CHIP renewal process.
- Keeping children enrolled in coverage
In Washington, officials created a streamlined renewal form for Medicaid and CHIP, and the state has seen its retention rate for family, children, and pregnancy Medicaid cases increase from 84 percent before 2014 to 91 percent today.
For more examples of ways state officials and advocates are working together to advance children’s coverage, read Promising Practices in Reaching, Enrolling, and Retaining Children in Coverage During Early ACA Implementation.
Health Centers’ Role in Affordable Care Act Outreach and Enrollment: Experience from Kentucky and Montana
The Affordable Care Act created new opportunities for health centers and primary care associations (PCA) to play a leading role in supporting outreach and enrollment into new and expanded health coverage programs. Health centers and PCAs received new funding, sometimes from multiple state and federal entities, new training and tools, and a new mandate to find and enroll eligible individuals, both within their patient caseload and in the broader community. In undertaking this charge, many health centers and PCAs found themselves engaging new partners, building stronger relationships with state Medicaid and insurance or exchange agencies, and often playing a central role in coordinating outreach and enrollment activities in their state or community.
To better understand the new roles of these entities and identify promising strategies in their coordination with state Medicaid and insurance/exchange agencies, NASHP undertook a case study review of Kentucky and Montana, two states with strong enrollment performance where the state PCA and health centers played an important role. With support from the Health Resources and Services Administration’s National Organizations of State and Local Officials Cooperative Agreement, NASHP interviewed representatives from the PCA, a health center, and a Medicaid agency in each state about their respective roles in and coordination of outreach and enrollment assistance during the first two years of Affordable Care Act implementation.
Findings from these interviews are summarized here, with case studies highlighting each state’s circumstances and experiences, followed by a discussion of common themes relating to collaboration with state and federal agencies, lessons learned, and future priorities for outreach and enrollment work with states.
State Marketplaces’ Proof Is in their Performance at Congressional Oversight Hearing
Last week, six state-based marketplace directors (CA, CT, HI, MA, MN, and OR) testified before the U.S. House of Representatives Energy and Commerce Committee’s Oversight and Investigations Subcommittee, where they faced tough questions on their marketplace performance, impact and future prospects. The hearing was notable for its intensive focus on operations, signaling a new emphasis on marketplace performance and outcomes. For those who missed it, here’s our recap on the highlights.
Marketplace Enrollment and Coverage: Marketplace and Congressional leaders shared evidence of a number of positive impacts that state-based marketplaces have had on the health care system including lower rates of uninsured, increased plan choice and competition, and steady or reduced growth of health insurance plan pricing. Five states, including Massachusetts, have lowered their uninsurance rates to below five percent. Connecticut testified that marketplace enrollment has exceeded federal goals by 200 percent while competition and oversight have kept marketplace premium rates flat. California noted that its active purchaser strategy, which requires issuers to offer the same benefits package so consumers can easily compare plans, has resulted in improved access to preventive care for most enrollees. California also testified that each resident will have at least three plans to choose from during the 2016 open enrollment period.
Improving Governance and Project Management: Subcommittee members and marketplace leaders freely admitted that marketplaces had seen their share of implementation challenges, including tight timeframes and mistakes in managing state and vendor work. States testified about changes they are implementing to improve operations, including reorganized governance structures, stricter project management, and new, more robust workplans. Massachusetts has replaced managers and hired for skills in IT systems oversight, and reestablished a formal governance structure with clearer reporting authority to the Secretary for Health and Human Services to strengthen the integration of marketplace and Medicaid systems. Oregon has moved its marketplace from an independent entity to a state agency charged with insurance market oversight, which allows for improved coordination, accountability, and economies of scale in staffing. Minnesota and are establishing new oversight and advisory authorities. Also suggested was stricter adherence by states and CMS to performance measurement gateways already developed for the marketplaces such as adherence to marketplace Blueprints.
Financing and Sustainability: Subcommittee members peppered state marketplace leads with detailed questions about budgets and sustainability. All states, reported they are on track to achieve financial sustainability, except Hawaii, which will transition its marketplace to the supported state-based marketplace model. Members raised concerns and signaled further investigation into state marketplaces’ operational and establishment spending, especially the use of federal establishment grants. While these grants were intended to only fund activities related to establishment, not operations, of the marketplaces, a lack of clarity on the definition of these types of activities has led to some confusion over appropriate use of funds. All states testified that they had not spent federal grants outside of the authority given to them under CMS, with the exception of Hawaii, which noted one item that it is in the process of reconciling with auditors before funding would be released. Where they had figures available, states shared details about operational and establishment budgets, with others expressing ability to review and report back further details to the Subcommittee. States also clarified that any funds granted to a state, but not ultimately approved for use by CMS would remain with the federal government.
Addressing Consumer Needs and Services: Each state has taken concrete steps to improve system functionality and implement new tools to better serve consumers. Many states reported positive utilization and consumer satisfaction survey findings during last year’s open enrollment period. Minnesota reported that more than 500,000 individuals had used their site, MNSure, to compare, shop and purchase coverage. Connecticut reported that 96 percent of consumers found the AccessHealth CT site easy to use. For the next open enrollment period, Minnesota is adding functionality to its enrollment system, improving website performance and Medicaid system functionality. Massachusetts is planning to improve customer service by adding four additional walk-in centers and evening and weekend hours to reduce call center demand.
Focus on Performance: Subcommittee members repeatedly asked for evidence of state performance, seeking a detailed accounting on state spending, state governance and oversight, federal audits, and renewal data. While state exchanges are already complying with substantial federal and state oversight and reporting requirements, as detailed in a NASHP brief released this week, the hearing indicates an increased focus on state outcomes and performance that state exchanges will want to heed for future years. Also underscored was that the marketplaces, by their nature as IT projects, are not static, and will continue to evolve and improve over time, something that should be accounted for as part of future oversight.
Looking ahead, most state marketplace leads said covering the remaining uninsured and for the marketplace were among their top priorities. . States and members also discussed the role of the marketplaces in the context of health care reform including improving access to higher value care. Importantly, states highlighted the value of flexibility as state-based marketplaces to tailor marketplace policies and structures to adapt to unique state needs and priorities (e.g., providing subsidies to a greater range of low-income individuals in Massachusetts or pursuing an active purchaser model to set benefit standards in California). How these and other state marketplaces demonstrate their value in innovating and improving coverage, in their own states and for the nation, will certainly be a topic for continued conversations in the years ahead.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
