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Updated Aug 18, 2021

This chart describes the regular and special enrollment periods when individuals may sign up for health insurance coverage through either the federal marketplace (healthcare.gov, which 36 states use) or state-operated marketplaces (used by 14 states and Washington, DC).

Marketplace	Original 2021 Open Enrollment Period	2021 COVID-19 Special Enrollment Period (SEP)
Federally facilitated marketplace (36 states)	Nov. 1 – Dec. 15, 2020	Feb. 15 – May 15, 2021*
State-Operated Marketplaces
California	Nov. 1, 2020 – Jan. 31, 2021	Feb. 1 – May 15, 2021 and April 12- Dec. 31, 2021**
Colorado	Nov. 1, 2020 – Jan. 15, 2021	Feb.8 – Aug. 15, 2021
Connecticut	Nov. 1, 2020 – Jan. 15, 2021	Feb. 15 – April 15, 2021 and May 1- Oct 31, 2021
DC	Nov. 1, 2020 – Jan. 31, 2021	Jan.1, 2021 – Jan. 31, 2022***
Idaho	Nov. 1 – Dec. 31, 2020	Mar. 1- April 30, 2021
Maryland	Nov. 1 – Dec. 15, 2020	Jan. 1 – Aug 15, 2021
Massachusetts	Nov. 1, 2020 – July 23, 2021
Minnesota	Nov. 1 – Dec. 22, 2020	Feb. 16 – July 16, 2021
Nevada	Nov. 1, 2020 – Jan. 15, 2021	Feb. 15 – August 15, 2021
New Jersey	Nov. 1, 2020 – Jan. 31, 2021	Feb. 1 – Nov. 30, 2021
New York	Nov. 1, 2020 – December 31, 2021
Pennsylvania	Nov. 1, 2020 – Jan. 15, 2021	Feb. 15 – Aug. 15, 2021
Rhode Island	Nov. 1, 2020 – Jan. 23, 2021	Feb.1 – Aug. 15, 2021
Vermont	Nov. 1, 2020 – Dec. 15, 2020	Feb. 16 –Oct. 1, 2021
Washington State	Nov. 1, 2020 – Jan. 15, 2021	Feb. 15 – Aug. 15, 2021

*Heathcare.gov opened a special enrollment period as a result of President Biden’s Jan. 28, 2021 executive order designed to strengthen Medicaid and the Affordable Care Act enrollment.  

**California closed its COVID-19 SEP on May 15, 2021 and reopened a new, separate SEP in response to the American Rescue Plan Act on April 12, 2021.

***Washington, DC will extend its COVID-19 SEP through the last day of the DC Health Link Individual & Family 2022 Open Enrollment Period (January 31, 2022), unless the District of Columbia COVID-19 Public Health Emergency (PHE), as declared by the Mayor, is still in place on that date, in which case the SEP is available until the end of the month in which the PHE ends.

American Rescue Plan Could Significantly Enhance Health Insurance Coverage

March 1, 2021/in Policy Blogs, Featured News Home CHIP, Consumer Affordability, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Relief and Recovery, State Insurance Marketplaces /by Christina Cousart and Anita Cardwell

Last week, the House passed the American Rescue Plan Act of 2021 (ARPA). The $1.9 trillion relief package’s current proposals would change health coverage programs, including Medicaid, health insurance marketplaces, and continuation coverage offered through the Consolidated Omnibus Budget Reconciliation Act (COBRA).

If enacted, the changes could have significant ramifications for states and individuals served by these programs. States should be prepared to act quickly to implement and/or respond to the changes, some of which will be effective immediately upon passage.

ARPA is now before the Senate, which may make modifications and will review its provisions to determine if they meet budget reconciliation rules. Both House and Senate leadership have expressed strong interest in quickly passing the legislation, with passage possible by mid-March.

The following highlights key proposed Medicaid and Children’s Health Insurance Program (CHIP) changes as well as provisions designed to help increase access to affordable care for individuals who have lost employer-sponsored insurance.

Key Medicaid and CHIP Provisions

Coverage of COVID-19 vaccines and treatment under Medicaid and CHIP:

Requires Medicaid and CHIP coverage of COVID-19 vaccines and treatment without cost sharing for all eligible enrollees;
Increases federal medical assistance percentage (FMAP) to 100 percent for vaccine administration for one year after the end of the public health emergency (PHE); and
Provides an option for states to provide coverage of COVID-19 vaccines and treatment without cost sharing for uninsured individuals at 100 percent FMAP.

Option to provide additional Medicaid and CHIP postpartum coverage:

Allows states to extend Medicaid or CHIP coverage for 12 months after childbirth. (This option would be available for seven years).

Enhanced FMAP for mobile crisis intervention services:

State option would provide Medicaid coverage for qualifying community-based mobile crisis intervention services.
Provides 85 percent FMAP for these services. (This option would be available for five years.)

Temporary FMAP increase to incentivize Medicaid expansion:

Provides 5 percentage point FMAP increase to states’ base FMAP rates for eight calendar quarters to states that opt to implement the Affordable Care Act’s Medicaid expansion after enactment of the American Rescue Plan. (This increase is in addition to the temporary 6.2 percentage-point FMAP increase available during the PHE provided by the Families First Coronavirus Response Act)
FMAP increase applies to all Medicaid eligibility groups except the expansion group. Newly expanding states would receive the current 90 percent FMAP provided for the expansion group.

Temporary extension of 100 percent FMAP for care provided at Urban Indian Organizations and Native Hawaiian Health Care Systems:

Provides 100 percent FMAP for eight calendar quarters for services provided at Urban Indian Health Programs or the Native Hawaiian Health Care System to Medicaid enrollees.

Sunset of Medicaid Drug Rebate Limit:

Beginning in calendar year 2023, this provision would eliminate the cap on Medicaid drug rebates.

Temporary enhanced FMAP for home- and community-based services:

Provides 7.35 percentage-point FMAP increase for one year to help states implement improvements to Medicaid home- and community-based services.

Creation of state strike teams for nursing facilities:

Provides $250 million to the US Department of Health and Human Services for states to create strike teams to help nursing facilities manage COVID-19 outbreaks.

Key Private Market Coverage Provisions

Support for continuation coverage through COBRA:

Provides federal funding so that individuals would only have to pay 15 percent of their premiums toward COBRA coverage. COBRA allows individuals who have experienced job loss to continue enrollment in their employer-sponsored health insurance plan for a period of up to 36 months. Normally, individuals pay 100 percent of COBRA premiums. Federal funding will be available through Sept. 30, 2021.

Requires employers to provide updated information to qualifying employees about the program and be prepared to expedite review for any employees who are denied premium assistance.

Enhanced tax credits to purchase coverage through health insurance marketplaces:

Provides a two-year enhancement to premium tax credits (PTCs) available to eligible individuals who qualify to purchase coverage through health insurance marketplaces. The enhancements both increase the amount of PTCs available at all income levels and eliminate the 400 percent earnings (of federal poverty level – FPL) limit to qualify for PTCs.
Funding would cap monthly premiums at no more than 8.5 percent of an individual’s income.
The PTC enhancements would be available for the 2021 and 2022 plan years. Individuals who are currently enrolled in marketplace coverage would be eligible for rebates to cover expenditures already made toward 2021 coverage.
Disregards income above 133 percent of FPL for purposes of calculating eligibility for PTCs for any individual who receives unemployment compensation in 2021.
For more information about these proposals, read the February, 2021 National Academy for State Health Policy (NASHP) blog, Congressional Proposals Could Improve Coverage Affordability and Access for Millions.

NASHP will follow the American Rescue Plan Act as it moves through Congress and will continue to share information on provisions that are critical to states.

Federal and State Special Enrollment Periods Increase Access to Insurance Coverage

February 1, 2021/in Policy California, Colorado, Connecticut, District Of Columbia, Idaho, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Washington Blogs, Featured News Home Eligibility and Enrollment, Health Coverage and Access, State Insurance Marketplaces /by Christina Cousart

Federal Insurance Rule Change Proposes an Insurer/Broker Alternative to State Exchanges

December 14, 2020/in Policy Essential Health Benefits, Health Coverage and Access, State Insurance Marketplaces /by Christina Cousart

Last month, the US Department of Health and Human Services (HHS) released its proposed 2022 Notice of Benefit and Payment Parameters, the annual rule that governs health insurance and the exchanges. Its most significant proposal is creation of a new option that allows a state to exclusively use direct enrollment by health insurers and brokers to enroll individuals in qualified health plans that meet all of the Affordable Care Act’s (ACA) coverage requirements, such pre-existing condition protections and essential health benefits.

By electing this option, a state would effectively eliminate use of a centralized health insurance exchange, which historically was designed to be a one-stop shop where consumers could compare all available qualified health plan (QHP) options to a private system marketing various coverage products. The exchanges also currently allow consumers to see if they qualified for Medicaid, which would be eliminated under this option.

If the federal proposal is approved, the option would be available to all states regardless of whether a state uses the federally facilitated exchange (FFE), operates its own state-based exchange (SBEs), or uses a hybrid model (SBE-FPs).

The proposed option allows states to move from using a health insurance exchange to a privatized system of enrollment via insurers and web-brokers.
The proposal could eliminate “no-wrong door” shopping across all ACA-compliant coverage, and would promote access to coverage alternatives.
Comments on the proposed rule are due by Dec. 30, 2020 and can be submitted here.

What is enhanced direct enrollment (EDE)?

The concept of direct enrollment (DE) is not new. Since the exchanges first became operational in 2014, there has always been an option allowing insurers and web-brokers to enroll eligible individuals into coverage. DE was designed to supplement the capacities of the exchanges by giving insurers and brokers a way to still reach out to individuals eligible for coverage and the federal advance premium tax credits (APTCs) and cost-sharing reductions (CSRs). In its early stages, DE was conducted by routing applicants from insurer or broker websites to the exchange, where the individual would complete an application to determine eligibility for coverage and subsidies. Once the application was complete, the individual would be routed back to the insurer or broker to complete enrollment.

In 2018, HHS established a new process for states using the FFE called enhanced direct enrollment (EDE), which allows individual seeking coverage to enroll directly with insurers or web-brokers without ever interacting with an exchange. The insurer or web-broker’s system interacts with an exchange behind the scenes, transferring the information necessary to determine an individual’s eligibility for coverage without that individual ever having to leave the insurer or web-broker website.

Since establishing the EDE option, participation by insurers and web-brokers has grown significantly. As of November 2020, 32 insurers and eight web-brokers were certified to conduct enhanced direct enrollment. In addition, three companies had been approved to serve as a DE technology vendor, providing insurers or brokers with the technology necessary to do enhanced direct enrollment. According to HHS, one-third of all FFE enrollments are conducted through a DE or EDE entity.

Development of the New EDE-Exchange Option

The proposed rule establishes a process so that a state can opt to have all enrollments go through EDE entities certified in the state, eliminating the option for residents to enroll via a health insurance exchange. The exchange (whether the state uses an FFE or SBE) would still exist in states that adopt this model, but would be limited to providing the back-end functionality necessary to determine a consumer’s eligibility for coverage, as well as maintenance of a general website with basic comparative information about the QHPs that may be available to a consumer.

This new option (referred to as FFE-DE or SBE-DE, depending if it is implemented by a state using the FFE or an SBE) would effectively eliminate the existence of a central, “one-stop shop” where applicants are presented with all available QHPs that they can compare, shop for, and enroll in. There is no requirement in the proposed rule that EDEs provide complete information about all the QHPs available to an applicant, though the proposed rule does include an inquiry from HHS about adding a requirement that web-brokers include information somewhere about the QHPs an individual cannot enroll in via its website. Further, EDEs may include information about alternative coverage products, such as short-term, limited-duration health insurance plans (short-term plans). A comparison between the model and traditional exchange are detailed in the table below.

The option to eliminate use of an exchange and adopt a model similar to the proposed rule’s FFE-DE was first proposed by Georgia and was recently approved. The Georgia Plan, called the Health Access Model, will move all “front-end functions” of an exchange (consumer outreach, customer services, and plan shopping, selection, and enrollment) to private entities, including insurers and web-brokers. These entities will interact with a state system that coordinates with HHS to determine applicants’ eligibility for federal subsidies. The federal government will then transfer subsidy payments directly to insurers with qualified enrolled individuals, as it does now.

In its application, Georgia officials state that a privatized system will provide its residents with “better access [and] improved customer service,” suggesting that competition and market incentives will drive private web-brokers to offer improved plan selection and enrollment assistance and local, customized customer service to attract the uninsured. The market incentives are primarily described as the commissions that web-brokers are paid for enrolling individuals into coverage. The state will also develop a website, which will contain information about all the health coverage options available in the state, and direct consumers as to where they can enroll in coverage including state-approved carriers and web-brokers. Georgia’s waiver was approved in November 2020.

Similar to the Georgia plan, the Centers for Medicare & Medicaid Services (CMS) states that use of EDEs through its proposed new model could enable the existence of “more curated, customized consumer experience designed to target diverse populations who need coverage.” The proposed rule also notes the ability of EDE entities to provide consumers with a “broader array” of options including ancillary products (e.g., vision, accident coverage), and alternative coverage products not sold through the exchanges, such as short-term plans. The proposed rule indicates these features may be especially important for consumers who do not qualify for federal subsidies, including individuals who are offered individual coverage health reimbursement accounts (HRAs) by their employers. (For more on individual coverage HRAs, read the NASHP blog, New Federal Health Reimbursement Proposal Adds New Variables to State Health Insurance Markets).

The proposal also would lower the user fee charged to issuers in states that opt to run the FFE-DE to 1.5 percent (the FFE fee is proposed to be 2.25 percent in 2022). The assumption is that savings from the lower user fee would be used by insurers to lower premiums or support enhancements to EDE platforms, though it is not a stated requirement in the HHS proposal. The proposed rule also suggests that states and the federal government could save money by no longer operating the full FFE or SBE models. It is assumed that instead, insurers and web-brokers would directly bear these operational costs, and may be able to do so at lower cost assuming their already enhanced technological capabilities.

The rule also indicates the potential for greater efficiency if consumers are allowed to enroll through various EDE entities available in a state rather than the “choke points” that may occur when a consumer only has access to one enrollment vehicle. However, because eligibility would still be conducted by exchanges, albeit on the backend, it is unclear how much efficiency could actually be attained through this method. It should also be noted that nothing currently prohibits an FFE state from having operational EDEs, and states could continue to function with EDEs and the exchange working in tandem.

As detailed in the table below, EDEs are required to meet many of the basic requirements similar to an exchange, including provisions to display accurate and complete information about the QHPs sold through their websites. However, none are required to clearly display all QHP options available to a consumer, and may only display some QHP options or even purposefully direct consumers away from QHP options. This is the case even if the consumer may be eligible for a state’s Medicaid program or federal subsidies that would help them to purchase an ACA-compliant QHP. In a report issued by the Center for Budget and Policy Priorities, several DEs were found to use tools that directed consumers away from QHPs and towards short-term plans. Such alternative forms of coverage do not meet all the coverage requirements enacted under the ACA, including guaranteed protections for individuals with pre-existing conditions, limits on cost-sharing, and provisions of essential health benefits (EHB). But, brokers, on average, are paid higher commissions for enrollment in short-term coverage than QHPs, which may influence DE practices.

If finalized as proposed, states looking to explore the new FFE-DE or SBE-DE option may decide to enact legislation or regulation to more strictly regulate EDEs, including prohibitions on practices that may divert individuals into coverage that may not best suit their financial, health, or family needs. States may also wish to consider policies to assure that EDEs do not negatively alter their risk pools by, for instance, diverting healthier individuals into alternatives that do not participate in insurer risk pools such as short-term plans.

The chart below provides additional details about the differences between the DE models and the health insurance exchanges. Comments on the rule are due by Dec. 30, 2020 and can be submitted here.

	Health Insurance Exchange (Traditional)	Direct Enrollment (DE)	Enhanced Direct Enrollment (EDE)
Definition	Enrollment platform through which individuals may shop, apply for, and enroll in qualified health plans (QHPs).	Process that allows individuals to enroll in a QHP directly through a DE entity (insurers or web-brokers), though eligibility applications are still completed and processed by an exchange.	A process that allows individuals to enroll in a QHP directly through a DE entity (insurers or web-brokers) without directly interacting with an exchange.
Operated by:	States (SBEs), federal government (FFE), or both (SBE-FPs)	DE entities (either a CMS-approved QHP issuer website or CMS-approved web-broker website)	DE entities – either a CMS-approved QHP issuer website or CMS-certified web-broker website.
Accountability and auditing	FFE and SBEs must comply with regular federal audits. In addition, many states conduct separate audits of their SBEs to ensure accountability.	DE entities must complete CMS certification before selling exchange products.	EDE entities must complete CMS certification before selling exchange products. Certification includes enhanced process for certifying compliance with privacy and security standards for transfer of enrollee data, as well as compliance with annual audits.
Eligibility and Enrollment Process
For private insurance coverage	An individual shops for and applies for coverage through the exchange. The exchange determines eligibility for QHPs, APTCs, and CSRs. If eligible, the individual may select and enroll in a QHP.	The individual shops for coverage through the DE partner. Upon applying, the individual is transferred to the exchange, where they complete their application to determine eligibility for QHPs, APTCs, or CSRs. Once completed, the individual is redirected back to the DE entity to select and enroll in a health plan.	Individual shops for and applies for coverage through the DE entity. If eligible, the individual may select and enroll in a QHP though the DE website. The DE entity’s system interacts “behind the scenes” with an exchange. The latter conducts the determination of eligibility for APTCs, CSRs, or QHPs.
For Medicaid coverage	An exchange determines applicant’s eligibility for Medicaid; provides “no wrong door” portal for eligible individuals to enroll in Medicaid. States using the FFE may opt to have the exchange only assess an applicant’s eligibility for Medicaid, after which the applicant is directed to the state Medicaid agency to enroll.	When the individual is transferred to the FFE, the FFE will assess or determine the applicant’s eligibility for Medicaid. If eligible, the FFE will send a notification to the applicant, the DE partner, and the state Medicaid office. Individual is not automatically enrolled in Medicaid coverage and may be directed to alternative coverage options.	The exchange will assess or determine the applicant’s eligibility for Medicaid as it processes the applicant’s information sent via the DE partner. If eligible, the FFE will send a notification to the applicant, the DE partner, and the state Medicaid office. Individual is not automatically enrolled in Medicaid coverage and may be directed to alternative coverage options.
Plans that can be displayed or sold through this platform:
All available QHP options	Yes	No	No, the proposed rule suggests a new requirement that web-brokers would have to identify to consumers QHPs not sold through it platform.
Display non-QHP options (including short-term plans)	No	Yes, non-QHP products must be displayed on a separate section of the website than QHPs.	Yes, non-QHP products must be displayed on a separate section of the website than QHPs. Proposed rule suggests a new requirement that EDE entities build three distinct sections of their websites, one for the sale of on-exchange QHPs, one for the sale of insurance products sold off-exchange (which may also include QHPs), and one for excepted benefits products (e.g., vision, long-term care).
Display of ancillary products (e.g., vision, accident insurance)	No	Yes	Yes
Required health plan details that must be displayed
Estimated premiums (total and net, including APTCs/CSRs)	Yes	Yes (for QHPs)	Yes (for QHPs)
Summary of benefits	Yes	Yes (for QHPs)	Yes (for QHPs)
Provider directory	Yes	Yes (for QHPs)	Yes (for QHPs)
Health plan metal level	Yes	Yes (for QHPs)	Yes (for QHPs)
Quality ratings	Yes	Yes (for QHPs)	Yes (for QHPs)
Enrollee satisfaction surveys	Yes	Yes (for QHPs)	Yes (for QHPs)
Shop and compare tools (sorting by premium, deductible, etc.)	Yes	Yes (for QHPs)	Yes (for QHPs)
Marketing and outreach requirements
Marketing requirements	Exchanges (FFE or SBE) are required to conduct marketing and outreach to consumers.	Exchanges conduct marketing and outreach. The DE entity may supplement as it chooses.	EDE entities are expected to conduct marketing and outreach. There are no direct requirements governing EDE marketing other than a prohibition that brokers “refrain from marketing or conduct that is misleading, coercive, or discriminatory.”

State-based Marketplace Strategies for Insurance Market Stabilization and Improvement Submitted to the Biden Transition Team

November 23, 2020/in Policy Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by NASHP Staff

The National Academy for State Health Policy (NASHP), in consultation with state-based health insurance marketplaces leaders, has submitted a list of priority strategies to President-elect Biden’s transition team to improve marketplace operations.

These “action items” are designed to lower costs, stabilize individual and small group health insurance markets, improve access to coverage, and enhance the consumer’s experience when purchasing small group or individual market coverage.

View or download the list of action items submitted to President-elect Biden’s transition team.

Read a blog about the submission, NASHP Outlines Priorities for the Biden Transition Team to Improve Health Insurance Markets.

NASHP is home to the State Health Exchange Leadership Network, a consortium of state leaders and staff dedicated to operation of the SBMs. These recommendations draw upon the experience of SBM leaders who have spent the past decade building and operating successful platforms for the procurement of health insurance coverage.

NASHP Outlines Priorities for the Biden Transition Team to Improve Health Insurance Markets

November 23, 2020/in Policy Blogs, Featured News Home Consumer Affordability, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Health System Costs, Medicaid Expansion, State Insurance Marketplaces /by NASHP Staff

President-elect Biden has pledged to build on the Affordable Care Act (ACA) to provide more insurance choices, reduce costs, and make the health care system less complex and more accessible.

Since launching in 2013, more than a dozen state-based health insurance marketplaces (SBMs) have had the flexibility to develop efficient and cost-effective strategies to serve more than 4 million Americans.

Drawing on its years of experience working with SBMs, the National Academy for State Health Policy (NASHP) has developed a list of priority actions that the incoming Biden Administration could take to address its goals of providing high-value, affordable, and accessible coverage to Americans.

Read/download the complete list of actions items submitted to the Biden transition team here.

SBMs have become tested sources of innovation, leveraging a variety of strategies to more efficiently and effectively deliver coverage options to consumers through:

Strategic and targeted marketing and outreach campaigns, and
Development of tools, resources, and policies tailored to the needs of local consumers and insurance markets.

NASHP is sharing the SBMs’ lessons learned with the Biden transition team in an action item report. They are summarized below.

There are 15 state-based marketplaces (SBMs) in the United States, with more states transitioning to the model. SBMs exercise more control over their operations, outreach, and marketing than states that use the federal marketplace, and often offer lower-priced health plans.

Explore State-based Health Insurance Marketplace Performance.

Immediate Actions to Address the COVID-19 Crisis

As COVID-19 surges across the country, Americans continue to reel from the impact of the pandemic, including income fluctuations, unemployment, and loss of once-secure benefits, including employer-sponsored insurance (ESI). At a time of continued financial uncertainty and when many individuals must navigate unfamiliar coverage options and eligibility processes, it is unreasonable to also impose roadblocks or penalties that hinder consumer’s ability to obtain or maintain needed coverage.

Flexibility from the Internal Revenue Services (IRS) to ensure that consumers are not unduly penalized during tax season because of inaccurate income reporting estimates could provide needed relief to families already experiencing financial hardship (read the NASHP blog, State-Based Marketplace Leaders Ask for Federal Reinforcement of Insurance Markets during COVID-19). Broadening special enrollment periods (SEP) to make it easier for individuals to enroll in coverage in the event of job or income loss could also ease the burden on individuals and families who lose ESI and need coverage. As evidenced by the hundreds of thousands of individuals who enrolled during SEPs in 2020, consumers are seeking open access to coverage and will need flexible enrollment channels as circumstances continue to fluctuate.

Simplifying and streamlining enrollment for qualified individuals:

While insurance subsidies, including advanced premium tax credits (APTC), are available to most individuals who earn between 100 to 400 percent of the federal poverty level (FPL), many are not able or are reluctant to access these benefits because of barriers that hinder access due to confusing eligibility and enrollment rules, often perpetuated by complex federal policies. These policies feature discrepancies between how eligibility is determined for various federal programs, including APTCs and Medicaid, as well as policies that deter qualified legal immigrants from enrolling in programs, such as the public charge rule. Additionally, complications in assessing the affordability of employer coverage — either for families that fall into the family glitch or those that are interested in exploring the use of health reimbursement arrangements (HRAs) — limit the ability of both employers and families to fully explore coverage options that can or should be available to them. Simplifying or rescinding policies that add to enrollment complexities will ensure that more individuals accurately receive the benefits that they qualify for.

Initiatives to prevent market segmentation:

Health insurance markets function most efficiently when they have a robust pool of enrollees across which to balance costs and risk. To generate this mix, the ACA consolidated the market, requiring all individual market plans to be sold in one risk pool (similarly, small group coverage must also operate using a single risk pool). However, recent actions taken by the Trump Administration have enabled the proliferation of alternative forms of coverage, including short-term, limited-duration, and association health plans, and health care sharing ministries. These alternatives are usually not required to meet the same rules as traditional insurance, including guaranteed coverage of certain benefits or protections for those with pre-existing conditions, nor are they required to participate in the single insurance risk pool. Yet, they do compete with insurance products, drawing individuals (often young and healthy) out of the insurance risk pool.

This latter competition may be exacerbated by the growth of direct enrollment entities – third-party enrollment entities that may opt to direct consumers to coverage alternatives. Issues may also arise from the federal government’s recent reinterpretation of the “guardrails” governing Section 1332 state innovation waivers, which opened the opportunities for waivers that allow for coverage alternatives.

Limiting the avenues by which these unregulated products can cut into or harm insurance markets will support the development of healthier, balanced markets and thereby lower costs to consumers.

Restoring and enhancing equal access to coverage and services:

Policies set in place under the ACA sought to ensure equal access to coverage and health services regardless of health status or other traits commonly used to discriminate against consumers, including race, sex, age, or national origin. Recent federal actions rolled back some of those protections, including actions that rescinded protections against discrimination based on gender identity and sexual orientation, as well as steps to improve language accessibility. Other actions reduced protections for consumers by providing an avenue for insurers to deny new enrollments in the case of enrollees who owe outstanding premium payments.

Individuals are given only limited windows in which to enroll in coverage, and barriers that prohibit them from enrolling during that time restrict their access to critical coverage. This is especially troublesome at a time when financial hardships from COVID-19 may have caused delays in timely premium payments. To enable access to coverage and better protections for consumers, it is important to reinstate or enhance consumer protections that improve access and safeguard against discriminatory practices.

Preserving market stability:

Above all, markets require consistency, otherwise insurers act to compensate for both real and perceived changes to their markets, especially ones that are expected to reduce enrollment or drive up costs. A drastic example of this was seen in 2017 when the federal government ceased payments to issuers to support to the cost-sharing reduction (CSR) program, followed closely by Congressional repeal of the individual mandate penalty. Premiums inflated, as insurers sought to offset predicted losses. Several states intervened, instituting policies to mitigate the effect of CSR losses, and in some cases passing their own individual mandates. To maintain market stability and avoid premium spikes, future policies (e.g., changes to the CSR program, premium adjustments, actuarial value calculators, or the poverty threshold) must be designed to minimize market impacts if they are enacted.

While many of these actions relate to reinforcement of federal requirements to ensure access to and stability of insurance markets, states will undoubtedly continue to lead as innovators and regulators of their markets. States will need the maximum flexibility available to them to continue to experiment and make changes to their markets to accommodate the evolving needs of their consumers and insurance markets. This includes continued flexibility over SBM operational functions, like open enrollment windows, as well as broader opportunities to innovate, like flexibility available through Section 1332 state innovation waivers (as conceived prior to the recent reinterpretation of the waiver guardrails). As new federal leadership emerges, NASHP will continue to monitor the actions of states and the federal government as both work to build better, stronger, health care systems.

As SCOTUS Considers ACA’s Future, State Marketplaces Enroll Consumers amid COVID-19

November 9, 2020/in Policy Blogs, Featured News Home Consumer Affordability, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, State Insurance Marketplaces /by Gia Gould

As the Supreme Court hears oral arguments today about the fate of the Affordable Care Act (ACA) in the case of California vs. Texas, state-based health insurance marketplaces (SBMs) are actively connecting consumers to health insurance coverage during the annual open enrollment period that launched Nov. 1.

While the court case casts a shadow of uncertainty over the ACA, COVID-19 and the ensuing economic crisis have increased the need for affordable coverage and forced SBMs to alter their consumer engagement strategies. Using lessons learned from their recent special enrollment periods (SEPs) to meet consumers’ coverage needs, SBMs are adapting outreach and enrollment efforts in recognition of social distancing standards.

Targeted Messaging to Promote Affordability and Accessibility

Recognizing the severe economic challenges many Americans face because of the pandemic, SBMs are carefully framing messages showcasing the affordability and accessibility of qualified health plan (QHP) coverage. As job and income losses make more individuals eligible for premium subsidies available through marketplaces, SBMs have adopted simple, straightforward messaging.

California’s open enrollment slogan, “This way to health insurance” conveys the exchange is available to provide a path to coverage for all consumers.
Minnesota’s promotion acknowledges the confusion that consumers may experience as they move from employer-sponsored insurance (ESI) and into the individual market with this targeted message: “UNsure about health insurance options? BEsure. MNsure.org.”

SBMs leaders recognize that access to high-quality, comprehensive health coverage is crucial to maintaining the health of individuals and communities, especially as thousands continue to be affected by COVID-19. SBMs are employing the following strategies to remind consumers that health coverage can provide peace of mind and critical care in the midst of the pandemic.

Washington, DC has distributed masks printed with the message, “Get Covered, Stay Covered” to existing customers, contact tracers, and community leaders to emphasize that both forms of “coverage” — masks and health insurance – are necessary to maintain health during a pandemic. DC Health Link branding will also be incorporated into social distancing signs across the district.
Massachusetts is highlighting that COVID-19 testing and treatment is covered by most marketplace plans and is promoting the “security” that comes when individuals know they and their families have coverage in the event of an emergency.

In addition to targeting messages to the uninsured, SBMs leaders recognize their existing customers may be vulnerable to losing coverage, especially because of changes in income or life circumstance that may change the amount of subsidies they are eligible for. This includes extreme fluxuations due to changes in employment status and changes in unemployment insurance (UI) payments. To ensure that customers remain enrolled in a comprehensive health plan, SBMs have utilized targeted email blasts, social media advertisements, and text messages to encourage consumers to update any change in their income or employment status — which could result in increased financial assistance or eligibility for Medicaid. SBMs are also encouraging consumers to remain in contact with their marketplaces as their circumstances change to ensure that the enrollees remain properly enrolled in coverage.

Modernizing Advertising and Media Campaigns

SBMs have total autonomy over their marketing and outreach campaigns, allowing them the flexibility to adjust their advertising based on shifting consumer behavior. As in years past, SBMs will advertise open enrollment through television ads, radio spots, out-of-home signage and branding, and targeted social media marketing. As individuals spend more time at home than ever before, SBMs have pivoted their advertising campaigns to account for new consumer patterns. With fewer commuting to work, several SBMs have transitioned their advertising away from the radio to digital streaming services like Spotify and Pandora. Similarly, many SBMs have diversified their digital media buys across streaming platforms like Hulu, YouTube, and Connected TV to reach consumers who are missed by traditional television campaigns.

As individuals spend more time at home than ever before, SBMs have pivoted their advertising campaigns to account for new consumer patterns. With fewer commuting to work, several SBMs have transitioned their advertising away from the radio to digital streaming services like Spotify and Pandora.

Idaho has shifted its advertising budget slightly to allocate more funds to digital media, which generates more website traffic than traditional media. However, Idaho will still invest significant resources into traditional media sources to reach consumers in rural areas who have limited access to internet services.
Washington State has collaborated with local newspapers to create customized and regionally relevant content. These media partners will feature articles, dedicate newsletter content, and display advertisements to draw attention to open enrollment.

Adjusting In-Person Outreach for a Socially Distanced World

To adhere to social distancing restrictions, SBMs have transitioned most of their outreach efforts to virtual platforms and now offer very limited in-person events and consumer assistance. SBMs will offer virtual outreach events through Zoom, Facebook Live, and YouTube to help familiarize consumers with the coverage options and financial assistance available through the marketplace. To focus attention to these events, SBMs have leveraged partnerships with government agencies, faith-based groups, schools, and community organizations that have served as direct community touch points throughout the pandemic.

To maximize their outreach efforts, several states have elected to use consumer data to identify and reach consumer groups that would most likely benefit from marketplace coverage.

Washington State has partnered with its Department of Financial Management to develop a map identifying communities with high rates of uninsurance to help inform the exchange about where outreach is needed.
In Minnesota, demographic data is utilized to target social media advertisements and website banners to reach individuals who are most likely to be uninsured.
Maryland’s Easy Enrollment program, which allows consumers to use the marketplace to estimate eligibility for coverage, has produced a list of over 40,000 consumers who have indicated that they are interested in learning more about coverage through the marketplace.

SBMs have also worked closely with their navigators and community partners to develop strategies to provide secure virtual enrollment assistance. Direct consumer assistance has been proven to significantly increase the likelihood that an individual will complete the enrollment process — particularly among low-income individuals and people of color. SBMs have adopted the following strategies to provide personalized enrollment assistance in a COVID-19 environment.

Connecticut is hosting several virtual enrollment fairs during October and November. During these events, a representative helps consumers walk through the enrollment process with a screen-share feature so both can view enrollment forms together.
Massachusetts has allocated additional funds to enable navigators to offer limited in-person assistance in place of walk-in centers. While navigators are not able to accept and process documents and payments, they can help customers with the application process.
Nevada is scheduled to host a series of Facebook Live events with staff available to answer consumer questions and provide real-time enrollment assistance.
In anticipation of their first open enrollment period as SBMs, New Jersey and Pennsylvania tripled their navigator programs to ensure that consumers would have the accessible support they need to navigate the new platform.

Strategies to Connect with the Recently Unemployed

With millions of Americans losing employment due to the pandemic, SBMs have taken steps to connect with individuals who have lost employer-sponsored insurance (ESI) coverage. A recent Commonwealth Fund study found that as of June 2020, 7.7 million Americans lost jobs with ESI as a result of the pandemic. Experts expect that unemployment and uninsurance will continue to rise as job losses become permanent and temporary policies, like grace periods granted to those unable to pay their monthly insurance premiums, expire. The SBMs officials acknowledge that many consumers who have lost ESI may be exploring coverage options on the individual market for the first time. To ease confusion and stress, SBMs have utilized the following strategies to connect the recently unemployed to coverage.

New Jersey’s SBM has coordinated with the Department of Labor (DOL) to include a link to the SBM website within DOL’s consumer portal so individuals are reminded of their health coverage options when they check the status of their unemployment claims.
Colorado has purchased targeted advertisements to reach those who search for Consolidated Omnibus Budget Reconciliation Act (COBRA) so consumers can compare cost and coverage options across programs.
The Washington Health Benefit Exchange is telling consumers, “Filing for unemployment benefits? Visit the exchange to stay covered” to remind them to seek a new form of coverage after losing their ESI.
Nevada includes informational pamphlets about open enrollment in direct mailers sent to individuals who have filed for unemployment. In addition, the state’s Department of Unemployment will share open enrollment information on its social media and web pages.

In addition to coordinating with their states’ labor and employment departments, several SBMs have bolstered strategies to connect with consumers who have recently been terminated by their employer. By monitoring Worker Adjustment and Retraining Notices, which require certain employers to give advance notice of mass layoffs, SBMs are able to identify employers that are about to conduct large-scale lay-offs and then work with their human resource departments to tailor an outreach strategy about marketplace coverage options. In many cases, consumers may access lower-cost coverage through the marketplace than through the COBRA coverage that employers are required to offer.

The open enrollment season for most states runs through Dec. 15, 2020, but several SBMs have extended their deadlines. Explore NASHP’s chart and interactive map, Where States Stand on Exchanges, for more information and links to SBM websites.

Thousands Flock to Health Insurance Marketplaces as Coverage Shifts due to COVID-19

July 2, 2020/in COVID-19 State Action Center Blogs, Featured News Home CHIP, COVID-19, Eligibility and Enrollment, Health Coverage and Access, State Insurance Marketplaces /by Christina Cousart

COVID-19 has affected nearly every aspect of American life, including access to health insurance coverage, which is critical during a pandemic. Job losses and reductions in hours have resulted in millions losing employer coverage or the income needed to pay premiums, forcing them to join the already sizeable ranks of the uninsured. State marketplaces have stepped in to make sure previously uninsured individuals and those losing coverage have a source of coverage.

Limited Options in Lieu of Employer Coverage

Limited safeguards exist for individuals who lose their employer-sponsored health insurance (ESI), including coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA), which allows individuals to retain their ESI for up to 18 months. However, the individual must pay the full cost of the premium (including any portion that the employer typically subsidizes), plus a marginal (2 percent) administrative fee to retain this coverage. With average ESI premiums ranging from $498 to $703 per month, this is a costly option for most individuals — especially those with uncertain future incomes. COBRA does not require small businesses with fewer than 20 employees to offer this option, and these businesses have been among the hardest hit by the current economic crisis. Also notable, if a business closes and terminates its group health plan, former employees no longer have the option to pay for their own coverage as part of that plan, as it no longer exists.

Many Americans whose incomes fall below 138 percent of the federal poverty level (FPL) –earning $17,609 per year for an individual – may qualify for Medicaid in the 35 states that have expanded eligibility for coverage up to this income limit. Individuals who lose their ESI, yet whose income is too high for Medicaid, may qualify for a special enrollment period (SEP) to purchase subsidized coverage available through the health insurance marketplaces.

Before the pandemic:

Nearly 50 percent of Americans accessed coverage through their employer;
About 35 percent were covered by a public program (Medicare or Medicaid);
Six percent purchased coverage on their own through individual markets; and
Nine percent of individuals were uninsured.

Source: Health Insurance Coverage of the Total Population, 2018, Kaiser Family Foundation.

Marketplace subsidies are available to individuals earning between 100 to 400 percent of FPL ($12,760 to $51,040 per year). In addition, states have taken swift action to ensure individuals can access and retain coverage — from prohibiting terminations of coverage triggered when an individual or business cannot pay their premiums to opening up SEPs targeted specifically for uninsured individuals to help them purchase coverage through the health insurance marketplaces in response to the pandemic.

Marketplace Enrollments Spike, Continued Increases Expected

As previously detailed in this June 1, 2020 NASHP blog, states are already reporting enrollment spikes in their Medicaid programs. Similar to Medicaid trends, states that operate their own health insurance marketplaces are also reporting a rise in enrollments, with over 240,000 SEP enrollments since early March (see table below for details). Of these new enrollments, more than 50,000 have signed up during the SEPS, which opened specifically so that uninsured individuals could enroll in coverage in response to the pandemic. These figures are proving to be significantly higher when compared with enrollments in 2019, for example:

Maryland reports its SEP enrollments are 42 percent higher than 2019; and
Washington State’s SEP enrollment has more than doubled over last year’s.

These figures are expected to grow as lingering economic impacts and the expiration of temporary policies to limit coverage losses (e.g., extended premium payment grace periods) leave more individuals uninsured.

Enrollments during State-Based Marketplaces’ COVID-19-Related SEPs*
updated as of 7/2/2020

State	COVID-19 SEP Enrollment	COVID-19 SEP Period
California	175,030	March 3 to July 31
Colorado	14,263	March 20 to April 30
Connecticut	5,629	March 19 to April 17
DC	3,172	March 18 to Sept. 15
Maryland	23,731	March 16 to July 15
Massachusetts	40,044	March 11 to July 23
Minnesota	9,482	March 23 to April 21
Nevada	6,017	March 17 to May 15
Rhode Island	4,229	March 14 to April 30
Vermont	1,545	March 20 to August 14
Washington	22,000	March 10 to May 8

As individuals continue to experience the economic fallout from COVID-19, states will continue to act and invest in resources necessary to provide coverage and related services to their residents. For many, this includes investment in strategies to encourage insurance coverage, including outreach conducted through Medicaid, employment agencies, and state-based marketplaces. However, many questions remain as states navigate this new coverage environment.

Will formerly uninsured individuals retain their newly purchased coverage? How will the shifting dynamics of both individual and group insurance markets impact coverage costs? Will consumers prefer to keep coverage purchased through the individual market, even as employer coverage become more available? The National Academy for State Health Policy will monitor emerging enrollment trends and share answers to these questions as changes continue to unfold.

*Data was not available at the time of publishing from state-based marketplaces in Idaho or New York. Idaho did not open a COVID-19 SEP; but enrollment is open year-round for the state’s highly regulated short-term insurance plans sold outside of the state’s marketplace.

Unless noted, data comes from state-based marketplace reports covering enrollments during the period of the COVID SEP.

Posts

Where States Stand on Exchanges

NASHP Expands State Health Policy Expertise with New Academy Members

2021 Individual Market Health Insurance Enrollment Periods