Monday, March 09, 2020

Coronavirus alert: How about an emergency Special Enrollment Period for the ACA marketplace?

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Update, 3/12: As noted in the updates at bottom, as of now five state-based marketplaces are running Special Enrollment Periods open to all, two of them triggered by the coronavirus emergency. CMS should do it for the states. 3/14: Rhode Island makes six. 3/16: New York comes on board. 3/17: Nevada is in. 3/18: Connecticut announces SEP. And Colorado will announce imminently. 3/20: Covered California, already open via a tax-season SEP, available to anyone who affirms they were not aware of the state's new individual mandate, today makes it unconditional with an emergency SEP open to all. And it's open through June 30, by far the longest emergency SEP. 3/20 II: MNSure announces a SEP running March 23 - April 1. 3/20 III: Vermont comes on board, sort of.

Every SBE except Idaho now has enrollment open to the uninsured.

If the coronavirus causes major economic disruption, as now seems likely, the ACA marketplace (including Medicaid enrollment) is likely to get a major stress test.

As I've noted previously, the marketplace has never experienced a recession; the unemployment rate has dropped steadily since it launched in 2014, and enrollment has been basically flat since 2016. It stands ready as a shock absorber when people are laid off.  Those who lose insurance through their jobs are eligible for a Special Enrollment Period.  The machinery for processing SEP requests had better be smooth.

Since subsidy eligibility depends on annual income, the earlier in the year layoffs begin, the more people will qualify for marketplace subsidies (annual income up to $49,960 for an individual) or Medicaid ($17,236). In Medicaid expansion states, even those who have crossed those earnings thresholds should be eligible for Medicaid one month forward if their income is below the monthly Medicaid threshold.* Under various emergency authorities, governors and the president can extend Medicaid eligibility and expedite enrollment, as was done in the wake of 9/11, Hurricane Katrina, and the Flint water crisis.

The marketplace also might be put to more immediate use.  CMS should declare a national Special Enrollment Period for the marketplace (Medicaid enrollment is year-round).

At first glance, such a rule might seem to place a heavy burden on insurers that would foot the bill for expensive hospital care. But the SEP might be a net plus for insurers. Relatively few who contract the coronavirus do require hospital care, and most of those are likely over age 65, though adults of all ages do contract the disease. Anxiety about being uncovered might prompt enough healthy and young people to enroll during the SEP to offset the cost of those who do require hospitalization. [UPDATE, 3/21: it's not true that a majority of hospitalized COVID-19 patients are Medicare age. OTOH, some actuaries anticipate that declines in medical treatment for conditions other than COVID-19 may offset the cost of treatment for the disease.]

Then again, it might not. Speak, actuaries.

Update, with a hat tip to David Anderson: Now would be a good time to pass balance billing legislation.

UPDATE 2: Charles Gaba notes that Special Enrollment Periods for all comers are currently in effect in California and Washington D.C.  Which highlights the fact that any state-based marketplace can declare an emergency SEP.

UPDATE 3: Maryland's exchange currently has in effect an innovative tax-time SEP whereby the uninsured can check a box to apply for a Special Enrollment Period. This could be part-rebranded as a Coronavirus SEP, though the administrative process in place -- check the box, file your taxes, receive a letter, etc. -- would have to be sped up. Update 3/14: Maryland has added a simpler Coronavirus-specific SEP through April 15.

UPDATE 4, 3/10/20: Via Charles Gaba, Washington state has indeed announced an emergency SEP in response to the Coronavirus. Note that the state emphasizes that the SEP is limited-time (thru April 8), presumably to discourage people from waiting until they're seriously ill to seek coverage.

UPDATE 5, 3/11/20: Massachusetts has now announced a SEP

UPDATE 6, 3/14/20: What about the Minnesota exchange, MNSure? They responded to a query as follows:
MNsure is working closely with Governor Walz, Minnesota state agencies, and other stakeholders to determine whether a special enrollment period is needed in Minnesota for individuals who did not enroll in coverage during the open enrollment period. At this time, there is no immediate plan to offer a special enrollment period, but we will continue to monitor the COVID-19 situation in Minnesota closely.
Like New York, Minnesota has a Basic Health Program for enrollees with incomes up to the 200% FPL, MinnesotaCare (built on a Medicaid-like program that predates the ACA), that allows year-round enrollment. That somewhat narrows the target range of a marketplace SEP.

UPDATE 7: The Rhode Island exchange has announced a SEP through April 15 on its home page. States with no SEP as yet: state-based marketplaces in NY, MN, VT, ID, CT, CO, NV. And the big enchilada: (38 states).

UPDATE 8, 3/16: New Jersey Governor Phil Murphy has asked CMS for a SEP for New Jersey. The state is currently an SBE using the federal platform, committed to launching its own online portal for 2021. Perhaps Coronavirus-related disruption will lead to a postponement of the state site launch.

Per NJ's request, it will be a kind of extraordinary moment if Seema Verma's CMS opens an emergency SEP in states. From a Republican point of view, I guess you could say, "You go to war with the individual insurance market you have." Honestly -- no snark if they open enrollment to a market not structured to their liking.

UPDATE 9, 3/16: New York has announced an emergency SEP running through April 15. Those who enroll between April 2 and April 15 will have coverage retroactive to April 1.

UPDATE 10, 3/17: Nevada has announced an emergency SEP through April 15. To access it, prospective enrollees can't simply log on: they are asked to call the exchange (1-800-547-2927) and are encouraged to work with a broker or navigator.  Information about the emergency SEP is here, albeit a bit buried under headings describing normal SEP standards. As the press release is apparently not posted, here is the upshot:
Carson City, Nev. –  In response to Governor Sisolak’s March 12th Emergency Declaration, the Silver State Health Insurance Exchange (Exchange), the state agency that connects Nevadans to qualified health plans through the online State Based Exchange (SBE), known as Nevada Health Link, announces a limited-time Exceptional Circumstance Special Enrollment Period (SEP) for qualified Nevadans who missed the Open Enrollment Period (OEP). The SEP runs from March 17, 2020 through April 15, 2020, and will allow eligible individuals to enroll in a qualified health plan through the SBE platform, Nevada Health Link. Individuals seeking a special enrollment are encouraged to contact the Customer Assistance Call Center between 9:00 a.m. to 5:00 p.m. Monday-Friday at 1-800-547-2927; TTY: 711. The Call Center will extend its hours on Saturday’s and Sunday’s (except for Easter Sunday) from March 21 through April 15 from 10:00 a.m. to 2:00 p.m. PST. The Exchange recommends working with a certified broker or navigator to enroll in the SEP. Nevada Health Link offers language assistance and if you are deaf, hard of hearing, or have a disability, accommodations are provided at no cost.

UPDATE 11, 3/18: Access Health Connecticut has opened an emergency SEP through April 2; as in Nevada, applicants must begin process with a phone call. Rather foolishly, they have announcement of the SEP in a rotating scroll of announcements; easy to miss. And via Charles Gaba, Colorado is on the brink.

UPDATE 12, 3/20: Covered California announces "Effective Friday, March 20, Covered California opened the health insurance exchange to any eligible uninsured individuals who need health care coverage amid the COVID-19 national emergency. Anyone who meets Covered California’s eligibility requirements, which are similar to those in place during the annual open-enrollment period, can sign up for coverage through June 30."

UPDATE 13: MNSure, the Minnesota SBE, announces a SEP running March 23-April 1. And Vermont.

UPDATE 14: CMS was widely expected to grant an emergency SEP for, but rejected the option with manifestly inaccurate and sophistic justification.  Meanwhile, many states have extended their deadlines. Charles Gaba has the goods, and I'll let him take it from here (he will keep tracking).

Related: The ACA as Recession Insurance

* While the marketplace considers income on an annual basis to determine subsidy eligibility, state Medicaid departments consider income on a monthly basis. That disjunct can create bureaucratic holdups, described in this post, at bottom

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