Friday, April 03, 2020

ACA enrollment train wreck coming

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Update, 4/21/20: On a CCIO webinar for enrollment assisters, a moderator said that as of now is accepting simple attestation from an applicant that she has lost health coverage -- the marketplace is not requiring documentation of loss of coverage. That's very good news.

On Tuesday, the Trump administration dashed widespread hopes that it would open an emergency Special Enrollment Period in the ACA marketplace for the 38 states using, the federal exchange, allowing anyone who was uninsured to apply for coverage. Twelve of the thirteen state-based exchanges have opened such emergency SEPs, and most are extending the deadline.

The White House told reporter Amy Lotven that an emergency SEP is not needed because "there's already special enrollment for job loss." That's wrong, as Charles Gaba and others pointed out: there's a SEP for loss of insurance that usually follows job loss.

Not only does that ordinary SEP exclude those who were uninsured before job loss -- it's also likely to make obtaining insurance a dauntingly difficult and dangerously slow process for the millions who do lose employer-based insurance and seek new coverage through

The normal SEP crawl

Shelli Quenga, Director of Programs at the Palmetto Project in North Charleston, South Carolina, a nonprofit brokerage* serving primarily low income clients, explained to me that obtaining a SEP after loss of job-based (or other) insurance coverage is difficult in the best of times. "The process is deliberately cumbersome, and it's going to cause people to remain without coverage," she worries.

First, you need a date  when your coverage ended, and that in itself can be difficult to obtain.
Once you have entered that information, the marketplace gives you thirty days to provide documentation -- a letter from your employer or the insurance carrier stating the coverage termination date. A letter offering COBRA, the extension of job-based insurance for which the ex-employee must pay full price, will also serve.  If documentation isn't provided within 30 days, you have to start the application process over again. And you have only a 60-day window from date of coverage loss to be granted a SEP.

Mission impossible?

All these difficulties are likely to be cubed in the coming tsunami of job loss and loss of insurance. Start with verifying the date that coverage was lost.  It can't be merely inferred. "People lose coverage in the middle of the month, at the end of the month, or at some random date," Quenga says.

Imagining current predicaments, Quenga posits, "You can't just go into your place of business and talk to them because the business is closed. "Your own supervisor may have been laid off. So who are you supposed to talk to?"

Once the termination date has been nailed down and an application started, the 30-day window to provide documentation begins (meanwhile, the applicant still lacks coverage). "Insurance companies typically don't provide the certificate of creditable coverage until your coverage has actually ended, and that usually takes two weeks if they're coming by snail mail," Quenga says.

In the coming crush, those letters are likely to be late. That's problematic: "If in 30 days don't have that proof then you have to start the application process all over again." Meanwhile, "you're still working within that tight 60-day window" that begins with loss of coverage.

Relatively simple tech demands stymie some applicants.  "Verification means that people have to print stuff," Quenga notes. "Most lower income people use their phones for their internet access. How are they going to print documents when they don't have a printer at home? If they have a printer, how are they going to afford to put ink in it right now? They need to be saving that money for food and shelter."

Assuming a person runs this gauntlet and files a SEP application, what then? "It's up to a federal contractor to review and approve the documents you submit," Quenga explains. She wonders about the functionality of such private businesses in the current crisis. "We don't know if they can work remotely. We don't know how many people are working for the contractor now. In my mind's eye I see them sitting in cubicles side by side -- that can't be happening now. So how are they processing those documents?"

As for the government bureaucracy, SEP documentation can be uploaded or mailed in. If an applicant does the latter, "someone has to be available at that office in London, Kentucky to open that mail and get it processed. Who's available to do that?"

Open the gate

Fixing these problems only requires political will, and that's a matter of degree. Quenga floats both a limited and a complete solution. "I don't know if the feds can say, during this period, we're not going to have any of the SEPs trigger this proof requirement -- what they call an SEP verification issue. Perhaps that's possible. We don't know, because they're certainly not telling us." [Update, 4/26: CMS has done just that.]

"But it would be much simpler to just open up enrollment right now so that anyone who is uninsured right now can apply and not have these verification issues."

As for the longer-term uninsured...

South Carolina, where the Palmetto Project is based, is one of fourteen states that have refused to enact the ACA Medicaid expansion, which means that people with incomes below 100% of the Federal Poverty Level are shut out of any federal help to obtain insurance. As I noted recently,  the CARES Act, the emergency COVID-19 relief bill signed into law on March 27, might open that slammed door a crack.

Here's how: the enhanced unemployment benefit provided, $600 per week for up to four months -- up to $10,400 -- counts as income in the subsidy calculation for the ACA marketplace. Many people with incomes hitherto below the poverty line, and therefore the ACA subsidy line -- $12,490 annually for an individual,  $25,750 for a family of four -- may get over the line with that boost. If their estimated annual income is between 100% and 138% FPL, low deductible coverage should be available for just 2% of income.

Quenga identifies bureaucratic hurdles here too, however.  A SEP is theoretically available if you were uninsured because your income was below 100% FPL and you report an income change that puts you over the threshold. But "that is the most difficult SEP to get," Quenga says.

"Every time we try for a SEP for income increase, it ends up going to a regional HHS office for processing. The marketplace thus far in our experience has been unable to approve any application we have submitted for someone coming out of the Medicaid coverage gap. We've been telling everyone at every elected and appointed level that this is a problem" in the marketplace.

People manning the marketplace helpline, Quenga says, "Do not understand this is a valid SEP. If you're going to claim it, you have to be prepared to escalate. It happens every single time. I fear for those people who don’t have an advocate."

Many observers ascribe the Trump administration's refusal to respond to a pandemic by opening ACA marketplace enrollment to all who seek insurance to spite -- an unwillingness to acknowledge that "Obamacare" programs may have a positive impact. Quenga, more charitably, notes, "these things are very complicated and many elected officials don't understand this whole process." She also notes, however, that the major health insurance trade groups expressed their readiness for an emergency SEP open to all comers -- and the administration blew them off.

That's too bad, because the SEP architecture is particularly Kafkaesque. "We have SEP applications from prior to this crisis that still haven't been processed," Quenga notes. "We have a transplant patient who's still waiting for her SEP to be approved after she lost coverage because she turned 19 and her Medicaid ended.  Now you're going to have all these new people who lost coverage apply? I don't know how they're going to process all of the paperwork."

Related: Enhanced unemployment benefit will skew ACA Medicaid/marketplace enrollment

Update: Charles Gaba provides vital context on the normal volume of SEPs (about 8k/day nationally) and the history of SEP verification (radically tightened by the Trump administration, natch).


*The Palmetto Project's enrollment assistance program was funded by a federal navigator grant in the ACA marketplace's early years. When the Trump administration gutted funding for navigators, Palmetto converted to a nonprofit brokerage to fund continuing operations.


  1. To prove loss of coverage a simple letter on company letterhead stating the person's name and the date their coverage ended has always been accepted for my SEP clients. Usually only takes two or three days for the Marketplace to approve the SEP, but I can understand how that could take longer now. Also, no need to print the letter. If the consumer has a digital copy, it can be uploaded to their Marketplace account.

  2. Glad to hear it's not always long and slow, Kevin -- but likely to get overloaded now. What state are you in again?
    As for mail-in, a bit of shorthand there, though note that the text does say docs can be uploaded. Shelli emphasized that for some applicants an upload is a bridge too far. I imagine that assisted applicants usually do upload.

    1. The Trump administration's proposal on Friday was shockingly good, at least at first hearing. An uninsured person would have hospital care for the virus covered at 100%, with a guarantee of no balance billing allowed. Sure beats a 55 year old buying a lousy silver plan on the exchanges for $600 a month and still having a $4500 deductible.