Wednesday, May 20, 2020

New Jersey's "Get Covered" message submerges Medicaid

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New Jersey, a very blue state with a liberal governor and large Democratic majorities in both houses of the legislature, is committed to helping hundreds of thousands of residents newly uninsured in the Covid-19 pandemic to find subsidized coverage. The state has launched an information campaign to help people get covered.

But New Jersey's ACA marketplace is stuck in limbo during a tough time. The state is in the process of creating its own state-based exchange (SBE), scheduled to launch on November 1. In the meantime, it's technically an SBE, but still using the federal exchange,, for enrollment.

That creates a messaging problem. The state has created a website, Get Covered New Jersey, to help people find coverage. But it has to be a complex switching station. Those eligible for subsidized marketplace coverage need to enroll through Those eligible for Medicaid -- probably the majority of the newly uninsured -- can also apply via but, for reasons explained below, are probably better off applying directly through the state's Medicaid program, New Jersey Family Care. Finally, those who earn too much to qualify for aid need to be aware of ACA-compliant plans offered off-exchange only, especially since these include the cheapest silver plan available.

Get Covered New Jersey tries, but in my view fails to help people figure out quickly what kind of help they're eligible for, and act accordingly.

The main problem is that the site doesn't foreground Medicaid or, most vitally, a Medicaid eligibility screener. According to an Urban Institute estimate, almost half of New Jersey's  newly uninsured residents (224,000 out of 489,000 by the study's more conservative of two estimates) should end up in Medicaid, while just under a quarter may enroll in marketplace coverage.

While GetCoveredNJ's main information page* mentions Medicaid at top and bottom, and links to NJ Family Care, the page's overwhelming emphasis in on the ACA marketplace (see screen shots at bottom or check out the page). That entangles the majority of people who can find subsidized insurance in complications that shouldn't concern them. These include:

1) Information about "Special Enrollment Periods." While enrollment in the ACA private plan marketplace normally is limited to a short season (Nov. 1 - Dec. 15 on, Medicaid enrollment is year-round. Since CMS has refused to open an emergency Special Enrollment Period (SEP) on (as 12 of 13 state-based exchanges have done), those who lose employer coverage or have another qualifying 'life change' have to apply for an individual SEP to seek private plan coverage.  GetCoveredNJ foregrounds information about the SEP and does not make clear that Medicaid enrollment is open year-round to all who qualify.

2) Screening for annual, rather than monthly, income.  While subsidies for ACA marketplace plans are based on annual income, Medicaid eligibility is based on current monthly income. GetCoveredNJ routes people to a proprietary eligibility screening tool that prompts for annual income only. People who earned substantial income before being laid off may miss the fact that their current income will qualify them for Medicaid.

People who lose employer coverage often don't think of themselves as candidates for Medicaid. But the income provided by unemployment insurance is likely to qualify a large plurality. This is especially true because the $600/week extra UI provided through July 31 by the CARES Act (the largest Covid-19 relief bill to date) does not count toward Medicaid or CHIP eligibility. It does count toward marketplace subsidy determination, which will further skew enrollment toward Medicaid rather than the marketplace.

The monthly eligibility threshold for Medicaid in states that have accepted the ACA expansion, as New Jersey has, is 138% FPL. At present, that's $1,468 for an individual, $1,983 for a couple, $2,498 for a family of three and $3,013 for a family of four. This information is nowhere to be found on GetCoveredNJ, and those who should go to NJ Family Care to check eligibility have no way to know that's where they should go first.

Front and center on the site should be a tool like this:

That's a tool on  GetCoveredNJ provides a link to the site -- but here too, a visitor who may not think of themselves as Medicaid material may not find her way to this screener. On, after clicking on "see if I can enroll," a visitor may choose "see if I qualify for Medicaid." If so, she'll find the tool above. She may also choose "see if I qualify for a special enrollment period" -- e.g., without knowing that such periods pertain to marketplace not Medicaid, or knowing whether her income is likely to qualify her for Medicaid. If so, she may find her way to a different screening tool, more oriented toward the private plan marketplace, that prompts for annual income, and so, again, may miss Medicaid eligibility.

A New Jerseyan who starts an application on may get enrolled in Medicaid if his income qualifies him. If current monthly income multiplied by 12 does not translate directly to estimated annual income, however, complications may arise. If monthly income exceeds the threshold but yearly income will come in below 138% FPL, won't recognize eligibility: a skilled enrollment assister in this case would contact the state Medicaid dept. to seek "gap" coverage. If current monthly income is below the threshold but annual income exceeds it, will theoretically route the applicant to Medicaid. But a half dozen highly experienced enrollment assisters have told me not to try this. When there's any ambiguity, they go straight through the state Medicaid website or department. For NJ, that's here.

What's missing on GetCoveredNJ, other than broadcasting Medicaid availability, is basic orientation by income. The uninsured will fall into one of three buckets: Medicaid, subsidized marketplace, unsubsidized marketplace. The Checkbook screening tool will handle both marketplace buckets -- usefully, it shows off-exchange plans for the unsubsidized. It will also point toward Medicaid coverage if the annual income qualifies the user. But because it does not take current monthly income into account, it's not suitable as an all-purpose screener. Medicaid information and screening needs to be foregrounded.

Here is the main information page GetCoveredNJ, reached after clicking "learn more" on the home page. Medicaid looks like an afterthought, subordinated in the top banner and then placed at the bottom of the implicit decision tree. The top note's reference to Medicaid does not make clear that no Special Enrollment Period is needed. Nor does the bottom note.

On the plus side, the state has launched an awareness campaign that includes a vital channel: the state Dept. of Labor:
“In this challenging time, affordable health care coverage is more important than ever. If you have lost your health coverage or otherwise need health insurance during this emergency, we are here to help. Human Services has worked with the Department of Labor and Workforce Development to ensure residents applying for unemployment insurance are aware they may qualify for NJ FamilyCare, our free or low-cost health insurance,” said Human Services Commissioner Carole Johnson. “Please visit to learn more and apply. We have made numerous policy changes to make it easier to apply and maintain NJFamilyCare coverage during this public health emergency.”   
As part of its transition to SBE status, the state has also bulked up enrollment assistance, funding for which was gutted in states using the federal exchange. The state has funded five navigator groups, up from just one funded by the feds before the transition. The GetCoveredNJ page provides a hot line phone number for enrollment help.

* The GetCoveredNJ home page also misses an opportunity to steer those who qualify toward Medicaid (NJ Family Care). While the central boxed message does include Medicaid, and rightly leaves Medicaid out of the requirement for a Special Enrollment Period, there is no link on this page to NJ Family Care, only a phone number on the right. The page's main draw is a "learn more" button to the page discussed in this post. The central text box, moreover, is preceded by a banner message that fails to exclude NJ Family Care from the SEP requirement.

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