Saturday, June 13, 2020

The elephant not in the room on ACA exchanges

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Here's the home page on the Maryland Health Connection, the state's ACA exchange. What's missing from this picture?

What's almost invisible: Medicaid. Medicaid. MEDICAID.

About 71% of those who lose job-based in this crisis will qualify for subsidized insurance, according to the Urban Institute's estimate. Two thirds of them will qualify for Medicaid, and about half as many for subsidized marketplace. In the 35 states that have enacted the ACA Medicaid expansion, almost* any adult age 65 whose current monthly household income drops below 138% of the Federal Poverty Level will qualify for Medicaid. That's $1468/month for an individual, $3,013 for a family of four. For children, the income thresholds are higher.

You'd never know this by visiting the home page of any ACA exchange. The exchanges were conceived as marketplaces for private plans. They give the impression that that's what almost everyone will seek and find. They're hiding a product that two thirds of "customers" should end up "buying."**

Those who fill out an application will be routed to Medicaid if eligible -- if they accurately report current monthly income. But because of misdirected messaging, many visitors to the exchanges may never get there. Alongside the lack of emphasis on Medicaid, or failure to post the eligibility criteria, exchange messaging and structure can cause people to miss their Medicaid eligibility in at least two ways, both in evidence above.

On the Maryland exchange home page, the "apply for coverage" box does mention Medicaid. If you click through to "get an estimate," you're directed to a screening tool that may point you toward Medicaid if you're likely eligible. But that's only true if your annual income qualifies you -- that's what the box prompts you to estimate. Medicaid eligibility, however, is based on current monthly income. So if you're newly unemployed and you've earned, say, $15,000 to date, and that plus unemployment insurance puts your income over 138% FPL, you'll get an estimate for marketplace coverage. That's usually far more expensive, often with daunting deductibles (depending on income). You may conclude that coverage is not affordable.

Those who are receiving the extra $600/week in unemployment benefits provided by the CARES Act may include that extra income in their estimate. That's correct for marketplace coverage, but not for Medicaid -- the income counts toward the former, but not the latter. The Maryland exchange has a page that does a nice job explaining how to handle this on the actual application:  add the $600/wk in the annual income estimate, but not the monthly. But again, you have to get there first, i.e. decide that applying is worthwhile. The screening tool, unlike the application, does not ask for monthly as well as annual income, and so may mislead.

The second problem is less acute on the Maryland exchange than on others, but still present. It's information about Special Enrollment Periods (SEPs) -- which are relevant to marketplace coverage but not Medicaid. The message "Uninsured Marylanders can enroll by June 15" does not specify marketplace and exclude Medicaid, as it should (Medicaid enrollment is available year-round). Yes, the box above does state that Medicaid is available year-round. But humans are not notorious for systematically reading all the text boxes on a page full of them.

The SEP problem is more acute on other exchanges. On Connect for Health Colorado, here's the first thing you see -- the only text you'll see without scrolling down, set in a pictorial background.

The Connect for Health Colorado home page does not mention Medicaid at all. In the plan preview tool, when prompted for an income estimate, you can choose to estimate on a weekly, monthly or annual basis. But there's no hint why you might want to choose monthly -- i.e. to determine whether you're eligible for Medicaid.

Maryland has been innovative and energetic in efforts to reduce the state's uninsured population, both before and during the pandemic. At tax time, the state reaches out to the uninsured and offers a Special Enrollment Period (SEP) to check out what kind of subsidized coverage they may be eligible for. If they check a box on their tax returns, the state will calculate whether they're eligible for Medicaid or subsidized marketplace coverage. Then, when the Covid-19 pandemic triggered mass job losses, the state opened an emergency SEP in which anyone who lacks insurance can enroll. That expires June 15.

Taken piece by piece, the messaging on the Maryland exchange is clear. The graphics are clean, the routing to the plan preview tool or an application efficient. Big picture, though, it's focused on the wrong thing. Medicaid is the primary catchment for the newly uninsured.  The exchange is not optimized for the catch.

Related: C'mon, states: take the wraps off Medicaid


* Legally present noncitizens who are subject to the federal 5-year bar for Medicaid coverage (or longer state waiting periods) are eligible for marketplace subsidies even if their income is below the Medicaid threshold (138% FPL). Below that level, a benchmark silver plan enhanced with Cost Sharing Reduction costs 2% of income.  Deductibles at this income level average about $200; annual out-of-pocket maximums average about $1,110.  The undocumented, alas, are not eligible forfull-service Medicaid or marketplace subsidies.

** It's not literally true that 2/3 of those who enroll in coverage via ACA exchanges enroll in Medicaid, because people find other paths to Medicaid. Enrollment assisters generally prefer state Medicaid websites, at least in the 25 "expansion" states that use If the exchanges were all truly and efficiently "one-door" portals to coverage, however, that ratio would probably hold.

1 comment:

  1. The other day I was helping a client who is planning to move to Maryland later this summer. I went to the Maryland Health Connection website to see if I could find contact info for Navigators or CACs, but the Find Assistance tool only shows brokers. There's a separate button one has to find and click in order to see the non-profits. I don't understand why ALL assiters are in the Find Assistance too... so, there's another problem with the website. :-)