Wednesday, April 07, 2021

ACA's emergency Special Enrollment Period most effective in states that have not expanded Medicaid

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CMS has released a report showing strong response in the first six weeks to the emergency Special Enrollment Period for the ACA marketplace that commenced on February 15. The emergency SEP, now extended to August 31, allows anyone who is uninsured to enroll in marketplace coverage, and allows current enrollees to change plans. From February 15 through March 31, 528,000 people enrolled via SEP this year, compared to 209,000 in 2020 and 171,000 in 2019.

The CMS report also highlights increased relative enrollment shares for black and lower income enrollees. In particular, the SEP is being accessed in large numbers by enrollees with incomes in the 100-138% FPL range -- that is, enrollees in states that have refused or not yet enacted the ACA Medicaid expansion who would be eligible for Medicaid had their states already embraced the expansion:

Among consumers requesting financial assistance, 41% have a household income between 100% and 138% of the federal poverty level, compared to 38% in 2020 and 33% in 2019.

The SEP continues a 2021 pattern: the pandemic, and government action to mitigate its financial impact, have boosted enrollment more in nonexpansion than in expansion states. In the Open Enrollment period for 2021, enrollment increased by 10% in nonexpansion states and was virtually flat in expansion states (up slightly in states that run their own exchanges, down slightly in expansion states that use  

In the first six weeks of the emergency SEP, enrollment in expansion states using was up 95% over same-period SEP enrollment in 2020. In the nonexpansion states (all of which use, enrollment was up 176% year-over-year. Among the 36 states using in 2021, nonexpansion states accounted for 70% of SEP enrollment from Feb. 15--March 31 in 2020, and 77% this year.  

Here's the state-by-state breakout:

                SEP enrollment in states, February 15--March 31, 2021 v. 2020

Enrollment in nonexpansion states likely continues to be boosted by the inclusion of emergency supplemental unemployment income in the income calculation for subsidy eligibility, which begins at 100% FPL; those with incomes below that level in nonexpansion states get no government help unless they qualify for Medicaid under states' narrower criteria. The extra UI appears to have pushed a significant number of nonexpansion state residents over the 100% FPL threshold. The recent premium subsidy increases, effective since enactment of the American Rescue Plan Act on March 11 and retroactive to January 1, may have provided a further enrollment boost in March, though the newly enhanced subsidies did not become visible on until April 1.

In any case, Covid relief legislation has at least nibbled at the edges of the "coverage gap" caused by  mostly southern states' refusal to enact the ACA Medicaid expansion.

Update: Charles Gaba also broke out expansion vs. nonexpansion state results, along with other observations.

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