Friday, March 25, 2022 should tell 600,000 low-income bronze plan enrollees: switch to silver

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The message above, provided to shoppers on who estimate low incomes, isn't enough to keep a significant number of low-income enrollees out of bronze plans.

My last post focused on the stubborn persistence of significant bronze plan selection among low-income enrollees in the ACA marketplace in 2022, despite the fact that premium subsidy increases provided by the American Rescue Plan Act made the benchmark silver plan with strong Cost Sharing Reduction free to enrollees with incomes up to 150% FPL, and much cheaper than in previous years for those with incomes in the 150-200% FPL range.

Among enrollees with income between 100% and 150% FPL, 14% -- more than 600,000 -- selected bronze plans for 2022. While bronze plan selection at incomes in the 100-150% range did tick down a bit from the prior year, it remained higher than in any year prior to 2021.

President Biden's January 28, 2021 Executive Order 14009, “Strengthening Medicaid and the Affordable Care Act," declares, "it is the policy of my Administration to protect and strengthen Medicaid and the ACA and to make high-quality healthcare accessible and affordable for every American." Bronze plans obtained by people with income below 150% FPL do not advance that policy.

Bronze plan single-person deductibles average over $7,000, compared to under $150 for silver plans as enhanced by the CSR provided to enrollees with incomes up to 150% FPL. Annual out-of-pocket maximums in bronze plans generally exceed $8,000,* compared to an average of $1,208 in silver plans. 

600,000 bronze plan enrollees below the 150% FPL threshold is almost 600,000 too many.

CMS has given itself a tool to reduce this underinsured population. Last July it finalized, and this month it implemented, a rule creating "monthly special enrollment period" for enrollees with incomes up to 150% FPL -- effectively establishing continuous year-round enrollment for the lowest-income marketplace applicants. The rule not only allows the uninsured to enroll outside the annual Open Enrollment Period; it also allows current enrollees with income up to 150% FPL to switch to a silver plan. 

An express purpose of the rule -- which invokes Biden's executive order as a governing principle --  is to provide scope for ramped-up marketing and outreach to educate and enroll hard-to-reach, low-income, low-information people, particularly those of limited English proficiency -- precisely the populations likely to enroll in bronze plans when high-CSR silver plans are available free.

In short, the rule is tailor-made for a marketing campaign focused on inducing low-income bronze plan enrollees to switch to silver. 

Let's take a look at the relevant provisions and rationales for the rule.

First, it's expressly premised on the availability of free silver plans.

HHS proposed making this special enrollment period available to individuals based on household income level because enhanced financial assistance provided by the ARP for ax years 2021 and 2022 is such that many individuals with a household income no greater than 150 percent of the FPL have access to a silver plan with a zero dollar monthly premium after the application of APTC (p. 77).

It's tailored to enable low-income enrollees to switch to silver plans...

HHS also proposed to add a new paragraph at § 155.420(a)(4)(ii)(D) to provide that an Exchange must permit eligible enrollees and their dependents to change to a silver-level plan, and to amend paragraph § 155.420(a)(4)(iii), which provides other plan category limitations for other special enrollment periods, to provide that these other plan category limitations do not apply to enrollees or dependents who qualify for the proposed special enrollment period (p. 78).  

and only to silver plans.

..enrollees with a newly-enrolling dependent or other household member may not use the new monthly special enrollment period to change to a plan of a different metal level other than a silver-level QHP to enroll together with their newly-enrolling household member, but can stay in the same plan or change to a silver plan to enroll together with the newly-enrolling household member. This limitation will help to mitigate adverse selection (p. 78).

Year-round enrollment at low incomes is premised on the difficulty of reaching low-income populations and on HHS's commitment to "extensive outreach and engagement efforts."

The APTC benefit changes under the ARP make affordable coverage available to more uninsured people. However, as discussed in the proposed rule, if past trends continue, HHS believes that some consumers who qualify for these benefits under the ARP may continue to forgo enrollment in premium-free coverage due to a lack of awareness of the opportunity to enroll or a misconception about what the coverage would cost, and that low-income consumers who have lacked coverage for more than a year may be especially difficult to reach. 68 Therefore, while HHS will undertake extensive outreach and engagement efforts to promote enrollment during the open enrollment period for 2022 coverage and to help ensure consumer awareness of existing special enrollment periods for which they may qualify, given the established challenges with promoting awareness of access to coverage among low-income consumers, HHS believes additional enrollment opportunities for low-income consumers are appropriate and in the best interest of low-income consumers. Additionally, as noted in the proposed rule, the monthly special enrollment period policy would align with EO 14009, which requires federal agencies to identify and appropriately address policies that create barriers to accessing ACA coverage, including access through mid-year enrollment (p. 82). 

The footnote (68) cites to a KFF brief that details the challenges of reaching the low income uninsured. 

HHS is particularly interested in getting low-income enrollees into silver plans and recognizes the difficulty of doing so (my emphasis).

Finally, HHS requested comment on strategies for providing outreach and education for consumers who may be eligible for this special enrollment period, in particular to help qualifying individuals understand and take advantage of the free or very low-cost coverage that is available to them. Within this group, HHS requested comments on strategies for educating consumers who qualify to enroll in a 94 percent AV silver plan about the benefits of enrolling in such a plan even if they are required to pay a small premium, as opposed to electing a premium-free bronze plan with a lower AV (p. 86). 

As that message indicates, some low-income bronze plan enrollees likely select bronze plans because, while two plans in every rating area are zero-premium, a desired insurer's silver plan may be significantly more expense than the benchmark (second cheapest) silver plan and so may have a substantial premium. In a few such cases, bronze plan enrollment may make sense. But these are relatively rare.

HHS adds a particular focus on legally present noncitizens with income below 100% FPL who are time-barred from Medicaid but eligible for free silver marketplace coverage. 

...several commenters agreed that lower-income individuals often face greater barriers to enrollment, such as a lack of an internet connection or other computer equipment, limited available time due to working multiple jobs, and LEP. Commenters also noted that this group of consumers is disproportionately made up of people of color. Several commenters noted that they expected this special enrollment period to be especially helpful to individuals in their area whose income is under 100 percent of the FPL, but who do not qualify for Medicaid because of their immigration status, and who therefore may qualify for APTC. They noted that this group can be difficult to reach through outreach and education, and therefore may benefit significantly from additional opportunities to enroll throughout the year. Several commenters voiced support for outreach and education to promote awareness of this special enrollment period as well as other special enrollment period qualifying events. Some added that currently-available enrollment opportunities are underutilized due to their complexity and due to the challenges associated with learning about and enrolling in coverage. Some commenters encouraged CMS to focus outreach and education efforts on vulnerable communities, individuals with LEP, immigrants, and the LGBTQ+ community (p. 87).

At incomes below 100% FPL, I would add, just 58% of enrollees chose silver plans -- though a significant percentage of enrollees below the 100% FPL threshold may be unsubsidized  --e.g., because applicants who are not time-barred from Medicaid are ineligible for subsidies if they report an income below 100% FPL. Many who do report an income below the threshold probably don't need to -- another issue that should address, and for which continuous enrollment at low incomes could be a help.

Finally, in detailing target populations and the challenges of reaching them, the rule summarizes a second KFF report (from May 2021), focused on the potential of the American Rescue Plan to reach the uninsured.

The report found that compared to the general non-elderly population in the U.S., this population is more likely to be Hispanic, people with a high school diploma or less, and young adults ages 19 to 34. Additionally, it found that uninsured people eligible for subsidies are more likely to live in rural areas and lack internet access than the general non-elderly population in the U.S. The report also noted that the estimated 6 million uninsured people who may be eligible for a zero dollar premium plan through the Exchange after application of APTC are more likely to be non-English speakers at home. Providing a monthly enrollment opportunity will give this population of uninsured people more opportunities to access coverage and provide more time for targeted outreach to consumers who may be harder to reach and enroll, such as those who are non-English speakers at home. HHS agrees with commenters’ support for robust outreach and education efforts targeted in particular to ensuring awareness and understanding of this special enrollment period and other enrollment opportunities, and will continue to work with stakeholders to develop and optimize targeted messaging (p. 88). 

As someone who created a login for myself as soon as the then-dysfunctional website allowed in fall 2013, I can report that the federal exchange bombards those with such log-ins with constant emails encouraging enrollment. Usually these emails focus on the availability of low premium coverage, as in "most enrollees can find a plan for $10 per month or less." Unlike with Medicaid enrollees, has an email address for virtually all current enrollees -- though many may not be comfortable with email or check it frequently. In any case, by any and all media, the exchange has information and tools to contact all low-income enrollees enrolled in bronze plans.

I have focused here on enrollees with income below 150% FPL because they are now granted continuous enrollment, but silver selection at incomes in the 150-200% FPL is also far lower than it should be, and lower than it was in all years prior to 2020 -- notwithstanding that a benchmark silver plan could cost a solo enrollee as much as $125-130/month in 2019, and thanks to ARPA now tops out at $43/month. See the prior post for more about this income group.


* A significant portion of bronze plans are High Deductible Health Plans linked to Health Savings Accounts, and by statute these plans have a somewhat lower out-of-pocket maximum, set at $7,050 in 2022. The tradeoff is that all services except for pre preventive care are subject to the deductible, whereas other bronze plans may exempt some services from the deductible, such as generic drugs or a limited number of primary care visits. 

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1 comment:

  1. I agree far too many consumers eligible for CSR are not in a silver plan. As someone who assists consumers with plan selection, I do want to add some perspective as to why the consumers pick bronze or gold instead of silver. There are some circumstances where CSR qualifying consumers pick gold.
    First, consumer assistance is just plain hard to find. This is particularly true for the Federal marketplace. I work in a state-based marketplace and we are luckily much better funded. Even so, it is very difficult to reach the consumers who need us the most. Navigators and application counselors are constrained in how we talk about the health plans. We are not allowed to make recommendations as to which plan may serve the consumer better. We can make factual statements such as “the silver plan will cost you much less over the course of a year.” But most consumers want to be told which plan to select. In the limited amount of time a consumer assistance worker has with a consumer, it is difficult to both enroll and educate them. I liken the ACA as giving everyone a car but ignoring driver’s education. So, often in the hour or so I have to work with someone, they just don’t grasp the implications of bronze vs. silver; out of pocket maximum; deductibles etc. Consumers with low income are very focused on their “right now.” My experience is that they don’t have the luxury of thinking about costs on an annual basis. It is week to week, month to month sometimes day to day. The lower premiums of bronze plans (pre-ARP) were just too hard to resist.
    Many consumers rely on automatic renewals, so if they were in a bronze plan they tend to stay there. This is particularly true for consumers who enroll on their own without assistance.
    Silver loading and its affect on APTC. In the area I serve, silver loading dramatically skewed the marketplace. Because silver plans were the most expensive and because we only had 2 silver plans, the second lowest cost silver plan was thus the most expensive. This significantly increased the amount of financial help from APTC available. Gold plans were a few dollars a month and had benefits like $0 cost sharing for primary care and generic prescription. This was true for the past 4 years only changing this year.
    Another reason pre-ARP folks did not choose silver is that silver plans have co-pays and co-insurance amounts for both prescriptions and primary care visits even with CSR. Consumers were willing to take the risk of having more financial exposure on an annual basis to keep their weekly and monthly expenses lower. This changed dramatically this year because of ARP, however, consumers who have experienced many significant shifts with plans and prices in the marketplace over the years are often reluctant to change even when it is in their financial best interest. In my area, we got a second carrier and the second lowest cost silver plan changed and APTC dropped by hundreds of dollars. Lots of folks went to silver and bronze from gold because of this.
    Just because a silver plan has a $0 premium, does not mean it has an adequate network. It does not guarantee that a particular provider will be in network. In rural area like mine, people want to keep the provider they are familiar with. They will pick a bronze with pre-deductible copays for primary care and prescriptions just so they can keep the same provider. Most consumers who have not had a major health event seem to underestimate the likelihood of it happening to them.
    The year-round SEP for those with income up to 150% of FPL will help. However, not yet implemented in my state. At that income level there is significant churn between Medicaid and marketplace. I wish there was a way that APTC could be used to allow those consumers to stay with their Medicaid Managed Care Organization. No change of providers, more stability/continuity of care for the consumer.
    Having just recently found your blog, I find it incredibly helpful and informative. Keep up the good work! Thanks.