Update: Ending presumed Medicare eligibility for New Jersey's elder ACA marketplace enrollees

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I’d like to provide a couple of updates regarding an abuse in New Jersey’s individual market that I wrote about in September (here and here). the issue in brief: in 2023, the state’s standard individual health plan contract stipulated that insurers could presume that enrollees over age 65 were eligible for Medicare unless they provide written proof otherwise. Failing that proof, the insurer would assume Medicare eligibility and act as a secondary payer to Medicare — paying only a small fraction of the enrollee’s bills while collecting a full premium. In 2023, about 9,000 enrollees via GetCoveredNJ, the state’s ACA exchange, were over age 65.

As I reported, in May 2023 CMS issued guidance that unambiguously stated that this practice — presuming Medicare eligibility for senior enrollees and acting as a secondary payer — violated ACA requirements. While New Jersey’s Department of Banking and Insurance did not respond to my queries about the New Jersey policy and the CMS guidance, they did respond to the same queries from an nj.com reporter, Karin Price Mueller, whom I approached about the issue. As they told Mueller, on September 27 DOBI issued a directive (described in Mueller’s paywalled article and in my followup post) to insurers in New Jersey’s individual market instructing them to comply with DOBI’s guidance — that is, cease presuming Medicare eligibility and acting as a secondary to Medicare simply because an enrollee was over age 65.

Where and how do people find plans in the ACA marketplace?

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On October 1, 2013, the day the ACA exchanges first opened for business, President Obama promised that the exchanges would enable shopping for health insurance “the same way you shop for a plane ticket on Kayak or a TV on Amazon.”

The wretched dysfunction at launch of the federal exchange, HealthCare.gov (and to varying degrees the state exchanges as well), evident that day, immediately made that promise a laugh line. While two months of technical and political hell ensued before HealthCare.gov was marginally functional, ultimately 7 million people did enroll for 2014 coverage — in line with CMS’s projections — and the image of the insurance shopper sorting through the options on the exchanges took hold. The functioning and messaging on the exchanges improved over time — though the proliferation in recent years of barely-differentiated plans complicated the task of plan selection.

In the ten years since then, I’ve written many posts about the weaknesses and strengths of the exchanges’ functionality and messaging. Do they make it easy to enter a few data points and preview plans and prices (net of subsidy) for the individual viewer? Do they adequately steer those eligible for strong Cost Sharing Reduction to silver plans? In the first cataclysm of the pandemic, did they make Medicaid availability clear? Do their decision support tools (highlighting plans likely to yield the lowest net costs) work well?

All of which might be said to obscure the fact that the unassisted enrollee navigating options via the government-hosted exchanges has become an increasingly rare bird. As insurers have reinvested in the marketplace, brokers selling ACA-compliant plans have proliferated (more than 74,000 were registered in 2023, up from 48,000 in 2019). Since 2021, the Biden administration has replenished the federally funded Navigator enrollment assistance program that the Trump administration had reduced to skeletal form (Navigator funding was cut from $63 million in 2016 to $10 million by 2018, then restored to about $100 million in 2022).

Unwinding to the marketplace in Maryland

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In October, CMS reported that of the roughly 5.5 million people disenrolled from Medicaid from the start of the “unwinding” (the end of the pandemic-induced 3-year moratorium on Medicaid disenrollments) through July 31, about 600,000 (592,291) had enrolled in ACA marketplace coverage. Another 95,000 enrolled in the Basic Health Programs that in New York and Minnesota serve lower income enrollees who would otherwise be eligible for subsidized marketplace coverage.

As Charles Gaba notes, these tallies suggest that about 12% of those disenrolled from Medicaid from April to July have enrolled in marketplace or BHP coverage. If that ratio held into November, about 1.1 million of the 10.1 million disenrolled from Medicaid according to KFF’s estimate may have ended up in the ACA marketplace. According to tracking by Georgetown’s Center for Children and Families, as of October, based on the most recent state reports ranging from July to September, net Medicaid enrollment was down by 5.8 million. Assuming that net disenrollment might top 7 million by now, the marketplace may have insured about 15% of the net coverage loss, perhaps a bit higher for adults (as most children who are not insured through employment-sponsored plans end up in Medicaid or CHIP). Here’s hoping a larger percentage of the newly disenrolled find coverage from employers — or already have done so, and have been double-insured since some point after Medicaid redeterminations were paused in March 2020.

While the marketplace is taking up only a modest sliver of those disenrolled from Medicaid, the influx represents a substantial boost to marketplace enrollment. David Stewart, Health Insurance Program Director at the Maryland Area Health Education Center West, which serves primarily rural counties, tells me that since May, appointment traffic for enrollment assistance in his program was more than double normal volume prior to the Open Enrollment Period that began on November 1. To get a sense of how that increase in interest might translate in enrollment I went to the Maryland Health Connection in search of data, and to my surprise, found detailed monthly reports. And indeed, new enrollments from May through September in Maryland in 2023 were more than triple the 2022 total. While enrollment in Maryland as of April 2023 was down 2.7% from April 2022, enrollment as of September 2023 was 13.2% higher than in September 2022.