New Jersey's Department of Banking and Insurance lays a trap for elderly enrollees in the state's ACA marketplace

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Filling out an application for subsidized health insurance in the ACA marketplace can be straightforward — or not so straightforward. If the exchange’s “trusted sources” of information do not readily identify you, uploading proof of identity nd getting it accepted can be a…process (especially in a family with mixed immigration status). If you are self-employed and your income is not obviously reflected in regular monthly payments, documenting your claimed income and having the documentation accepted can also be a multi-stage process.

That said, once your documentation is accepted and your monthly subsidy is assessed, you are good to go, right?

Not always. Not in New Jersey, anyway, where the insurer can come after you for additional documentation — and potentially reduce your coverage to a shadow.

What I've learned as an ACA assister

This Open Enrollment period I've been volunteering a few hours per week as a Certified Application Counselor (CAC) for the ACA marketplace, at an office in Newark, NJ. I haven't had as much experience as I would have liked, but here, very generally, are a few things I've learned.

• The government could save a lot of money by opening Medicare and Medicaid to all legally present immigrants*.  Marketplace premiums for Medicare-age immigrants are sky-high -- and often paid entirely by the federal government. Oddly, marketplace plans may actually be better than traditional Medicare for elderly immigrants -- if they stay in network, e.g., if their middle-aged children can find them in-network providers. That's because marketplace plans, unlike traditional Medicare, have an out-of-pocket maximum. Then again, dual eligibles would be better of Medicare/Medicaid.


• Similarly, legally present immigrants with Medicaid-eligible income but subject to the 5-year bar for Medicaid eligibility cost the government more in marketplace plans than they would in Medicaid (as does anyone; see Private Option, Arkansas). They would also be better off in Medicaid -- the out-of-pocket costs attached to silver plans, even with strong Cost Sharing Reduction attached, are a high bar for people with Medicaid-eligible incomes.

Are 2.5 million off-exchange health plan enrollees subsidy-eligible?

A recent HHS ASPE* analysis of the ACA marketplace and the uninsured found that an estimated 2.5 million people currently enrolled in health plans bought in the off-exchange individual market are potentially eligible for premium subsidies in the ACA marketplace. That is, 2.5 million people may have foregone subsidies by buying off-exchange or may be eligible for them in 2017. That's a pretty eye-popping number -- indicating that 70% of those currently enrolled in the individual market (on- and off-exchange) are subsidy-eligible.

HHS further estimated that 9 million of the uninsured are potentially eligible for subsidies in the ACA marketplace, and that a total of 20.9 million people are subsidy-eligible -- more than double the 9.4 million enrolled in subsidized marketplace plans as of March 31 of this year. Those estimates are markedly different from those of the Kaiser Family Foundation, which estimates that 5.4 million of the uninsured are potentially subsidy-eligible, and pegs the total subsidy-eligible population at 14.9 million.

The HHS analysis is based on different survey data than the Kaiser estimate: HHS uses the National Health Interview Survey (NHIS) while Kaiser relies on the Current Population Survey (CPS). But HHS's higher estimates may stem in large part from two more fundamental differences.