2018 MIDTERM ELECTION

Time: D H M S

CMS makes 2nd sneak play to semi-privatize ACA exchanges (and this *may* be OK)

A few days ago, CMS announced that they're retooling the ACA's SHOP program (at least on the federal exchange) so that instead of small businesses using HealthCare.Gov for eligibility verification, enrollment and payments, going forward it will only be used for verification, with the businesses then being kicked over to the actual insurance carrier website in order to actually enroll in the policies and make payments.

Although the Trump Administration and HHS Secretary Tom Price are hell bent on killing off the ACA altogether, this move didn't bother me for several reasons. For one thing, the SHOP program has always been kind of a dud anyway, with only around 230,000 people being enrolled in it nationally. For another, a business signing up their employees for coverage is a very different animal from an individual signing their family up for a policy. Finally, for several reasons, SHOP enrollment across the dozen or so state-based exchanges is actually higher than it is across the 3 dozen states covered by HC.gov, and the state-based exchanges aren't impacted by this policy anyway.

Today, however, CMS has issued another press release regarding a new WBE (Web Broker Entities) policy which on the surface seems perfectly reasonable, but which raises some concerns under the surface.

I haven't written much about WBEs in the past; in fact, I've only written one full post about them before today. WBEs are authorized online private insurance brokers like eHealth, GoHealth, HealthSherpa and so forth, many of which were already operating before the ACA exchanges launched. WBEs have been certified by CMS to market and sell ACA exchange policies through their own websites, with an API hook which, again, has enrollees fill out part of their information on the WBE site but then get kicked over to HC.gov or a state exchange site to complete the enrollment process. Here's a list of certified WBEs as of 2016; there were around 80 of them last year. I presume they make money via insurance carrier commissions, although many of the carriers have been cutting back or even eliminating broker commissions for exchange policies anyway, so I'm not entirely sure how they're able to make a profit.

In any event, here's today's press release:

The Center for Medicare and Medicaid Services (CMS) announces streamlined direct enrollment process for consumers seeking Exchange coverage

Today, the Centers for Medicare & Medicaid Services (CMS) announced a new streamlined and simplified direct enrollment process for consumers signing up for individual market coverage through Exchanges that use HealthCare.gov. Consumers applying for individual market coverage during the upcoming open enrollment period through direct enrollment partners will now be able to complete their application using one website. This reduces needless regulatory burden for businesses that provide direct enrollment services and offers consumers easier access to healthcare comparisons and shopping experiences for coverage offered through HealthCare.gov.

“This is another important step to help create stability in the health insurance market,” said CMS Administrator Seema Verma. “It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage. It is time to get the federal government out of the way and give patients the best tools to make their own healthcare decisions. We look forward to continuing to work with private partners to make sure these streamlined enrollment pathways are available, secure, and ensure a high degree of program integrity.”

In prior years, consumers who signed up for health coverage using a third party website were redirected to HealthCare.gov to complete their application. Consumer feedback showed that the process was confusing and made it harder to finish the application. The new process allows consumers to start and finish their application through the third-party website of direct enrollment partners approved to use the proxy direct enrollment pathway.

The guidance announced today is part of a larger CMS effort intended to stabilize the health insurance market by providing more ways for consumers to access coverage. Read more about the guidance.

The link goes to a longer CMS document which goes into more detail about the new policy. There's language about access to enrollee data, security provisions, approved practices and so forth, but you get the gist.

Basically, this means that, similar to the new SHOP policy, instead of using the WBE site for the first part of the enrollment process and then completing it at HC.gov or a state exchange, the entire process would be handled directly via the WBE website.

Again, on the surface, this isn't necessarily a terrible thing...and if the current administration wasn't hell bent on killing the ACA altogether and completely privatizing all health insurance transactions, it might be a reasonable move. I had a Twitter discussion about it with folks like Josh Schultz, Ken Kelly, Wesley Sanders and others which reassured me on some points but also raised a few concerns on others:

  • First, both of these moves (the SHOP and WBE policies) are clearly meant to eat away at the "need" and purpose of the actual ACA exchanges, relegating them to a pure eligibilty verifciation role, while privatizing other parts of the process as much as possible. Again, that's not necessarily a bad thing, but it raises a big red flag regarding future moves.
  • Second, depending on how it's done, this could potentially allow WBEs to only display the ACA exchange policies (Qualified Health Plans, or QHPs) which they want to, as opposed to displaying all of them in an unbiased, apples to apples fashion as HealthCare.Gov and the state exchanges require.

According to Wesley Sanders, the ACA itself does allow for this:

Per 45 CFR 156.1230, the issuer direct enrollment pathway doesn't require display of other issuers' QHPs...Issuer does have to have a link to healthcare.gov but I'm not expecting CMS to be super fussed about how prominent it is

...if the broker entity is truly acting as a broker, they have to display all QHPs. If it's a site run by the issuer, the issuer can just display their own plans (but still must display all their QHPs)

...so a move along these lines isn't a shocking change to the law, just one which hadn't been implemented previously. It sounds like eHealth/etc. could bury a tiny link to HC.gov at the very bottom of the website to comply if they wanted to. Meanwhile, it would allow carriers like Kaiser Permanente, Molina, Moda etc. to enroll people "on exchange" (including ACA tax credits if eligible) via their own websites without ever going to HC.gov or even letting the enrollee know that the policy they're enrolling in is "on exchange".

Whether this is a good or bad thing depends on your POV, really. Before it was dismantled by GOP Governor Matt Bevin, the Kentucky ACA exchange, kynect, was praised by Kentucky residents...even though many of those enrolled in policies via kynect never understood that they were enrolled in "Obamacare" or "the Affordable Care Act". They thought that "kynect" was some totally unrelated state-run program. This has led to...misunderstandings, to say the least.

In short, as long as concerns about things like security/sharing of sensitive enrollee data, manipulation of enrollees into policies which aren't the best option for them and so on are appropriately handled, this might be a reasonable change to improve the ACA exchanges...but it's being done purely as a way of undermining and weakening the exchanges, it's a bad move which should set off red flags for ACA supporters.