UPDATE: Calls growing for CMS to offer COVID-19 Special Enrollment Period via HealthCare.Gov

Tue, 03/17/2020 - 10:48am

One week ago, in light of the growing COVID-19 crisis, I noted that California, the District of Columbia and Maryland were each offering Special Enrollment Periods which had nothing whatsoever to do with the pandemic.

California's SEP is for uninsured residents who didn't know that the state had reinstated the individual mandate penalty and expanded financial subsidies to those earning 400-600% of the Federal Poverty Line; DC is offering one for those who didn't know they had also reinstated the mandate penalty; and Maryland passed a clever law last year which lets residents check a box when they file their state taxes if they're uninsured which tells the state to contact them to help them enroll.

I concluded that:

...as far as I know, there's nothing preventing other state-based exchanges from establishing Special Enrollment Periods for the coronavirus crisis if they want to.

Sure enough, just a few hours later, the Washington HealthPlanFinder became the first state-based ACA exchange to announce an official COVID-19-triggered Special Enrollment Period (SEP).

Several other state-based exchanges have since followed suit, including Massachusetts, Rhode Island and New York, while Maryland has expanded their "EZ Enrollment" SEP (which over 18,000 people have taken advantage of already anyway) into a full COVID-19 SEP.

As of this morning, here's where things stand:

The Colorado, Connecticut, Idaho, Minnesota, Nevada and Vermont exchanges haven't announced a COVID-19 SEP as of yet.

Here's the formal response from Connect for Health Colorado:

"Connect for Health Colorado, along with the Division of Insurance (DOI), will continue to monitor the COVID-19 situation in Colorado. At this time, a new Special Enrollment period has not been issued in response to COVID-19, although the DOI did issue a bulletin on health and safety measures for consumers. Coloradans can enroll in a plan if they experience certain Life Change Events, including loss of job-based or Health First Colorado (Medicaid) coverage. Coloradans may also be eligible to enroll if they experience changes or losses in income, which should be reported to Connect for Health Colorado."

Here's the formal response Andrew Sprung got from MNsure:

MNsure is working closely with Governor Walz, Minnesota state agencies, and other stakeholders to determine whether a special enrollment period is needed in Minnesota for individuals who did not enroll in coverage during the open enrollment period. At this time, there is no immediate plan to offer a special enrollment period, but we will continue to monitor the COVID-19 situation in Minnesota closely.

  • Update 3/18: Access Health CT also just announced an SEP through 4/02 as well.
  • Update 3/18: I've received the following response from Your Health Idaho. I'll contact the ID Insurance Dept. as well to see what they say:

COVID-19 (coronavirus) is not currently considered grounds for a Special Enrollment Period in Idaho. Questions around the potential offering of an SEP would be best answered by the Idaho Department of Insurance. This really falls within their regulatory authority. YHI will follow their guidance and support whatever decision is made.

I've also confirmed that the VERMONT exchange board is at least discussing doing so.

Also suspiciously silent, however, is the Big One: HealthCare.Gov. As of this writing, when you visit HC.gov, the only mention of COVID-19 is a blog post link from March 6th. This is the full post:

3 things to know about coronavirus disease and your Marketplace coverage

  • Coronavirus.gov is the source for the latest information about COVID-19 prevention, symptoms, and answers to common questions.
  • USA.gov has the latest information about what the U.S. Government is doing in response to COVID-19.

You may be hearing about the coronavirus (officially called 2019-novel coronavirus or COVID-19) in the news. Currently, the rules in your Marketplace health plan for treatment for COVID-19, remain the same as for the treatment of any other viral infection. Check with your health insurance company for their specific benefits and coverage policy. Here are some other things to know about how your Marketplace health plan works when it comes to coronavirus:

Understanding your coverage

  • Lab and other services: Individual and small group market issuers are generally required to include laboratory services as a category of Essential Health Benefits. Coverage for a specific diagnostic or laboratory service can vary by plan, so check with your health insurance company about their coverage for lab tests and related services for diagnosis and treatment of COVID-19. Standard cost sharing may apply. This is also true for your health plan’s coverage for physician and hospital services related to the diagnosis and treatment of COVID-19.
  • Telehealth: Telehealth services or home health visits may already be covered by many health insurance companies. You should check with your health insurance company to determine whether these services are covered and what you’ll pay.
  • Enrolling in coverage: If you aren’t currently enrolled in coverage, you can see if you qualify for a Special Enrollment Period. As a reminder, federal law and regulations provide protections against pre-existing condition exclusions in health insurance coverage. If you are eligible, health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Marketplace plans can’t terminate coverage due to a change in health status, including diagnosis or treatment of COVID-19.

For more information about the Coronavirus, please visit: coronavirus.gov

That's it. While there's a link to SEP info, there's been no action taken to add the pandemic to the list of "Qualifying Life Events"...it still lists the standard QLEs such as losing existing coverage, turning 26, moving, getting married/divorced, giving birth/adopting a child and so forth.

Seeing how HealthCare.Gov hosts the ACA exchanges for 38 states, this seems like a bit of a problem, and I'm not the only one who's noticed. On March 12th, two days after I posted my original blog entry, Michigan Governor Gretchen Whitmer openly called for CMS to announce a HC.gov SEP to help respond to the coronavirus crisis:

“During this crisis, we must do everything we can to ensure access to quality, affordable health care,” said Governor Whitmer. “That’s why we’re calling on the president to allow for a special enrollment period, and why we’re taking action today in Michigan to expand opportunities for safe, quality care through telemedicine. We will continue to work with our partners across both state and federal government, as well as those in the private sector, to ensure Michiganders everywhere can access the care they need.”

“When we expand access through telemedicine, we can help reduce the number of Michiganders who need to visit their health care provider in person, which will help slow the spread of disease and ensure our health facilities have adequate staff and resources to care for those who are sick,” said Michigan Department of Health and Human services (MDHHS) Director Robert Gordon. “And when we expand coverage through a special enrollment period, we can ensure access to quality, affordable care to more Michiganders. This is about keeping the people of Michigan safe and combatting the spread of COVID-19.”

Whitmer correctly pointed out that there's ample precedent for doing so:

After Hurricanes Harvey, Irma, and Maria devastated communities across the Southern United States, the Centers for Medicare and Medicaid Services announced a special enrollment period for those impacted by the hurricanes. Special enrollment periods have also been used to respond to more personal situations such as house fires or domestic violence.

This is true. Hell, CMS even allowed an SEP for the state of Maine due to "high winds" (not even a hurricane force) around the same time.

On March 13th, 25 U.S. Senators, including both of mine here in Michigan (Gary Peters and Debbie Stabenow) joined Gov. Whitmer's plea with a letter sent to HHS Secretary Alex Azar and CMS Administrator Seema Verma:

Dear Secretary Azar and Administrator Verma:

In light of the ongoing outbreak of novel coronavirus (COVID-19) in the United States, we write to express our concern regarding the increasing rates of individuals and families who are uninsured or underinsured. We ask that the Department of Health and Human Services and the Centers for Medicare and Medicaid Services allow individuals who are at-risk for COVID-19 to access affordable health care options through the health insurance marketplaces with a special enrollment period. We must do everything in our power to improve access to health care at a time when we are encouraging people who may have been exposed to COVID-19 to come forward, get tested, and seek treatment to help prevent further spread of the disease.

As you know, the U.S. Census Bureau released new data in November 2019 showing that the uninsured rate increased from 7.9 percent in 2017 to 8.5 percent in 2018. This amounts to nearly 2 million more people, bringing the total to 27.5 million uninsured Americans. Many more people likely have insufficient insurance coverage through short-term limited duration insurance or “junk” plans, which could still leave someone facing expensive medical bills if hospitalized for treatment for COVID-19 or seasonal flu.

We are deeply concerned that individuals and families will be forced to choose between getting tested and seeking care for COVID-19 to protect themselves, their families, and communities from further spread and being left with thousands of dollars in bills that they are unable to pay. In addition, when the uninsured or underinsured are unable to pay their medical bills, it is health care providers who are left to make up the shortfall. Health care providers are already relying on emergency resources to pay for increased capacity and medical supplies in order to be prepared for further spread of COVID-19.

As such, and given the ongoing unprecedented public health crisis, we ask that HHS and CMS work to establish special enrollment periods for anyone seeking individual or family coverage through the health exchanges. Having comprehensive, affordable coverage is essential to ensure the health and well-being of the American people, particularly given the lack of access to testing for the COVID-19 and the uncertain trajectory of the outbreak. It is imperative for patients to receive covered care, regardless of whether they test positive or negative for the virus. Patients should not feel the need to avoid care out of fear of incurring medical bills they cannot afford.

Patients must have access to affordable health insurance that will cover needed health care services for testing and treatment, especially now, when the broader public health is at risk. While there are many unknowns about how this outbreak will progress in the United States, we can certainly all agree that increasing the rate of insurance coverage will be critical to managing this outbreak and the expenses associated with increased need for health care services, such as costly hospitalizations. Thank you for your attention to this critical issue and we look forward to your response.

On March 15th, New Jersey Governor Phil Murphy joined Gov. Whitmer (NJ is transitioning to their own state-based exchange but it won't be ready to go until this November):

TRENTON – Responding to the global COVID-19 pandemic, Governor Phil Murphy today requested the federal government open a Special Enrollment Period (SEP) in New Jersey to allow uninsured and underinsured residents to enroll in health coverage through the federal health insurance exchange.

The Governor’s request was issued in a letter sent to U.S. Department Health and Human Services Secretary Alex Azar and U.S. Centers for Medicare and Medicaid Services Administrator Seema Verma.

“With COVID-19 now a pandemic and confirmed cases increasing in New Jersey and across the country, it is imperative that we take all appropriate actions to increase access to screening, testing, and treatment related to COVID-19. While I have coordinated across state agencies to take emergency action to facilitate access to screening, testing and access to care for the residents of New Jersey, more can be done to ensure every individual has access to appropriate health care during this crisis,” Governor Murphy wrote. “Therefore, as New Jersey transitions from a State Based Exchange on the Federal Platform to a State Based Exchange, I respectfully urge the Administrator of the Centers for Medicare & Medicaid Services to authorize a Special Enrollment Period in New Jersey to allow individuals to access affordable health insurance options through the federal platform.”

Several states that operate a State-Based Exchange have already established a Special Enrollment Period in response to COVID-19. However, federal action is required for the establishment of an SEP in states that operate on the federal platform, Healthcare.gov. Governor Murphy is calling for a special enrollment period of at least 60 days for all eligible uninsured and underinsured persons to purchase health coverage through the federal platform, and for that coverage to be in place as soon as possible.

“With no vaccine in place and a high degree of uncertainty about the direction that the virus will take, increasing access to health coverage will play a role in managing this outbreak. Similar to actions CMS has taken in the past during major weather events such as hurricanes, creating a SEP is a responsible action that will benefit individuals, as well as contribute to the management of this public health crisis,” added Governor Murphy.

“As the state responds to the COVID-19 situation, we want to ensure that residents have the coverage they need to access testing and treatment if necessary. We have taken action to require carriers regulated by the state to waive cost sharing for COVID-19 testing. However we can do more and, in this case, we need the federal government’s assistance,” said Department of Banking and Insurance Commissioner Marlene Caride. “Clearly, we do not want residents to be apprehensive about seeking treatment because they are not insured or concerned about medical bills. We are asking the federal government to establish a special enrollment period for our residents, and for that coverage to be in place as soon as possible.”

U.S. Senator Bob Menendez and 24 of his colleagues recently sent a letter requesting a Special Enrollment Period for consumers in response to COVID-19. Senator Menendez and U.S. Senator Cory Booker also introduced legislation to support the response to the pandemic including to create a special enrollment period for individuals impacted by COVID-19, among other initiatives. The Governor’s letter may be found here.

Yesterday, both Health Action New Mexico and BeWell NM (New Mexico's state-based exchange which, like New Jersey, isn't splitting off from HC.gov until this November) also issued letters urging HC.gov to launch a coronavirus SEP:

To Whom It May Concern,

COVID-19 presents a challenge to our health care system that most Americans have not experienced in our lifetimes. It is critical that all levels of government work together to reduce barriers to coverage and care during this challenging time. That is why Health Action New Mexico strongly supports the creation of a Special Enrollment Period (SEP) for plans offered on healthcare.gov.

Both a general SEP lasting through April and a rolling SEP for qualifying uninsured individuals who contract COVID-19 are prudent measures, given the magnitude of this challenge. Other measures to reduce the financial exposure of patients who require testing and treatment are also strongly supported. According to the Robert Wood Johnson Foundation, “While... costs clearly pose a barrier for the uninsured, the likelihood of significant cost-sharing, combined with a wariness about out-of-network billing, may deter even those with insurance from seeking care.1” Efforts to limit these costs could help slow the spread of disease by making COVID-19 testing and treatment more accessible for those who need it, especially for populations with limited income.

We respectfully request swift action for measures to expand enrollment opportunities and reduce cost barriers for individuals and families who qualify for coverage on healthcare.gov.

Sincerely,

Colin Baillio
Director of Policy and Communications Health Action New Mexico Colin@HealthActionNM.org
(505) 331-8818

March 15, 2020

Re: COVID-19 Special Enrollment Period

Dear Secretary Azar:

The New Mexico Health Insurance Exchange (NMHIX), also known as beWellnm, respectfully requests that the federal government open an Enrollment Period in response to the COVID-19 emergency. Doing so would be consistent with the Public Health Emergency declared by Governor Michelle Lujan Grisham on March 11 and the National Emergency declared by President Donald Trump on March 13.

The importance of providing access to health care during this emergency cannot be overstated. Individuals deserve every effort from policymakers to eliminate barriers. This is especially important among those who are uninsured and under-insured. Giving individuals a new opportunity to enroll in health coverage is another tool to help stem the tide of COVID-19. The states of Washington and Maryland have already announced enrollment periods, and the federal exchange must quickly follow their lead.

We recognize that protecting the integrity of the health system, from insurance carriers to hospitals, is critical. Having an enrollment period does not have to undermine that priority, and opportunities will emerge through collaboration to accomplish all goals.

Please do not hesitate to contact our Exchange if we may be of assistance. We look forward to your support of our request.

Sincerely,

Jeffery Bustamante
Chief Executive Officer
beWellnm, New Mexico’s Health Insurance Exchange

cc: Administrator Seema Verma

Once again: There's only two reasons why limited-time Open Enrollment Periods exist in the first place:

  • 1. To help prevent people from gaming the system & causing premiums to skyrocket by waiting until they're sick/injured to sign up
  • 2. To help goad/spur people into action (deadlines are proven to be very effective at getting people off their butts)

The thing is, this is a pandemic. "Ensuring a stable risk pool" isn't exactly a top priority for anyone at this particular moment, and the economic consequences of this disaster are going to be rampant for quite awhile no matter what anyway. Right now the top priority should be making certain as many people are covered as possible. And "deadly global pandemic" is likely to be pretty "inspirational", I'd imagine.

In other words, the worst that can happen by allowing a COVID-19 SEP is if no one takes advantage of it, in which case it's no harm, no foul anyway.

HealthCare.Gov and the remaining state-based exchanges should announce COVID-19 SEPs.

UPDATE: Welp.

200+ Organizations Call for Expansion of Health Insurance Enrollment During Coronavirus Crisis

Washington, D.C. -- Moments ago, more than 200 organizations sent a letter to Vice President Mike Pence, Secretary of Health and Human Services (HHS) Alex M. Azar II, and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma urging them to expand opportunities for Americans to enroll in health coverage through the Affordable Care Act (ACA) health insurance marketplace.

With the coronavirus causing health and financial crises nationwide, 207 leading national, state, and local organizations are calling on the federal government to create an emergency, 60-day special enrollment period (SEP), in Healthcare.gov states, and to encourage state-based exchanges to do so as well. During this 60 day period, anyone who wishes to enroll in coverage could select a plan outside of the traditional enrollment period that runs from November 1 to December 15 of every year.

(As noted above, the "encourage state-based exchanges" part is mostly moot at this point, as practically all of them already have, although the time periods vary widely)

“With every passing day, it becomes even more apparent that the coronavirus will have deep, long-lasting impacts on our nation’s health, economy, and overall security,” said Erin Hemlin, Director of Health Policy and Advocacy for Young Invincibles, the organization that coordinated the letter. “As young people work to stay healthy and financially secure, it’s as important as ever that they have quality, affordable health insurance to help blunt the impact of any medical costs that they incur during this crisis. Now is the time for the Trump Administration to cast aside its ideological opposition to the Affordable Care Act and use every tool they have available to expand access to the coverage that people need. We’re eager and ready to work with the Administration to ensure every young person can stay healthy and secure as they navigate this pandemic.”

Along with open a 60 day SEP period, the organizations also called for HHS to:

  • Waive any verification processes that would delay critical access to coverage
  • Invest significant resources in educating the public about this SEP through digital and television ads
  • Create materials in multiple languages, accessible formats for people with disabilities, and resources for hard-to-reach populations to give diverse populations access to this SEP
  • Engage application assisters who would help consumers sign up through the SEP
  • Focus significant outreach and advertising efforts to employers and employees most at-risk of losing employer-based coverage.

“The COVID-19 pandemic has exposed the vast shortcomings of our nation’s health system and the critical importance of affordable coverage and care for all,” said Emily Stewart, Executive Director of Community Catalyst, another group leading the organizing effort. “The best way to stem the deepening impact of the crisis is to take care of the people who have faced unjust barriers to economic security and health care, including disproportionate numbers of people of color. We call on the Trump Administration to do more. Today, we join more than 200 organizations to demand an emergency special enrollment period so that people across the country can access critical care in this time of need.”

You can read the full letter and a list of signing organizations here.

Here's the list of cosigning organizations:

  • 1,000 Days
  • ABLE NH (Advocates Building Lasting Equality in NH)
  • ACA Consumer Advocacy (disclosure: I'm a board member)
  • ACCESS (Michigan)
  • Access Living of Metropolitan Chicago
  • Advocates for Youth
  • African Services Committee
  • AIDS Foundation of Chicago
  • Alaska Children's Trust
  • Alliance for a Just Society
  • American Association on Health and Disability
  • American Cancer Society Cancer Action Network
  • American College of Obstetricians and Gynecologists
  • American Diabetes Association
  • American Federation of State, County & Municipal
  • Employees
  • American Federation of Teachers
  • American Medical Student Association
  • American Muslim Health Professionals
  • American Psychological Association
  • Arcora Foundation
  • Arkansas Advocates for Children and Families
  • Asian & Pacific Islander American Health Forum
  • Association of State and Territorial Dental Directors
  • Bazelon Center for Mental Health Law
  • Bi-State Primary Care Association
  • Black Women's Health Imperative
  • California Pan-Ethnic Health Network
  • Catalyst Miami
  • Center for Health Progress
  • Center for Independence of the Disabled, NY
  • Center for Medicare Advocacy, Inc.
  • Center for Patient Partnerships
  • Center for Popular Democracy
  • Center for Public Policy Priorities (Texas)
  • Central Virginia Health Services
  • Champaign County Health Care Consumers
  • Chicago Coalition for the Homeless
  • Children's Action Alliance
  • Children's Defense Fund - Texas
  • Circle Up, United Methodist Women for Moms
  • Citizen Action of New York
  • Citizen Action of Wisconsin
  • Clare Housing
  • Clay-Battelle Health Services Association
  • Coalition for Asian American Children and Families
  • Coalition of Texans with Disabilities
  • Community Catalyst
  • Community Dental Health NPO
  • Consumers for Affordable Health Care
  • Covering Wisconsin
  • Detroit Community Solutions
  • Empire Justice Center
  • End Domestic Abuse Wisconsin
  • Epilepsy Florida
  • Equal Hope
  • EverThrive Illinois
  • Faith in Public Life
  • Families USA
  • Family and Child Treatment of Southern Nevada
  • Family Voices of Tennessee
  • FamilyCare
  • Farmworker Justice
  • First Focus on Children
  • Florida ADAPT
  • Foley Waite LLC, NJMSA
  • Foundation Communities Prosper Centers
  • Future Smiles
  • Gay Men's Health Crisis, Inc
  • Georgia Budget and Policy Institute
  • Georgia Watch
  • Georgians for a Healthy Future
  • Get America Covered
  • GO2 Foundation for Lung Cancer
  • Health & Medicine Policy Research Group
  • Health Care for All Massachusetts
  • Health Care for All New York
  • Health Care Voter
  • Hometown Action
  • Houston Health Department
  • HRCHC - Hope Rising
  • Human Rights Campaign
  • Illinois Academy of Family Physicians
  • Illinois Action for Children
  • Illinois Coalition for Immigrant and Refugee Rights
  • Illinois Primary Health Care Association
  • Illinois Public Health Institute
  • Indivisible
  • Iowa Citizens for Community Improvement
  • Jen Mishory, Senior Fellow, The Century Foundation
  • Justice in Aging
  • Kentucky Equal Justice Center
  • Kentucky Voices for Health
  • KidCare Coalition of Miami-Dade
  • Lakeshore Foundation
  • Latino Coalition for a Healthy California
  • Latino Outreach of New Jersey
  • Legacy Community Health Services
  • Leukemia & Lymphoma Society
  • Maine Equal Justice
  • Manatee Children's Services
  • Manatee County Habitat for Humanity
  • March for Moms
  • March of Dimes
  • MaryCatherine Jones Consulting, LLC
  • Maryland Citizens’ Health Initiative
  • Medicaid-Medicare-CHIP Services Dental Association
  • Medicare Rights Center
  • Michigan Oral Health Coalition
  • Mississippi Center for Justice
  • Missouri Health Care For All
  • Missouri Rural Crisis Center
  • Monroe Health Center
  • Montana Women Vote
  • NAMI Texas
  • National Alliance on Mental Illness
  • National Association of Social Workers
  • National Association of Social Workers – Texas
  • Chapter
  • National Council of Jewish Women
  • National Family Planning & Reproductive Health
  • Association
  • National Health Council
  • National Health Law Program
  • National Institute for Reproductive Health (NIRH)
  • National Patient Advocate Foundation
  • National Women's Health Network
  • Nebraska Appleseed
  • New Futures
  • New Hampshire Nurses Association
  • New Jersey Citizen Action
  • New Voices for Reproductive Justice
  • New York Immigration Coalition
  • North Carolina AIDS Action Network
  • North Carolina Child
  • Northwest Health Law Advocates
  • Oklahoma Policy Institute
  • OneAmerica
  • Out2Enroll
  • Palmetto Project
  • Partnership for Children's Oral Health
  • PDI Surgery Center
  • Pennsylvania Health Access Network
  • People’s Action
  • Planned Parenthood Federation of America
  • PolicyRx
  • Power to Decide
  • Preston-Taylor Community Health Centers, Inc.
  • Prevention Access Campaign
  • Primary Care Access Network (PCAN)
  • ProHealth TES
  • Protect Our Care Illinois
  • Protect our Care New Hampshire
  • Public Citizen
  • Raising Women's Voices for the Health Care We Need
  • Senior Mobile Dental
  • Shea Writing and Training Solutions, Inc.
  • Shriver Center on Poverty Law
  • Sight & Sound Care LLC
  • South Carolina Appleseed Legal Justice Center
  • Southern Vermont Area Health Education Center
  • TakeAction Minnesota
  • TeethFirst
  • Tennessee Disability Coalition
  • Tennessee Health Care Campaign
  • Tennessee Justice Center
  • Texas Association of Community Health Centers, Inc.
  • Texas Nurses Association
  • The Actors Fund
  • The American Institute of Dental Public Health
  • The Bingham Program
  • The Commonwealth Institute for Fiscal Analysis
  • The Connecticut Oral Health Initiative, Inc.
  • The Kidz Club Prescribed Pediatric Extended Care
  • Center
  • The Los Angeles Trust for Children's Health
  • The Praxis Project
  • The Rhode Island JASYCEE Alliance
  • Treatment Action Group
  • Triage Cancer
  • Trinity Health
  • Trust for America's Health
  • UHCAN Ohio
  • UnidosUS
  • Union for Reform Judaism
  • United Action for Idaho
  • United Vision for Idaho
  • United Way of Dane County
  • United Way of Williamson County
  • United Way Worldwide
  • United Ways of Texas
  • Utah Health Policy Project
  • Virginia Coalition of Latino Organizations
  • Virginia Health Catalyst
  • Virginia Organizing
  • Virginia Poverty Law Center
  • Voices for Vermont's Children
  • Washington CAN
  • Washtenaw Health Plan
  • West Central Initiative
  • West Virginia Center on Budget and Policy
  • West Virginia Citizen Action
  • West Virginia FREE
  • West Virginians for Affordable Health Care
  • Whole Child Manatee
  • Wisconsin Alliance for Women's Health
  • Wisconsin Faith Voices for Justice
  • Women's Health and Family Planning Association of
  • Texas
  • Young Invincibles
Healthcare.Gov
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