Well I'll Be! VT & DC Don't Allow Off-Exchange Enrollments.

Hat Tip To: 
Esther Ferington

Earlier today, contributor Esther Ferington brought an old New York Times article from last October to my attention. The article is actually about off-exchange enrollments as an option to using the exchanges, but the opening line of the story includes an interesting snippet:

WITH so much attention being paid to the troubled debut of the Obama administration’s health insurance exchanges, another alternative has largely gone unnoticed: unless you live in Washington, D.C., or Vermont, you can also buy insurance outside the exchanges — by going directly to insurance brokers, agents or company Web sites.

Huh. "Unless you live in Washington, D.C. or Vermont"? I hadn't heard anything about there being any states (or districts, in the case of DC) that weren't allowing direct enrollments...I didnt' even realize that was an option.

However, I did a little more searching and also found this article over at VTDigger.org, also from last fall (just before the exchanges launched):

The new market will present Vermonters with a completely new way to buy health insurance. Rather than buying coverage directly from an insurer, Vermonters will buy it online through a government-managed market. The state and federal governments will have unprecedented power over how Vermonters can buy health insurance and what health insurance products are available....


For the roughly 100,000 Vermonters buying insurance independently or through businesses with 50 or fewer full-time employees (that is, 30 hours plus), you will be legally required to buy health insurance on this market beginning in 2014. Both employers and employees of these small businesses will be required to use the market.

Well, what do you know? Looks like this is the case for VT (and, I presume, DC) after all.

I ran another search to see if I could confirm that the District of Columbia also requires individual policies to be enrolled via the exchange; the only reference I found was this Washington Post article, which states that:

...the D.C. Council voted in June to require that all small businesses buying policies in 2015 must go through the exchange. That was an effort to make the insurance pool as large as possible.

...Another group — the estimated 25,000 people who buy insurance on their own, rather than getting it from employers — might use the exchange to try to find better deals, District officials said. The law also requires some congressional staff members to use the marketplaces, and that could produce an influx of young and healthy people in DC Health Link.

I knew about the requirement that Congressional staffers use the DC exchange (and in fact, they have to use the SHOP exchange, not the individual one, for some reason). This doesn't definitively state that anyone buying an individual/family policy has to do so via the exchange in DC, but until I hear definitively one way or the other, I'll assume that the NY Times has it correct. If anyone knows otherwise, please feel free to correct me.

UPDATE: I've confirmed independently that sure enough, states do have the option of requiring individual/family QHPs to be purchased via the exchange only. Also, the Kaiser Family Founation confirms that the DC exchange requirement includes the individual/family market as well:

In June 2013, the DC City Council passed legislation requiring carriers to sell all individual and small group products through DC Health Link, effectively dissolving the non-Marketplace individual and small group markets. Individual plans may only be offered through the Marketplace beginning on January 1, 2014, while small group plans have until January 1, 2015 to transition to DC Health Link. In addition, the SHOP and individual markets will be merged into a single risk pool.

I guess it makes sense--both of them are running their own exchanges. DC probably has some special regulatory/administrative requirements anyway since it isn't actually a state, and of course Vermont has already pledged to make the move to Single Payer in the next couple of years anyway, so it makes perfect sense for them to do this. I just didn't realize that they could, and hadn't read/heard anything about individual states being allowed to do so if they wanted. I'm guessing it only applies to the states running their own exchanges?

For practical purposes this mostly just means that I can block out 2 cells on the spreadsheet which I no longer have to attempt to hunt down Off-Exchange enrollments for. It also may help explain why DC is showing a much higher Young Adult percentage than most of the states are (which was Esther's original point), as well as partially explaining Vermont's seemingly locked-at-the-hip Individual/Small Business/SHOP enrollment process (you may recall there were a couple of times where I couldn't figure out whether to enter Vermont's small business enrollments under "SHOP" or "Off-Exchange"...now I know why).

Anyway, this makes my job easier, and I thought this was an interesting quirk of the ACA that hadn't gotten much attention.