Idaho: Notes of interest from Your Health Idaho's March (yes, March) board meeting

Your Health Idaho, the only red state standalone ACA exchange in operation since Kentucky's kynect exchange was shuttered a few years back, doesn't post updates very often, but when they do there's usually a few noteworthy items. Back in March they held a semi-annual board meeting which included a few items:

8. OPEN ENROLLMENT 2019 UPDATE

Mr. Kelly said YHI’s effectuations as of the end of January are just over 101,000 and prelim February results at 98,700. There were significant enrollment shifts between the carriers specifically with SelectHealth gaining membership due to a low-price position. Modest growth continues for the dental carriers overall with significant growth for Delta Dental. Strong seasonality is seen in effectuation trends in January and February. And as expected, the average premium is just under $500 which was anticipated with the rate increase of about 5 percent.

Mr. Kelly said that the metal tier mix shifted to the lower cost bronze plans from last January to this January. Gold membership was down slightly, indicating price sensitivity amongst consumers. Enrollment by carrier by metal tier for the month of February shows SelectHealth with an even distribution between bronze and silver. Whereas Blue Cross has a slightly heavier mix of Bronze than Silver.

Ms. Fulkerson recalled seeing a similar shift in 2017 to 2018. Mr. Kelly said the impact of silver loading in 2017 to 2018 resulted from a couple of things. In the fall of 2017, the Administration stopped funding CSRs and when plans were released in 2018, the silver plans had the full cost of the CSR’s embedded in the premium. The APTC went up based on the cost of the silver plan making the bronze more affordable.

Chairman Edgington asked how many premiums are no-cost under the scenario just described. Mr. Kelly said he does not have that information but will follow up. Mr. Shores said there is a high number of zero premiums.

This is the main reason why House Democrats went from being gung-ho about reinstating CSR reimbursement payments after Donald Trump cut them off back in 2017 to actually not being in such a rush to do so. Again: Trump tried to "blow up" the exchanges by cutting off CSR funding, but he didn't understand how CSR subsidies work, and thanks to a clever workaround by the carriers, exchanges & state insurance commissioners, they've managed to actually cancel out most of the sabotage to the point that some people are actually getting zero premium policies as a result. The wonder of it all.

Ms. Nagashima said appeal volumes are down from the prior year which indicates that the shortened open enrollment dates were better communicated, and the enrollment process is more user-friendly. YHI’s reconciliation team and process worked very effectively last year resulting in being better prepared for open enrollment when it began this year. The appeals decline also indicates better internal training and support. Finally, a decline in appeals indicates more streamlined and effective Consumer Connector training and support. The Consumer Connectors have indicated that the increasing information, effective use of the policy manual, and the consistency of YHI’s customer advocate responses has helped them to better help their consumers.

It's honestly refreshing to see how well the ACA can work when given a chance and people working in good faith to make it so...even in a deep red state which is generally seen as hostile to the law. Case in point: 

Ms. McMartin said Outreach and Education efforts, now that open enrollment is over, have turned towards qualifying life events, special enrollment periods, and overall awareness of coverage and Your Health Idaho as a state-based exchange. Community presentations have been centered around that SEP piece and the qualifying life event. YHI’s team recently presented to the Department of Corrections to their team of reentry program specialists. These specialists work with the inmates that are being released and that can qualify for a special enrollment period for them. YHI also continues to work with the Boise Learns community education program. On a quarterly basis, YHI’s team presents to the public and again centered around SEPs and overall coverage.

Ms. McMartin said in the events space, YHI recently had a table at an Idaho Steelheads game and interacted with over 500 individuals. Other events include the Idaho conference on refugees, the Hispanic health & job fair, and the Nez Perce job & college fair. Today, YHI’s outreach coordinator is in Pocatello attending the Idaho State University Health Fair and will also be meeting with some community groups to maximize our time there.

Mr. Shores asked about income verification of inmates. Ms. McMartin said that this is really on the DHW side and if those inmates were to come to us, YHI would refer them back to DHW to determine that income piece. Mr. Kelly said they go thru the same income verification process that everyone else does. The difference with APTC is that it is projected income. Mr. Shores said the issue is that they don’t have jobs, they don’t have any history, and that makes it difficult for DHW to verify. Ms. Hammon added that DHW doesn’t always look a past income, but instead can look at current income. As long as they have income, it can be verified.

That's an interesting twist I hadn't considered. The ACA's premium subsidy formula is based on how much you expect to earn over the following year...which is generally estimated based on your income this year. The problem for prisoners who were just released is obvious.

Ms. McMartin continued and said in 2018 we saw significant growth in our Outreach and Education program. We increased our footprint outside of the Treasure Valley, which was our main goal. In 2019, as the program matures, we want to think strategically about events and community outreach. And although we would like to be everywhere and attend everything, our resources do not allow for that. The goal now becomes identifying key opportunities in key areas and we are looking at exploring larger events for exposure and brand awareness. YHI would like to maintain community education and outreach initiatives to supplement those larger events and we want to leverage those existing partnerships to cultivate new opportunities, especially those organizations that have a large statewide presence where we can piggyback on those efforts.

Everything in this section relates to H.R. 1386, which was just passed by the U.S. House of Representatives yesterday. The Trump Administration slashed the federal budget for ACA navigators for HealthCare.Gov by 84% over the past two years; HR1386 would restore the funding as well as requiring the HHS Dept. to actually utilize that money properly, which the Trump Administration hasn't been doing. Your Health Idaho, as a state-based exchange, has their own outreach/navigator program and budget.

Ms. McMartin said in looking at the advertising campaign for OE6, it is split almost 50/50 with traditional media (television and radio) and digital media. This is consistent with previous years and has been proven effective as demonstrated by our 25M total campaign impressions. The strategy for OE6 was to build on the success of previous years and then supplement with the online channels (Sling, Roku, etc.). In the digital space, we aim to maintain a strong presence and drive traffic to our website. This is a large tactical shift this year we focused on getting more qualified users to our site and then interact when they get there, rather than just drive traffic to our site.

...Ms. McMartin reviewed the wins which included leveraging state-wide partnerships for OE events, flexibility with radio messaging and live reads to target markets, website conversions, and market surveys. Some opportunities are to continue engaging outside of the Treasure Valley, reevaluate the open enrollment open house event format, more communication with internal teams regarding timing and execution of consumer robocalls and emails, and updates to the external website with more detail around account creation and sharing a more holistic view of the enrollment process.

This section relates to H.R. 987, also passed by the U.S. House yesterday, which would restore HC.gov's marketing/outreach budget, which has also been slashed by 90% by the Trump Administration.

Again, to reiterate: Idaho is a deep red state, yet they fully recognize the importance of a robust marketing, awareness, education and outreach program.

The next section is all about the 2020 NBPP (Notice for Benefit & Payment Parameters):

Mr. Kelly said the Proposed Payment Rules for 2020 didn’t have any specific actions that impacted YHI. The more intriguing comments were in their preamble which was they were seeking comments on, but not implementing rules for 2020. Those two items were auto renewals, or restrictions on auto-renewing, and silver loading, or the prohibition of silver loading. We submitted comments primarily focused on auto-renewals and we also signed on a letter with all the other state-based exchanges with comments on both of these items and reinforcing state flexibility. Many of the concerns that were raised particularly on the auto-renewal process and because the FFM does it completely opposite of the way Idaho does it. In Idaho you renew and are ready to go at 12:01am on November 1st, while the FFM waits and lets you choose a plan and then auto renews consumers who have not chosen a plan on December 15th. The challenge being that on the FFM, if you don’t like what you are renewed in, open-enrollment is over and no changes can be made. Those two items were also key talking points in DC earlier this week and we believed they heard us loud and clear.

Fortunately, CMS ultimately decided not to scrap autorenewals or silver loading for another year, which is a good thing on both counts.

The next paragraph is interesting mostly because it's a reminder that even some of those who run the ACA exchanges don't understand some aspects of the twists and turns of the law over the years:

Chair Edgington asked Mr. Kelly to explain the cost-share reduction. Mr. Kelly said in the fall of 2017 the Trump Administration ceased funding of cost share reductions. At that point, the carriers estimated the cost of continuing to provide those benefits, as required by law to provide, and added that cost to the silver plan premium. This practice is commonly known as silver-loading. The preamble asked for feedback on if CMS were to prohibit silver loading. The vast majority of states did participate in silver-loading as opposed to spreading that cost across all metal tiers when the benefit is only derived from those people that are on a silver plan. Chair Edgington clarified that the second lowest silver is where the subsidy is set so why would we not want that to be as high as it needs to be. Mr. Kelly said we are in favor of silver loading in the absence of funding of CSRs or any similar mechanism. In other words, prohibition of silver loading in absence of CSR funding creates a number of issues for both consumers and carriers, essentially market destabilization.

The #TexasFoldEm mention is pretty brief:

Mr. Kelly said in December, there was a ruling by a Texas judge that said ACA unconstitutional and it is working its way thru the courts and we will continue to watch as it progresses.

Yup. Not much the actual exchanges themselves can do one way or the other beyond crossing their fingers that the lawsuit gets shut down.

The last item that was confirmed while in DC, numerous bills going through the House, though none have made it to the floor and only three that are close like reinsurance, outreach funding and a new bill that allows for funding for new state-based marketplaces. We believe those have support in the House but are unlikely to make it out of the Senate.

The first one has been delayed, the second and third were just passed through the House yesterday, but no, none of them are likely to go anywhere in the Senate.

Mr. Kelly moved to the state policy update and said the primary thing for YHI is watching Medicaid expansion. There was a sideboard bill earlier this year from the Senate Health and Welfare Committee and that bill has been on hold. We have seen some activity this week two print hearings and a Committee hearing that will take place tomorrow. There are three primary components to that bill: work requirements, legislative action is required if federal funding drops below 90%, and partial expansion. Partial expansion means everything up to 100 percent would be Medicaid and 100 to 138 percent of the poverty level, the consumer would have a choice to get an APTC to use on the exchange or go onto Medicaid. The work requirements and the APTC option would require waivers so we will see what happens and adjust accordingly.

As a reminder, this meeting took place in March. Here's what ended up happening re. Idaho Medicaid expansion since then.