Welcome to Amy's ACA Exchange Roundup!

Over at Inside Health Policy, Amy Lotven has put together a fantastic roundup of all the stuff going on (or coming up) this year for ACA exchanges and enrollees. I've summarized the key points here, but read the full piece over there if you can (paywalled):

The Medicaid unwinding

The end of the maintenance of effort requirement will be the most significant event for exchange stakeholders in 2023, according to various sources who work closely with health insurance exchanges across the country.

...Estimates of how many people could lose Medicaid benefits and have access to other coverage range from about 15 million to 18 million, and of those about 2.5 million could be eligible for exchange coverage according to recent analyses by HHS and the Urban Institute.

...[President/CEO of Sotheon Rob] Miller says he’s thrilled that a few states, including their clients in Massachusetts, will be automatically transferring people disenrolled from Medicaid - and who would be fully subsidized - into the Massachusetts Health Connector.

Other states which plan on auto-transferring / auto-enrolling Medicaid disenrollees into exchange plans (with either $0 or nominal cost to the enrollees) include Rhode Island and California.

...States are also planning communications strategies and making or highlighting other policy decisions that can help ensure people losing Medicaid can transition into exchange coverage, if eligible.

States highlighted in the article as making targeted efforts like this include Pennsylvania, Maine and Connecticut.

...While some sources say state-run exchanges are in a better position than healthcare.gov ahead of the unwinding, CMS officials say the agency is laser-focused on ensuring that people who lose their Medicaid benefits can retain coverage. Emphasizing that commitment, CMS on Jan. 27 announced a new, 16-month special enrollment period will be available on healthcare.gov for people who are disenrolled from Medicaid.

...CMS also dedicated $12 million for navigators to help with the unwinding process.

...The agency ran a pilot program during open enrollment in which healthcare.gov sent additional reminder letters to people who had been declined Medicaid but were eligible to enroll in an ACA plan. In six counties in Arizona, Florida and North Carolina, healthcare.gov directly linked anyone denied Medicaid coverage with a specific Navigator who could contact the applicant and help to enroll them in exchange coverage, if they choose.

CMS says it intends to broaden the scope of the Direct Assister to Consumer pilot once the unwinding kicks in.

They should keep this program in place even beyond the unwinding period, assuming it's proven to be successful.

Five states have shifted away from healthcare.gov to run their own exchanges since 2019, when Nevada became the first to take on the challenge, and exchange sources believe that the trend away from the federal exchange will continue in 2023 and beyond.

Virginia is already scheduled to shift to their own state-based exchange this fall, and last year there was a bill introduced (by Republican legislators, to my surprise!) in my home state of Michigan to make the move as well. It didn't go anywhere, but could be re-introduced this year under the new Democratic legislative majority.

The IHP article says that Arkansas, Illinois, North Carolina and even Texas may make the move over the next few years...and Georgia may do so as well, although I have serious suspicions about the motives involved in this case.

In fact, at some point the script may flip to the point that it's the federal exchange which may be at risk, with one source predicting that smaller states which don't have enough of an enrollment base to justify their own ACA exchanges banding together to form multi-state exchanges (think the Dakotas, Wyoming, Alaska and so on...although both Vermont and Rhode Island seem to be chugging along with their own exchanges just fine).

Exchange watchers also expect a busy year for several existing state-based exchanges, which have had their vendors in place for years and may be considering system updates.

There may be a “tech refresh,” says Miller, who says he’s excited to see what other capabilities states may be exploring. Miller has been pushing for states to handle consumer billing, which Softheon can support. Some states did try to manage billing in the past, but found it to be difficult, he points out.

If memory serves, Massachusetts, Rhode Island and Washington State were the only state-based exchanges which handled premium payments the first year or two, and Washington eventually gave up. Honesty, however, I would not recommend SBMs attempt to tackle handling billing unless they're absolutely certain it can be done seamlessly, and even then I'm not sure it's a net positive. It involves taking on additional security issues while also confusing enrollees, many of whom already think that the ACA exchanges are their insurer and blame them if their private insurance carrier makes a mistake or tries to defraud them.

Miller also hopes that any refresh would add the enhanced direct enrollment (EDE) option offered by healthcare.gov that lets web-brokers and insurers enroll consumers without having to go through the federal eligibility hub.

The EDE entities bring in a good portion of enrollment, but no state exchange has implemented the system. But Miller says some are thinking about it. He advises any state that moves forward to use the same technology as CMS.

Former CCIIO Director Randy Pate, who led the implementation of the EDE system while at CMS, also says that any state that transitions to an SBM should build in the EDE from the ground level.

I absolutely agree with this, however, and it has nothing to do with Sotheon being an advertiser on this site (via the W3LL banner ads). HealthSherpa, the largest EDE on the market (also an ACA Signups advertiser) appears to have either directly or indirectly handled as much as a stunning 50% of total HealthCare.Gov enrollment over the past Open Enrollment Period. In fact, the rapid growth of EDEs on the federal exchange is part of the reaso why HC.gov enrollment growth has outstripped state-based exchange enrollment this year (the main reason, of course, is that all of the states refusing to expand Medicaid are hosted by the federal exchange).

Lotven's article also touches on the expansion of standardized plans, the crackdown (in theory) on network adequacy rules, and the long-awaited release of a new rule limiting #ShortAssPlans (short-term, limited duration policies which aren't ACA-compliant).

Finally, the big legal case dangling over everyone's head (isn't there always one?) is the Braidwood v. HHS case, which deals with the ACA's requirement that insurance carriers provide a long list of preventative services at no out of pocket cost to the enrollee:

O’Connor has not ruled on the scope of any remedy to the legal issues, but the plaintiffs seek to invalidate the preventative services coverage mandate on a national level, while the Department of Justice argued in brief filed Jan. 27 that the court should apply only targeted relief that addresses the claims upon which the plaintiff prevailed.

Arguments over the scope of the remedy have been fully briefed, so a district court ruling could be out at any time.

Meanwhile, consumer advocates, who believe the case will eventually land at the Supreme Court, have been urging states to adopt the ACA’s coverage requirements so that at least some consumers will have access to cost-free coverage if the federal provision is thrown out.