Healthcare.Gov

Last Thanksgiving, regular readers may recall that I went on a bit of a rant regarding the annual Notice of Benefit & Payments Parameters, which is a yearly collection of administrative tweaks made by the CMS Administator regarding the specific way in which a slew of ACA policies are actually implemented.

Out of the dozen or so rule changes included in the 2022 NBPP, several of them were perfectly reasonable; several were fairly nominal or neutral...and several of them should have set off red flags everywhere for the incoming Biden Administration, including:

  • Allowing states to flat-out privatize their ACA marketplaces
  • Pushing navigators and assisters to use private, 3rd-party direct enrollment brokers
  • Codifying the Trump Administration's warped interpretation of ACA Section 1332 waivers

There's also a couple of rules in the 2022 NBPP which I opposed, but which won't cause too much damage (at least relative to the three above):

Three years ago, I posted what seemed to be a fairly naive question:

All of this brings me to my question:

  • Last summer the Trump administration announced that they were slashing their advertising budget by 90%, from $100 million to just $10 million.
  • They also announced that they were slashing $23 million out of the navigator/outreach program for open enrollment.
  • That means they cut HealthCare.Gov's total budget by $113 million.

So my question is this: Where exactly did that money go?

For that matter, assuming HC.gov is set to bring in $300 million more this year, but doesn't plan on reinstating that $113 million for advertising/outreach, doesn't that mean they should be profiting by over $400 million? Again, if so, where is that money going?

UPDATE: It looks like the 2022 NBPP will be open for Public Comment starting on December 4th and ending on December 30th at 5pm. This is obviously 4 days shorter than the typical 30-day minimum, and it includes Christmas Eve & Christmas Day as well. I've been informed that this is technically legal as allowing a minimum of 30 days is a guideline, not requirement...but it sure wouldn't look good if the rule is brought in front of a judge.

The Affordable Care Act includes a long list of codified instructions about what's required under the law. However, like any major piece of legislation, many of the specific details are left up to the agency responsible for implementing the law.

Back in March & April, I wrote a lot about COVID-19 Special Enrollment Periods...and especially about the fact that the largest ACA exchange of all, HealthCare.Gov, kept refusing to do so in spite of massive pressure from governors, members of Congress and nearly every advocacy group under the sun, as well as the U.S. Chamber of Commerce and even the health insurance industry itself...which is especially remarkable given that it was BCBSA & AHIP who insisted on cracking down on Special Enrollment Periods in the first place a few years earlier.

On March 31st, I posted the following:

Back in April, in the midst of the earlier stages of the COVID-19 pandemic sweeping through much of the nation, there was a loud outcry for the various ACA health insurance exchanges, including the federal exchange at HealthCare.Gov which hosts enrollment for over 3 dozen states, to re-open enrollment to anyone who missed the official Open Enrollment Period which had ended several months earlier.

Eventually, twelve of the thirteen state-based exchanges did just that, launching COVID-19-specific Special Enrollment Periods of varying time periods for any resident who would normally be eligible to enroll during Open Enrollment to do so. Many of those SBEs would go on to extend the deadlines of their SEPs by a month...or two months...or even more. As of this writing, in fact, California, Maryland, New York and the District of Columbia are are still offering "open" COVID-19 SEPs.

For the past few months, I've been keeping track, to the best of my ability, of how many people have been enrolling in ACA exchange policies utilizing the COVID-19-specific Special Enrollment Periods which have been offered by 12 of the 13 state-based exchanges (SBEs). My most recent update brings the grand total of confirmed SEP enrollments to at least 260,000 across 8 states, averaging around 3,500 per day.

The actual number is obviously higher than this, of course, since I don't have any data from the other four state exchanges (DC, New York, Rhode Island and Vermont), although three of those four are pretty small anyway...and even in New York, their unique "Essential Plan" (the Basic Health Plan program established under the ACA itself) has likely been sucking up the bulk of individual market enrollees earning up to 200% FPL anyway...and you can enroll in the Essential Plan year-round regardless of the pandemic. I therefore doubt that NY's COVID SEP numbers for those earning more than 200% FPL are that dramatic. All told, I'd expect NY, RI, VT & DC to only add perhaps another 25,000 or so QHP enrollees to the table below:

I've been making a LOT of fuss lately about how important it is for CMS Administrator Seema Verma to give the green light to an official "Open" COVID-19 Special Enrollment Period (SEP) via the federal ACA exchange (HealthCare.Gov). Last week I projected that if every state were to offer a full 60-day "open" SEP ("open" means that any uninsured U.S. citizen or eligible documented resident could sign up without requiring a Qualifying Life Event), somewhere between 2.5 - 3.3 million Americans would likely enroll during that 2-month period.

Of that number, I projected that around 1.8 - 2.3 million additional people would likely reside in the 38 states hosted by HealthCare.Gov, with the remainder living in the 12 states which are offering COVID-specific SEPs (although the deadlines in those states vary, and some do require enrollees to jump through at least minimal hoops to enroll).

For over a month now, I (and many, many others) have been pleading with HHS Secretary Alex Azar, CMS Administrator Seema Verma and CMS itself to launch a formal, "open" COVID-19 specific Special Enrollment Period for the millions of people living in the 38 states hosted by HealthCare.Gov who are uninsured but who don't qualify for Medicaid, CHIP or other "year-round enrollment" programs such as the Essential Plan in New York, MinnesotaCare in Minnesota or ConnectorCare in Massachusetts. Even the insurance industry--which normally hates letting people enroll at any time outside of the official Open Enrollment Period--has been calling for them to do so.

Yesterday I ran an exclusive analysis based on existing COVID-19 Special Enrollment Period (SEP) data to figure out a) roughly how many Americans are likely to enroll in ACA exchange coverage using this SEP in the twelve states offering one, and b) how many additional Americans would likely #GetCovered via ACA exchange policies in the other 39 states which don't currently have a CV19 SEP in place.

As I've explained before, while pretty much anyone who loses their employer-based health insurance is automatically eligible for a normal 60-day Special Enrollment Period regardless of what state they live in, under the current pandemic/mass layoff situation, the standard "loss of coverage" SEP is a red tape nightmare under Trump Administration regulations since you have to provide hard-to-get documentation of your status and have it verified by CMS, which can take weeks.

4/16/20: Important Update at bottom!

With all the anger at CMS Administrator Seema Verma, HHS Secretary Alex Azar and of course Donald Trump himself over CMS's refusal (to date) to open up a COVID-19 specific Special Enrollment Period on the federal ACA exchange (HealthCare.Gov), last week I decided to try and figure out just how many people are enrolling across the 12 state-based exchanges which are offering CV19 SEPs...and just as importantly, how many people would likely take advantage of a CV19-specific SEP on the federal exchange if and when they ever decide to go ahead and launch one.

I noted this a couple of weeks ago, but I'm updating this post because the official CMS 2020 Open Enrollment Period report has just been released, so I have final numbers for every state now.

Normally this would be a big, wonky, in-depth analysis, but I'm gonna keep it relatively basic this year for two reasons: First, because the final numbers are only slightly different from what I had them at already (seriously, I was only off by around 5,300 enrollees out of over 11.4 million total); second, because with the COVID-19 pandemic having killed well over 5,000 Americans already with no end in sight, I'm not sure anyone really gives a crap at the moment.

Me, 3/31/20, 1:14pm:

Well, today I received a likely answer which is depressing but not surprising at all: According to my sources, there isn't any technical, logistical, personnel or support reasons why HealthCare.Gov couldn't launch a formal COVID-19 Special Enrollment Period at any time. The only logical conclusion is that the White House has decided not to allow one for political reasons.

...The more people who come to rely on the Affordable Care Act--especially the ACA exchange operated by the Trump Administration itself--the more difficult it's going to be to justify the Trump Administration continuing to support a lawsuit with the sole purpose of attempting to have the ACA struck down by the Supreme Court...which they're continuing to try and do even in the middle of a pandemic.

Susannah Luthi, Politico, 3/31/20, 5:19pm:

Trump rejects Obamacare special enrollment period amid pandemic

Three weeks ago I reported that there were growing calls from many quarters for CMS Administrator Seema Verma and HHS Secretary Alex Azar to open up a federal Special Enrollment Period at HealthCare.Gov tied specifically to the COVID-19 pandemic.

Over the next week or so, more and more of the 13 state-based ACA exchanges announced just such a COVID-19 SEP; eventually 12 out of 13 state-based exchanges did so (Idaho is the odd man out), and eventually even the health insurance industry (which is normally opposed to allowing exceptions to the official Open Enrollment Period) were onboard with a COVID SEP. Two weeks ago I was 95% certain that HC.gov would be announcing one at any moment.

And then...nothing. Nothing last week. Nothing yesterday. Nothing as of this writing.

No one has been shouting from the rooftops louder than I have for HHS Secretary Alex Azar or CMS Administrator Seema Verma to join nearly all of the state-based ACA exchanges in announcing an official Special Enrollment Period (SEP) in light of the ongoing Coronavirus pandemic, and I'm still urging them to do so as soon as possible. The federal ACA exchange, HealthCare.Gov, hosts ACA enrollment for 38 states representing around 75% of the national population, so this is a pretty big deal.

Having said that, it's important to keep in mind that even without a COVID-19-specific SEP, many people already qualify to enroll in ACA-compliant healthcare coverage anyway, whether they're currently uninsured or because they're about to be...or because their personal circumstances are about to change. And none of these have anything to do with the COVID-19 crisis, although it's certainly going to cause a whole lot more people to qualify for two of those changes:

Special Enrollment Period (SEP)

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.

In response to tremendous pressure after yesterday's major technical issues at HealthCare.Gov, CMS Administrator Seema Verma just announced that the deadline for people to #GetCovered in the 38 states which host their ACA enrollment platform with HealthCare.Gov will indeed be extended by 2 days:

We at @CMSGov want to ensure a seamless shopping experience for everyone seeking coverage, so starting at 3 pm ET today, we are extending the marketplace #OpenEnrollment deadline until 3 am ET December 18! https://t.co/HmVdpJlX2C

— Administrator Seema Verma (@SeemaCMS) December 16, 2019

(I originally misread this as being a 3-day extension, but it's only 2 days, since it runs through midnight Pacific Time on Tuesday.)

Dammit, I took a couple of hours off to rewatch The Force Awakens with my kid (in anticipation of The Rise of Skywalker coming out this week), and look what happens...

HealthCare.Gov is not letting people login to enroll. This is the second outage, the first lasted 15 minutes. We're 8 minutes into the second. Last time this happened, 100k people could not enroll. @CMSGov must extend the deadline.

— Joshua Peck (@JoshuaFAPeck) December 15, 2019

When I loaded the site, I got the same error screen...but when I refreshed, the login screen came back up again.

Over at the Washington Post, reporter Yasmeen Abutaleb has a disturbing-sounding story which immediately caught my eye and raised major internal alarms within the healthcare wonk/advocate community:

Critics say ‘junk plans’ are being pushed on ACA exchanges

The Trump administration has encouraged consumers to use private brokers, who often make more money if they sell the less robust plans.

The Trump administration is encouraging consumers on the Obamacare individual market to seek help from private brokers, who are permitted to sell short-term health plans that critics deride as “junk” because they don’t protect people with preexisting conditions, or cover costly services such as hospital care, in many cases.

So far, this is nothing new; I've been warning people about this since day one...it's the 2nd item on my "Seven Important Things to Remember" blog post from November 1st:

A week or so ago I  noted that several of the 13 state-based exchanges (remember, Nevada split off of HC.gov this year) had opened up their ACA exchange websites for prospective enrollees to window shop for 2020 coverage. One of them, Covered California, actually started allowing people to enroll already; the rest were for comparison shopping only.

Well, as of today, residents of every state can window shop for 2020 healthcare policies, because HealthCare.Gov has followed suit and is now letting you plug in your household & income info to see what plans are available next year, what the unsubsidized premiums are, and (most importantly for a lot of people) what sort of financial assistance you may be eligible for.

There have been some interesting modifications to the interface and workflow of HC.gov this year:

FEDERAL HEALTH INSURANCE EXCHANGE 2020 OPEN ENROLLMENT 

HealthCare.gov incorrectly sent out open enrollment notices

LAS VEGAS (KLAS) — In a statement issued by Nevada Health Link, the organization announced that it had become aware that the Federal Health Insurance Marketplace, known as HealthCare.gov had incorrectly sent notices to Nevada consumers regarding the upcoming open enrollment period.

The incorrect notices were sent to Nevada consumers via mail, email and through notices on the HealthCare.gov portal.

"These notices from the Marketplace were sent in error. Nevadans who received these notices from the Marketplace should be aware that NevadaHealthLink.com is the only place to get enrolled in a qualified health plan during the next open enrollment period beginning on November 1, 2019," said Heather Korbulic, Executive Director for the Silver State Health Insurance Exchange.

Nevada consumers are asked to reach out to the Nevada Health Link consumer assistance center for further questions by calling 1-800-547-2927.

Not much to add here.

Some Guy, June 25, 2015 (right after the Supreme Court ruling in King vs. Burwell):

It's even conceivable--unlikely, but conceivable--that a few years from now, after 1) The ACA has become even more firmly entrenched nationally; 2) the software/technology for running a state exchange has become even more streamlined, simplified, faster, easier to use, cheaper, etc etc; and 3) (hopefully) some changed attitudes/changed administration officials (ahem), a few states on HC.gov now may even decide to go ahead and move onto their own "full" exchange/website after all...completely of their own volition.

February 2018:

Nevada wants out of federal health exchange

Nevada's Silver State Health Insurance Exchange took the first step on Thursday to getting out of the federal healthcare.gov system and build its own exchange.

UPDATE 3/26/19: In light of last night's bombshell announcement that the Trump DOJ is now officially calling for the entire ACA to be repealed in the #TexasFoldEm lawsuit, the wording of yesterday's press release from Trump's CMS division is straight out of 1984 territory:

CMS Issues the 2019 Exchange Open Enrollment Period Final Report
Agency also extends the policy allowing issuers to continue “grandmothered” plans

The Centers for Medicare & Medicaid Services (CMS) today released the Health Insurance Exchanges 2019 Open Enrollment Report. With the Trump Administration’s focus on making healthcare more affordable, the report confirms another successful open enrollment period coinciding with a stabilization of premiums after years of substantial increases. Specifically, the report shows plan selections in Exchange plans in the 50 states and D.C. remained steady at 11.4 million. This represents a minimal decline of around 300,000 plan selections from the same time last year. Also, as outlined in the report, average total premiums for plans selected through HealthCare.gov dropped by 1.5 percent from the prior year, the first decline since the Exchanges began operations in 2014.

So I was reading this thread on Twitter...

When people say “oh the shutdown only affects government workers,” remind them that IT requires maintenance. GOV websites that help businesses are going offline by the dozens per week https://t.co/1wGeTgsCyy pic.twitter.com/sYmBwTYFSq

— Ned Pyle (@NerdPyle) January 17, 2019

How many government servers were not patched in the past month? How many applications and website frameworks were not updated? How many pentests were postponed? How many logs were not examined for intruders?

— Ned Pyle (@NerdPyle) January 17, 2019

Imagine if your private company simply stopped having employees show up for a month. The government is no different and the impact is larger than all but the most massive private sector orgs

— Ned Pyle (@NerdPyle) January 17, 2019

ACASignups.net, February 11, 2018:

That should mean that the average HC.gov premium is around $600 or so per month in 2018. The 3.5% surcharge hasn't changed for 2018, which means the federal exchange should take in something like $252/year per enrollee. Total enrollment in HC.gov plans was down 5% this year, so I'll assume average effectuated enrollment will be as well...somewhere around7.13 million per month. That means ~$1.8 billion in HC.gov revenue directly from the premium surcharge.

All of this brings me to my question:

As I warned back on December 19th when CMS released the Week 7 HealthCare.Gov Enrollment Snapshot Report, the final, official enrollment tally for the 2019 Open Enrollment Period was almost certain to end up slightly lower than the Week 7 cumulative numbers indicated. There are several reasons for this: Some people who were auto-renewed contact HC.gov to cancel their 2019 renewals, while others had their enrollments involuntarily denied or otherwise cancelled due to problems with verifying their identity, address or legal residency status.

Last year around 79,000 QHP selections were dropped in the final report; I expected this to be slightly lower, at around 75,000. I'm pleased to report, however, that according to CMS, only around 43,000 people were scrubbed from the 39 states hosted by HealthCare.Gov this year:

Final Weekly Enrollment Snapshot for the 2019 Enrollment Period

So, how likely is HC.gov to reach last year's total in the final week? Well...not very likely, but let's do the math anyway. Again, this is for the 39 states hosted by HC.gov only; it does NOT include the 12 state-based exchanges, which are mostly AHEAD of last year so far.

  • Last year, 8,743,642 people selected QHPs via HC.gov total:
    •  4,580,782 actively re-enrolled
    • 1,702,429 were auto-reenrolled
    • 2,460,431 were new enrollees
  • Of those 8.74 million total, there are likely around 6.16 million currently enrolled as of December
  • Last year, 97% of those still enrolled as of December re-enrolled (actively or passively). If that holds true this year, that'll be around 5.97 million total renewals
  • That means HC.gov would need 2.77 million new enrollees total

So, where did things stand as of 12/08?

Right alongside the 2019 Public Use Files being posted, HealthCare.Gov is now open for people to window shop for 2019 ACA individual market healthcare policies.

Remember, HC.gov only hosts the ACA marketplace for 39 states; 12 states operate their own marketplace websites, and most of those have been open for window shopping for several weeks now. In fact, Covered California has allowed people to actually sign up for 2019 since October 15th.

Fire up the Wayback Machine, Peabody, and take us to September 2015:

AP's NEW "HC.gov Security Flaws" story attacks problems FIXED UP TO A YEAR AGO.

Last night I posted what seemed, at first, to be a merely-amusing (if a bit depressing) story about a Florida news station website accidentally (?) reposting a year-old AP newswire story about potential security vulnerabilities at Healthcare.Gov:

"Critical" flaw found in HealthCare.gov security

WASHINGTON -- The government's own watchdogs tried to hack into HealthCare.gov earlier this year and found what they termed a critical vulnerability - but also came away with respect for some of the health insurance site's security features.

Those are among the conclusions of a report released Tuesday by the Health and Human Services Department inspector general, who focuses on health care fraud.

PLEASE NOTE IMPORTANT UPDATES BELOW.

I just received the following from a healthcare broker, who I trust from past communication exchanges, who wishes to remain anonymous. I'm presenting it as sent, with the only changes being breaking it out into paragraphs for readability & with their state's identifying information removed.

Glossery:

According to this article from last May, the total budget for operating HealthCare.Gov, the federal ACA marketplace/exchange which covers 39 states,was around $2.1 billion in 2016. Donald Trump proposed slashing the budget down by about 20% to $1.7 billion in 2017.

Where does that money come from? Well, HealthCare.Gov, the federal ACA marketplace/exchange which covers 39 states, is not funded out of the general federal budget. Instead, it's funded by assessing a 3.5% premium surcharge on policies sold on it.

OK, that's not quite true; the 3.5% only applies to the 34 states which are fully operated by the federal exchange; there are 5 states (Arkansas, Kentucky, Nevada, New Mexico and Oregon) which have their own exchange operations but "piggyback" on HC.gov's technical platform; those states were charged just 1.5% of premiums in 2017 and 2.0% for 2018. However, those 5 states combined only make up around 5% of all HC.gov enrollments, so the lower fees only knock perhaps 2% off the total user fee revenue.

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