Should Medicaid recipients worry about losing their coverage in 2022?

Key takeaways

The COVID-19 pandemic has cast a spotlight on the importance of the various safety net systems that the U.S. has in place. Medicaid is a prime example: As of July 2021, enrollment in Medicaid/CHIP exceeded 83.6 million people, with more than 12 million new enrollees since early 2020.

This enrollment growth — more than 17% in 17 months — is obviously tied to the widespread job and income losses that affected millions of Americans as a result of the COVID pandemic. Fortunately, Medicaid was able to step in and provide health coverage when people lost their income; without it, millions of additional Americans would have joined the ranks of the uninsured. We didn’t see that happen in 2020, thanks in large part to the availability of Medicaid and CHIP.

But the continued enrollment growth in Medicaid is primarily due to the fact that the Families First Coronavirus Response Act (FFCRA), enacted in March 2020, provides states with additional federal funding for their Medicaid programs, as long as they don’t disenroll people from Medicaid during the COVID public health emergency (PHE) period. And all states accepted the additional federal Medicaid funding.

So while there is normally quite a bit of turnover in the Medicaid program — with some people losing eligibility each month — enrollment has trended upward for nearly two years, without the normal disenrollments that were routine prior to the pandemic.

The end of public health emergency could mean disenrollment for millions who have Medicaid coverage

But the PHE will eventually end — possibly in mid-April — and millions of Americans could lose their Medicaid coverage soon thereafter. There are very real concerns that many people who are actually still eligible for Medicaid might lose their coverage due to onerous paper-based eligibility redetermination systems.

We’re hopeful that states will work to make the redeterminations and renewals process as transparent, accurate, and simple as possible. But our goal today is to help you understand what you need to know in order to maintain coverage if you’re one of the millions of people who could potentially lose Medicaid eligibility in the coming months.

When will Medicaid eligibility redeterminations happen?

The federal PHE was first declared in March 2020, and most recently extended in January 2022. The extensions are valid for 90 days at a time, and the PHE is currently scheduled to continue through April 16, 2022. At this point, nobody knows whether the PHE will be extended again. It will depend on the state of the pandemic at that point, and we’ve all seen how quickly the COVID tide can turn.

But the Biden administration informed governors in early 2021 that HHS would give states 60 days notice prior to letting the PHE terminate, so that they can begin planning for the substantial work that will be involved with a return to normal Medicaid operations.

After the month that the PHE ends, states have up to 12 months to complete eligibility redeterminations based on members’ changed circumstances, as well as pending eligibility verifications and renewals (this timeframe was initially set at six months as of late 2020, but as the pandemic dragged on and states’ backlog of suspended eligibility redeterminations grew, the Biden administration extended it to 12 months).

But regardless of how quickly a state opts to start redetermining eligibility and disenrolling people who are no longer Medicaid eligible, the additional federal Medicaid funding will only continue through the end of the quarter in which the PHE ends. As of the start of the next quarter, states will revert to receiving their normal federal Medicaid funding. This does incentivize states, to some extent, to process eligibility redeterminations quickly.

For a person who is no longer Medicaid-eligible under normal rules, Medicaid coverage can end as early as the end of the month that the PHE ends. So if the PHE ends in April, some people will lose their Medicaid coverage at the end of April. But the overall pace of Medicaid eligibility redeterminations and disenrollments will vary considerably from one state to another in the months after the PHE ends.

How many people will lose Medicaid coverage when the public health emergency ends?

An Urban Institute analysis published in September 2021 projected that up to 15 million people could lose Medicaid coverage in 2022. And that was based on an assumption that the PHE would continue only through the end of 2021.

We now know that it will continue through at least mid-April 2022, and each additional month adds to the backlog of renewals and eligibility redeterminations that have been growing since March 2020.

What are your coverage options if you lose your Medicaid?

If you’re still eligible for Medicaid under your state’s rules, you’ll be able to keep your coverage. You may have to submit documentation to the state to prove your ongoing eligibility, so pay close attention to any requests for information that you receive.

Many states have continued to send out these renewal notifications and information requests throughout the pandemic. They could not disenroll people who didn’t respond or whose data indicated that they were no longer eligible, but they will be able to start terminating coverage for those individuals once the PHE ends. But if you’ve recently submitted renewal information to your state and it’s clear that you’re still eligible, your coverage will continue as usual until your next renewal period.

If you no longer meet your state’s Medicaid eligibility guidelines, it’s a good idea to understand what your options will be once the PHE ends and your state begins disenrolling people who aren’t Medicaid eligibility.

Can you appeal your state’s decision to disenroll you from Medicaid?

If your state notifies you that you’re no longer eligible for Medicaid and you believe that you are still eligible, you can appeal the state’s decision. (Be prepared to provide proof of your ongoing eligibility under your state’s Medicaid rules.)

What are your options if you’re no longer eligible for Medicaid?

What if your income has increased to a level that’s no longer Medicaid-eligible? Or maybe your circumstances have changed — perhaps your income is the same but you have fewer people in your household and your income now puts you at a higher percentage of the poverty level. There are millions of people who became eligible for Medicaid at some point since March 2020, and are still enrolled in Medicaid even though they would not be determined eligible if they were to apply today.

For those individuals, there will generally be two primary options for post-Medicaid coverage: An employer-sponsored plan, or a plan obtained in the health insurance exchange/marketplace. According to the Urban Institute’s analysis, about a third of the people losing Medicaid will be eligible for premium tax credits (subsidies) in the marketplace, while about two-thirds will be eligible for employer-sponsored coverage that meets the ACA’s definition of affordable (note that some of those people might not have access to coverage that’s actually affordable, due to the family glitch).

Most of the people who will become eligible for marketplace subsidies will be adults, as the majority of the children who transition away from Medicaid will be eligible for CHIP instead. (Children are always much less likely than adults to qualify for marketplace subsidies. That’s because Medicaid and CHIP eligibility for children extend to significantly higher income ranges, and marketplace subsidies are never available if a person is eligible for Medicaid or CHIP.)

What should you do if you currently have Medicaid coverage?

If you’re currently enrolled in Medicaid, it’s a good idea to familiarize yourself with your state’s eligibility rules, and figure out whether you’d be eligible if you were to apply today, with your current circumstances and income.

If the answer is yes, be sure you pay close attention to any requests for additional information from your state’s Medicaid office, as they may need that in order to keep your coverage in force.

But if the answer is no, be prepared for a coverage termination notice at some point after the PHE ends.

Here’s what you need to keep in mind for that:

  • If you have access to an employer-sponsored health plan, your loss of Medicaid coverage will trigger a special enrollment period that will allow you to enroll in the employer-sponsored plan. This window is only required to be 30 days, so don’t put this off.
  • If you do not have access to an employer-sponsored health plan, you can apply for a premium tax credit (subsidy) to offset the cost of coverage in the health insurance marketplace in your state. Depending on your income, you might also qualify for cost-sharing reductions (CSR), which will make your out-of-pocket costs more affordable as long as you select a Silver-level plan (you can use premium subsidies with plans at any metal level, but CSR benefits only come with Silver plans).
  • The window to enroll in a marketplace plan will start 60 days before your Medicaid coverage ends, and will continue for 60 days after it ends. But in order to have seamless coverage, you’ll need to submit your application before your Medicaid ends. Your new marketplace plan cannot have a retroactive effective date and won’t take effect until at least the first of the month after you apply. So you’ll have a gap in coverage if you submit your marketplace application after your Medicaid coverage has terminated.
  • The subsidies that are currently available in the marketplace are particularly generous, thanks to the American Rescue Plan, and you might be pleasantly surprised to see how affordable the coverage will be. The enhanced subsidies (ie, even better than the Affordable Care Act’s original subsidies) will remain in place through the end of 2022 — and Congress might extend them for future years (even if they don’t, the regular ACA subsidies will continue to be available after 2022).

The main point to keep in mind is that the opportunity to transition to new coverage, from an employer or through the marketplace, is time-limited. If you miss your special enrollment period, you’ll have to wait until the next annual open enrollment period to sign up for coverage (in the individual market, that starts November 1; employers set their own enrollment windows).

New special enrollment period for low-income enrollees

There is a new special enrollment period that allows people with household income up to 150% of the poverty level to enroll in coverage year-round, for as long as the enhanced subsidies remain in place (so at least through the end of 2022, and possibly longer).

For people whose income has increased enough to make them ineligible for Medicaid, but still eligible for this special enrollment period, there will be more flexibility in terms of access to coverage. But although HHS finalized this special enrollment period in September 2021, it won’t be available on HealthCare.gov (and enhanced direct enrollment partner websites) until late March 2022 (it’s available prior to that for people who call the HealthCare.gov call center and enroll via phone). The new low-income special enrollment period is optional for the 18 state-run exchanges, although several of them had already made it available as of February (Colorado, Pennsylvania, New Jersey, California, Maine, and Rhode Island). More are likely to follow suit once it debuts on HealthCare.gov.

But it’s still in your best interest to submit an application as soon as possible, even after the new low-income special enrollment period becomes widely available. Free or nearly free coverage will be available in the marketplace for people eligible for this special enrollment period (this is a result of the American Rescue Plan’s subsidy enhancements). And since coverage cannot be backdated, it’s essential to ensure that you’re covered before any medical needs arise.

So the best course of action is to simply enroll in a marketplace plan as soon as you know that your Medicaid coverage will be terminated (assuming you don’t have access to an employer-sponsored plan), in order to avoid any gap in coverage. This is true regardless of whether you’ll qualify for the new low-income special enrollment period, since you’ll have a normal loss-of-coverage special enrollment period when your Medicaid ends, and you can take advantage of it right away.

Don’t panic: Coverage is almost certainly available

The impending termination of the PHE and return to business-as-usual for Medicaid can be a nerve-wracking prospect for some enrollees. Many people who enrolled in Medicaid since early 2020 have never experienced the regular eligibility redeterminations and renewal processes that have long been a part of Medicaid, and those will resume once the PHE ends.

The primary things to keep in mind: Your Medicaid coverage will continue if you continue to meet the eligibility guidelines and submit any necessary documentation as soon as it’s requested by the state. And if you’re no longer eligible for Medicaid, you’re almost certainly eligible for an employer-sponsored plan or a subsidized plan in the marketplace. Don’t panic, but also don’t delay, as your opportunity to enroll in new coverage will likely be time-limited.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

How the American Rescue Plan Act would boost marketplace premium subsidies

Key takeaways

Last weekend, the House of Representatives passed the American Rescue Plan Act of 2021 (H.R. 1319), an economic stimulus package designed to provide relief from the impact of COVID-19 on Americans. The bill has the support of the majority of Americans – including those registered as Republicans and Independents.

H.R. 1319 is now under consideration in the Senate, so we don’t yet know exactly what will be included in the final legislation. But the health insurance provisions in the House version of the legislation are unchanged from what the House Ways and Means Committee had initially proposed, and have not been sticking points for the bill thus far.

Several provisions in H.R. 1319 are designed to make health coverage more accessible and affordable. Today we’re taking a look at how the legislation would change the ACA’s premium subsidy structure for 2021 and 2022, and the impact that would have on the premiums that Americans pay for individual and family health coverage.

Help for 12 million marketplace enrollees, plus more who will newly enroll

If you’re among the 12 million people who purchase ACA-compliant coverage in the health insurance marketplaces, your coverage is likely to become more affordable under H.R. 1319.

What’s more, the Congressional Budget Office estimates that an additional 1.7 million people – most of whom are currently uninsured – would enroll in health plans through the marketplaces in 2022 as a result of the enhanced premium subsidies.

No one would pay more than 8.5% of their income for the benchmark plan

Some opponents of the legislation have criticized its premium subsidy enhancements as a handout to wealthy Americans. But that’s only because the legislation is designed to remedy the subsidy cliff – which can result in some households paying as much as half of their annual income for health insurance premiums. It’s a situation that’s obviously neither realistic nor sustainable for policyholders.

The Affordable Care Act (ACA) only provides premium tax credits (aka premium subsidies) if a household’s ACA-specific modified adjusted gross income doesn’t exceed 400 percent of the federal poverty level. For 2021 coverage in the continental U.S., that’s about $51,000 for a single person and $104,800 for a family of four. Depending on where you live, that might be a comfortable income – but not if you have to spend 20, 30, 40 or even 50 percent of that income on health insurance.

H.R. 1319’s adjustment to the premium tax credit guidelines would temporarily – for this year and next year – eliminate the income cap for premium subsidies. That means that – regardless of income – no one would have to pay more than 8.5 percent of their household income for the benchmark plan (the second-lowest-cost Silver plan available in the exchange in a given area).

Under this approach, subsidies would phase out gradually as income increases. Plan buyers would not be eligible for a subsidy if the benchmark plan’s full price wouldn’t be more than 8.5 percent of the household’s income. But in some areas of the country – and particularly for older applicants, who can be charged as much as three times the premiums young adults pay – premium subsidy eligibility could end up extending well above 400 percent of the poverty level.

In addition to addressing the subsidy cliff, H.R. 1319 also enhances premium subsidies for marketplace buyers who are already subsidy-eligible. The subsidies would get larger across the board, making after-subsidy premiums more affordable for most enrollees. At every income level, the legislation would reduce the percentage of income that people are expected to pay for the benchmark plan, which would result in larger subsidies.

Larger subsidies? Here are a few examples.

How much larger? It would depend on location, income, and age. Let’s take a look at some examples.

We’ll consider applicants with various income levels and ages in three locations: Albuquerque, New Mexico – where premiums are among the nation’s lowest; Jackson, Mississippi – where premiums are close to the national average; and Cheyenne, Wyoming – where premiums are among the nation’s highest.

In each location, we’ll see how things would play out for a 25-year-old, a 60-year-old, and a family of four (45-year-old parents, and kids who are 13 and 10), all at varying income levels.

American Rescue Plan Act impact on health insurance subsidiesYou can see the full comparison in this spreadsheet. (Current premiums were obtained via HealthCare.gov’s browsing tool. Premiums under H.R. 1319 were calculated using the proposed applicable percentage table in Section 9661(a) and the methodology outlined here, which would be unchanged under the new legislation.)

In most cases, you’ll notice that the subsidy amount is larger under H.R. 1319, resulting in a lower benchmark premium and also a lower price for the lowest-cost plan available to that applicant (or more plans available with no premium at all). This is because the new legislation specifically reduces the percentage of income that people have to pay for the benchmark plan. That, in turn, drives up the subsidy amounts that are necessary to reduce the benchmark premium. And since premium subsidies can be applied to any metal-level plan, it also results in a lower cost for the other available plans (or more premium-free plans, depending on the circumstances).

As you consider these numbers, note that if the current subsidy amount is $0, either the benchmark plan is already considered affordable for that person, or their income is over 400 percent of the poverty level and subsidies are simply not available. If the subsidy amount is $0 under the H.R. 1319 scenario, it means that the benchmark plan would not cost more than 8.5 percent of the applicant’s income.

As you can see, the additional subsidies would be widely available, but would be more substantial for people who are currently paying the highest premiums. Under the current rules, it may not be realistic for our Wyoming family to pay more than $30,000 in annual premiums (enrolling in the benchmark plan, with premiums in excess of $2,500 per month). The American Rescue Plan Act would bring their annual premiums for the benchmark plan down to under $10,000, which is much more manageable.

The legislation is not, however, a giveaway to wealthy Americans. If that family earned $500,000, they still wouldn’t get a premium subsidy under H.R. 1319, because even at $2,528/month, the full-price cost of the benchmark plan would only amount to 6 percent of their income. Unlike Medicare and the tax breaks for employer-sponsored health insurance, financial assistance with individual market health insurance would not extend to the wealthiest applicants.

By capping premiums at 8.5 percent of income, H.R. 1319 provides targeted premium assistance only where it’s needed. And by enhancing the existing premium subsidies, the legislation makes it easier for people at all income levels to afford health coverage.

Premium enhancements would be retroactive but also temporary

Assuming these premium subsidy enhancements are approved by the Senate, they’ll be retroactive to the start of 2021. Current enrollees will be able to start claiming any applicable extra subsidy immediately, or they can wait and claim it on their 2021 tax return. The additional premium subsidies would also be available for 2022, but would no longer be available as of 2023 unless additional legislation is enacted to extend them.

And there’s currently a special enrollment period – which continues through May 15 in most states – during which people can sign up for coverage if they haven’t already. In most states, this window can also be used by people who already have coverage and wish to change their plan, so this is definitely a good time to reconsider your health insurance coverage and make sure you’re taking advantage of the benefits that are available to you.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post How the American Rescue Plan Act would boost marketplace premium subsidies appeared first on healthinsurance.org.

How the American Rescue Plan Act will boost marketplace premium subsidies

Key takeaways

Edit: The Senate passed H.R.1319 on March 6, and the House passed the bill again on March 10. President Biden signed it into law on March 11. CMS published some initial information for marketplace enrollees on March 12.

Last weekend, the House of Representatives passed the American Rescue Plan Act of 2021 (H.R. 1319), an economic stimulus package designed to provide relief from the impact of COVID-19 on Americans. The bill has the support of the majority of Americans – including those registered as Republicans and Independents.

H.R. 1319 is now under consideration in the Senate, so we don’t yet know exactly what will be included in the final legislation. But the health insurance provisions in the House version of the legislation are unchanged from what the House Ways and Means Committee had initially proposed, and have not been sticking points for the bill thus far.

Several provisions in H.R. 1319 are designed to make health coverage more accessible and affordable. Today we’re taking a look at how the legislation would change the ACA’s premium subsidy structure for 2021 and 2022, and the impact that would have on the premiums that Americans pay for individual and family health coverage.

Help for 12 million marketplace enrollees, plus more who will newly enroll

If you’re among the 12 million people who purchase ACA-compliant coverage in the health insurance marketplaces, your coverage is likely to become more affordable under H.R. 1319.

What’s more, the Congressional Budget Office estimates that an additional 1.7 million people – most of whom are currently uninsured – would enroll in health plans through the marketplaces in 2022 as a result of the enhanced premium subsidies.

No one would pay more than 8.5% of their income for the benchmark plan

Some opponents of the legislation have criticized its premium subsidy enhancements as a handout to wealthy Americans. But that’s only because the legislation is designed to remedy the subsidy cliff – which can result in some households paying as much as half of their annual income for health insurance premiums. It’s a situation that’s obviously neither realistic nor sustainable for policyholders.

The Affordable Care Act (ACA) only provides premium tax credits (aka premium subsidies) if a household’s ACA-specific modified adjusted gross income doesn’t exceed 400 percent of the federal poverty level. For 2021 coverage in the continental U.S., that’s about $51,000 for a single person and $104,800 for a family of four. Depending on where you live, that might be a comfortable income – but not if you have to spend 20, 30, 40 or even 50 percent of that income on health insurance.

H.R. 1319’s adjustment to the premium tax credit guidelines would temporarily – for this year and next year – eliminate the income cap for premium subsidies. That means that – regardless of income – no one would have to pay more than 8.5 percent of their household income for the benchmark plan (the second-lowest-cost Silver plan available in the exchange in a given area).

Under this approach, subsidies would phase out gradually as income increases. Plan buyers would not be eligible for a subsidy if the benchmark plan’s full price wouldn’t be more than 8.5 percent of the household’s income. But in some areas of the country – and particularly for older applicants, who can be charged as much as three times the premiums young adults pay – premium subsidy eligibility could end up extending well above 400 percent of the poverty level.

In addition to addressing the subsidy cliff, H.R. 1319 also enhances premium subsidies for marketplace buyers who are already subsidy-eligible. The subsidies would get larger across the board, making after-subsidy premiums more affordable for most enrollees. At every income level, the legislation would reduce the percentage of income that people are expected to pay for the benchmark plan, which would result in larger subsidies.

Larger subsidies? Here are a few examples.

How much larger? It would depend on location, income, and age. Let’s take a look at some examples.

We’ll consider applicants with various income levels and ages in three locations: Albuquerque, New Mexico – where premiums are among the nation’s lowest; Jackson, Mississippi – where premiums are close to the national average; and Cheyenne, Wyoming – where premiums are among the nation’s highest.

In each location, we’ll see how things would play out for a 25-year-old, a 60-year-old, and a family of four (45-year-old parents, and kids who are 13 and 10), all at varying income levels.

American Rescue Plan Act impact on health insurance subsidiesYou can see the full comparison in this spreadsheet. (Current premiums were obtained via HealthCare.gov’s browsing tool. Premiums under H.R. 1319 were calculated using the proposed applicable percentage table in Section 9661(a) and the methodology outlined here, which would be unchanged under the new legislation.)

In most cases, you’ll notice that the subsidy amount is larger under H.R. 1319, resulting in a lower benchmark premium and also a lower price for the lowest-cost plan available to that applicant (or more plans available with no premium at all). This is because the new legislation specifically reduces the percentage of income that people have to pay for the benchmark plan. That, in turn, drives up the subsidy amounts that are necessary to reduce the benchmark premium. And since premium subsidies can be applied to any metal-level plan, it also results in a lower cost for the other available plans (or more premium-free plans, depending on the circumstances).

As you consider these numbers, note that if the current subsidy amount is $0, either the benchmark plan is already considered affordable for that person, or their income is over 400 percent of the poverty level and subsidies are simply not available. If the subsidy amount is $0 under the H.R. 1319 scenario, it means that the benchmark plan would not cost more than 8.5 percent of the applicant’s income.

As you can see, the additional subsidies would be widely available, but would be more substantial for people who are currently paying the highest premiums. Under the current rules, it may not be realistic for our Wyoming family to pay more than $30,000 in annual premiums (enrolling in the benchmark plan, with premiums in excess of $2,500 per month). The American Rescue Plan Act would bring their annual premiums for the benchmark plan down to under $10,000, which is much more manageable.

The legislation is not, however, a giveaway to wealthy Americans. If that family earned $500,000, they still wouldn’t get a premium subsidy under H.R. 1319, because even at $2,528/month, the full-price cost of the benchmark plan would only amount to 6 percent of their income. Unlike Medicare and the tax breaks for employer-sponsored health insurance, financial assistance with individual market health insurance would not extend to the wealthiest applicants.

By capping premiums at 8.5 percent of income, H.R. 1319 provides targeted premium assistance only where it’s needed. And by enhancing the existing premium subsidies, the legislation makes it easier for people at all income levels to afford health coverage.

Premium enhancements would be retroactive but also temporary

Assuming these premium subsidy enhancements are approved by the Senate, they’ll be retroactive to the start of 2021. Current enrollees will be able to start claiming any applicable extra subsidy immediately, or they can wait and claim it on their 2021 tax return. The additional premium subsidies would also be available for 2022, but would no longer be available as of 2023 unless additional legislation is enacted to extend them.

And there’s currently a special enrollment period – which continues through May 15 in most states – during which people can sign up for coverage if they haven’t already. In most states, this window can also be used by people who already have coverage and wish to change their plan, so this is definitely a good time to reconsider your health insurance coverage and make sure you’re taking advantage of the benefits that are available to you.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post How the American Rescue Plan Act will boost marketplace premium subsidies appeared first on healthinsurance.org.

The Scoop: health insurance news – February 24, 2021

In this edition

Idaho is final state to open COVID-related enrollment window

Before we delve into this week’s news, a reminder that enrollment is now open for 2021 individual/family health insurance in every state except Idaho – but Idaho’s enrollment period will start on Monday. Uninsured people have another opportunity to sign up for coverage, and in most states, people who already have coverage can use this window as an opportunity to switch to a different plan if it would better meet their needs.

The Biden administration and the states that run their own exchanges are also pouring a great deal of money into marketing and outreach during this period, in an effort to reach the millions of uninsured Americans who don’t yet know about the coverage and financial assistance available to them via the marketplace or Medicaid. In most states, the enrollment window continues through May 15, but there are several states with different deadlines.

Bills under consideration in Maryland, California would connect unemployment applicants with health coverage

California S.B. 644, introduced last week, would help to connect unemployed California residents with health coverage resources, starting in July 2022. Under the terms of the legislation, the California Employment Development Department (EDD) would provide Covered California (the state-run exchange) with contact information for people who apply for programs administered by the EDD, including unemployment benefits, state disability, paid family leave, etc. Covered California would then reach out to these individuals, determine whether they’re eligible for Medi-Cal or premium subsidies, and help them get enrolled in coverage if they choose to do so.

In Maryland, a similar bill (H.B. 1002) would allow people seeking unemployment benefits to consent to having their contact information and other relevant information shared with Maryland Health Connection (the state-run exchange) and the Maryland Department of Health. These agencies could then determine whether the resident would be eligible for financial assistance with their health insurance, and help them enroll in coverage. Maryland already has an “easy enrollment” program that connects residents with the health insurance exchange via their tax returns; H.B.1002 would expand the outreach to include people dealing with the loss of a job.

DOJ asks Supreme Court to cancel hearing in Medicaid work requirement case

On Monday, the Department of Justice asked the Supreme Court to scrap the oral arguments that are scheduled to be heard next month in a case to determine the legality of Medicaid work requirements. The case focuses on the work requirements in Arkansas and New Hampshire, but it would have ramifications for work requirements that the Trump administration approved in several other states as well.

Work requirements are not currently in effect in any state, and would not be compatible with the current rules that allow states to receive additional COVID-related federal Medicaid funding, on the condition that enrollees’ coverage not be terminated during the pandemic emergency period. But some states, including Arkansas, hope to eventually reimpose a Medicaid work requirement.

The Biden administration notified states earlier this month that the Medicaid work requirements that were approved over the last few years are now being reconsidered. Arkansas, which had the previous administration’s support in the work requirement lawsuit, filed a brief asking the Supreme Court to ignore the Department of Justice’s request and continue with the scheduled oral arguments next month. But Arkansas officials have also said that they will not seek reapproval for the work requirement when the current waiver expires at the end of this year, and are instead considering a work incentive program that would provide private coverage to people who participate in the program, and traditional Medicaid to those who don’t.

Virginia lawmakers head to conference committee over reinsurance funding

Virginia lawmakers have been working on a bill to create a reinsurance program in the state. But as has been the case in some other states that have considered reinsurance programs, there’s disagreement over how to cover the state’s portion of the funding.

The measure passed by Virginia’s House of Delegates earlier this month called for an assessment on individual/family and large group health plans in the state (but not small-group plans), set at 1% of the prior year’s premium revenue. But the Senate has proposed funding the state’s share of the reinsurance program – estimated at $40 to $60 million – from general fund revenues, without the need for an assessment on health insurers.

The two chambers are taking the measure into a conference committee, and have until March 1 to come to an agreement. Assuming they do reach an agreement, the reinsurance program is slated to take effect in 2023 – but it’s possible that the conference committee could work out an arrangement that allows it to take effect in 2022 instead. (Most other states that have established reinsurance programs have had them up and running by the plan year immediately following the enactment of legislation to start the program.)

Iowa, Kentucky Houses approve bills limiting insulin cost-sharing; other states consider similar bills

Yesterday, Kentucky’s House of Representatives voted unanimously to pass H.B. 95, which would require state-regulated health plans to cap cost-sharing for insulin at $30/month, starting in 2022. The measure now heads to Kentucky’s Senate for further consideration. A similar bill – but with a cost-sharing limit of $100/month – passed in Iowa’s House of Representatives earlier this month.

A bill that would cap insulin cost-sharing at $50/month was introduced in California’s Senate last week. And although Illinois was one of the states that enacted legislation last year to cap insulin cost-sharing at $100/month, a new bill was introduced in the Illinois House last week that would lower that cap to $30/month. West Virginia also enacted a $100/month cap last year, but a new bill was introduced this month in West Virginia’s Senate that would lower the cap to $25/month.

In 2019, Colorado became the first state to enact legislation to limit cost-sharing for insulin. Several other states enacted similar legislation last year, and several more had already begun considering bills to limit cost-sharing for insulin earlier this year.

South Dakota becomes fifth state to allow non-insurance Farm Bureau health plans

South Dakota Gov. Kristi Noem signed a bill last week that will allow the South Dakota Farm Bureau to offer health plans that will not be considered health insurance, and that will be specifically exempt from state and federal insurance laws and regulations. Tennessee, Kansas, Iowa, and Indiana already allow this type of plan to be sold.

South Dakota Farm Bureau noted that its plans to partner with a third-party administrator to offer the new plans. SDFB does intend to cover the Affordable Care Act’s essential health benefits, but it’s expected that that plan will use medical underwriting as a mechanism to keep costs down.

Oscar Health to become publicly traded company, with 31 million shares for sale next week

Oscar Health has filed to become a publicly traded company, with stock sales expected to begin next week. Oscar plans to offer 31 million shares, priced at $32 – $34 per share, potentially raising a billion dollars in the initial public offering. Shares will trade on the NY Stock Exchange under the ticker symbol OSCR.

Oscar offers health plans in 18 states this year. They have more than half a million members, most of whom are enrolled in individual/family plans obtained via the health insurance marketplaces. Although most insurers in the individual market struggled with losses in the early years of ACA implementation, many of them have since become profitable. But Oscar’s losses have continued to mount, despite steady expansion into new states and expansion into the Medicare Advantage market last year.

Senate committee hearings focus on HHS Secretary nominee Xavier Becerra

The Senate Health Committee held a hearing yesterday with California Attorney General Xavier Becerra, President Biden’s nominee to lead the Department of Health and Human Services. Another hearing takes place today, with the Senate Committee on Finance. The committees will then make a recommendation to the rest of the Senate, and the nomination will be sent to the full Senate for debate and a confirmation vote. If Becerra is confirmed, he would be the first Latino Secretary of Health and Human Services.

Becerra was previously in the U.S. House of Representatives from 1993 to 2017. He voted for the Affordable Care Act in 2009/10 and then voted to protect it numerous times over the ensuing years. Becerra became California’s Attorney General in 2017, taking over from Kamala Harris when she was elected to the Senate. He led numerous legal battles against the Trump administration, and some Senate Republicans have expressed opposition to his nomination.

Democrats and the White House have expressed confidence that Becerra will be confirmed. With the 50-50 split in the Senate, Becerra could be confirmed on a party-line vote, with Vice President Kamala Harris casting the tie-breaking vote. But moderate West Virginia Democrat Joe Manchin has indicated that he’s undecided on Becerra’s nomination. There are, however, moderate Republicans who may support Becerra’s confirmation.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post The Scoop: health insurance news – February 24, 2021 appeared first on healthinsurance.org.

The Scoop: health insurance news – February 17, 2021

In this edition

COVID-related enrollment window starts in most states

Although open enrollment ended two months ago in most of the country, a new one-time enrollment opportunity is available for 2021 coverage. Uninsured Americans nationwide have access to this enrollment window, and in most states, it can also be used by people who want to pick a different plan or switch from off-exchange to on-exchange coverage.

This enrollment window – a response to the ongoing COVID emergency – is now underway nationwide, with the exception of Idaho, which announced on Monday that a special enrollment period would begin March 1. In almost every state, the enrollment period continues through May 15, although there are seven state-run exchanges that have – for now – different end dates:

If you’re not yet enrolled in health coverage for 2021, or if you’re enrolled in something like a short-term plan, Farm Bureau plan, or health care sharing ministry plan, this enrollment window – which does not require a qualifying event – is an opportunity to secure real health insurance coverage for the rest of the year.

And keep an eye on the COVID relief legislation that Congress is considering. It could end up providing enrollees with much larger and more widely available premium subsidies, making it particularly important that people get enrolled in on-exchange coverage before the end of this enrollment window.

CMS notifies states that Medicaid work requirements are being reconsidered

Last week, the Biden administration began notifying states with approved Medicaid work requirements that CMS is considering withdrawing the approval for these programs. The letters were sent to Arizona, Arkansas, Georgia, Indiana, Nebraska, New Hampshire, Ohio, South Carolina, Utah, and Wisconsin, and clarify that CMS “has preliminarily determined that allowing work and other community engagement requirements to take effect … would not promote the objectives of the Medicaid program.”

There are currently no Medicaid work requirements in effect. Some have been overturned by the courts, some have been postponed voluntarily by the states, and others have been suspended or postponed due to the COVID pandemic and the ban on coverage terminations that states are required to adhere to in order to receive enhanced federal Medicaid funding during the pandemic. The Supreme Court will hear oral arguments next month in Arkansas v. Gresham, to determine whether the Trump administration’s approval of a Medicaid work requirement in Arkansas was lawful.

CMS also sent a letter (see Michigan’s here) last week to states that currently operate 1115 waivers, rescinding a previous letter that former CMS Administrator Seema Verma sent to states in early January. Verma’s letter had stated that if CMS were to terminate or withdraw approval for part or all of a state’s 1115 waiver, there would be a nine-month delay before the changes took effect.

South Dakota legislature passes bill to allow sale of Farm Bureau plans

Last week, we told you about a bill in South Dakota that would allow the state to join Tennessee, Kansas, Iowa, and Indiana in allowing Farm Bureau (or other agricultural organizations domiciled in the state for at least 25 years) to sell medically underwritten health plans that would specifically not be considered health insurance and thus would be exempt from insurance laws and regulations, including state laws as well as the Affordable Care Act’s rules.

The bill had already passed the Senate at that point, and has since passed in the South Dakota House as well. It’s now under consideration by GOP Gov. Kristi Noem, who consistently voted against the Affordable Care Act during her time in Congress.

There are other states where Farm Bureau partners with health insurers to offer ACA-compliant health insurance (Michigan is an example), and the Nebraska Farm Bureau partners with Medica to offer guaranteed-issue short-term health insurance during a limited annual enrollment period. But these approaches are not the same as allowing an agricultural organization to offer products that are specifically not considered health insurance.

Kansas Senate legislation would allow short-term health plans in Kansas to follow federal rules

Kansas is one of the states where the rules for short-term health plans are more restrictive than the current federal rules. But S.B. 199, introduced last week in the Kansas Senate, would change that. Kansas currently limits short-term health plans to a single renewal, which means their total duration cannot exceed 24 months. S.B. 199 would allow short-term health plans in Kansas to have total durations of up to 36 months – in line with current federal rules. The Biden administration may roll back the Trump-era rules for short-term plans, however, which would eventually make more relaxed state rules moot.

Aetna plans to rejoin exchanges for 2022

CVS Health/Aetna plans to offer health coverage in at least some health insurance exchanges during the open enrollment period that starts this November, although the insurer has not yet provided details in terms of where it will participate. Aetna had previously offered coverage in some exchanges, but had exited all of them by the end of 2017, and has not participated since. CVS/Aetna opting back into the exchanges would continue the trend that has been ongoing in 2019, 2020, and 2021, with insurers joining or rejoining the exchanges, after numerous insurers – including Aetna – left the exchanges in 2017 and 2018.

Aetna’s previous exit from the health insurance exchanges happened before the company was acquired by CVS. But the exit was controversial, and linked to the Department of Justice’s decision to block a merger between Humana and Aetna. Here’s what David Anderson wrote about this in 2016, and Charles Gaba has put together a timeline of Aetna’s 2016 decision-making process.

Washington state Senate committee approves legislation to ensure coverage of gender-affirming healthcare

Washington state lawmakers are considering S.B. 5313, which would require state-regulated health plans to provide non-discriminatory coverage for medically necessary gender-affirming care. Insurers would not, for example, be able to deny coverage for services needed by transgender members, such as facial feminization, breast reductions, breast implants, etc. by classifying them as cosmetic procedures.

The bill was overwhelmingly approved last week by the Washington Senate’s Committee on Health and Long Term Care.

Rhode Island legislation would create commission to consider single-payer health program

Legislation was introduced in Rhode Island last week that calls for the creation of a special legislative committee tasked with “a comprehensive study to determine the pros and cons of implementing a single-payer (health coverage) program in Rhode Island.” The legislation notes that an “improved Medicare-for-all type single-payer program” would be in the state’s best interest. There are not currently any states that have single-payer health coverage systems, although there are others that are considering similar studies.

Medicaid buy-in legislation introduced in West Virginia

Legislation has been introduced in several states this year that would create Medicaid buy-in programs. With the introduction of H.B. 2241, West Virginia is the latest state where lawmakers are considering this possibility. The idea is to create a public option program by allowing residents – who would not otherwise be eligible for Medicaid – to purchase Medicaid coverage as an alternative to purchasing private health insurance. There are not yet any states where Medicaid buy-in programs have been enacted; Nevada has come the closest, but the Medicaid buy-in legislation that lawmakers passed in 2017 was vetoed by Nevada’s governor.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post The Scoop: health insurance news – February 17, 2021 appeared first on healthinsurance.org.

The Scoop: health insurance news – February 10, 2021

In this edition

COVID-related enrollment window starts Monday in most states

In every state except Connecticut, Idaho, and Vermont, a COVID-related enrollment window will be open by next week. (In a few states, they’re already open.) During these enrollment windows, consumers can sign up for ACA-compliant health coverage without a qualifying event.

In most states, the enrollment window applies to anyone eligible to use the marketplace, including people who are already enrolled and want to make a plan change. But some of the state-run exchanges are limiting eligibility to only people who are currently uninsured, or to people who aren’t already enrolled through the exchange. And some states are extending the COVID-related enrollment window to off-exchange plans as well, although financial assistance is never available outside the exchange.

If you’re uninsured or know someone who is, this is an opportunity to have coverage in place for the rest of 2021, with an effective date as early as March 1. Millions of uninsured Americans are eligible for premium subsidies substantial enough to cover the full cost of at least some plans in the marketplace. And Congress is considering COVID relief measures (described below) that would make coverage even more affordable.

House committees propose health insurance provisions as part of COVID package

The House Ways and Means Committee unveiled a set of nine COVID relief proposals this week. Subtitle G, related to “promoting economic security,” includes several important health insurance provisions:

  • For 2021 and 2022, the normal rules for the percentage of income a person is expected to pay for on-exchange health insurance would be modified to be much more generous. People with income up to 150 percent of the federal poverty level would pay nothing for the benchmark plan. And nobody would pay more than 8.5 percent of their income, including people who earn over 400 percent of the poverty level (and are currently not eligible for a premium tax credit at all, regardless of how much of their income they have to pay for health coverage).
  • For 2020 only, excess premium tax credits would not have to be repaid to the IRS. This is something that several insurance commissioners from around the country suggested to President Biden before he took office. Premium subsidy reconciliation can catch people off guard at the best of times — and 2020 was a particularly complicated year.
  • People receiving unemployment benefits in 2021 would receive a premium tax credit that would fully cover the cost of the benchmark plan.

The House Energy and Commerce Committee also published its proposed COVID relief measures this week, including a provision that would provide additional financial incentives for the states to expand Medicaid eligibility if they haven’t already. There are still a dozen states that haven’t expanded Medicaid.

Under current rules, if and when they expand eligibility, the federal government will cover 90 percent of the cost for the newly eligible population, and will continue to fund the rest of the state’s Medicaid program at the state’s normal matching rate (varies from 50 percent to about 76 percent, depending on the state). But under the committee’s legislative proposal relating to Medicaid, states that newly expand Medicaid would get an additional 5 percent federal funding match for their whole Medicaid program, for the first two years of Medicaid expansion.

The committees will markup these proposals this week, and a floor vote in the House on the final COVID relief legislation is planned for later this month.

Virginia House bill would implement reinsurance program in 2023

Legislation was introduced in Virginia last month to create a reinsurance program in the state. Last week, the Virginia House of Delegates passed the bill by a wide margin, and a Virginia Senate committee unanimously agreed to consider the bill during a special session that starts today.

If it’s passed and signed into law, the legislation calls for the state to submit a 1332 waiver proposal to the federal government by January 2022, and for the reinsurance program to be implemented by January 2023. (This is a fairly long timeline. We’ve seen several states implement reinsurance programs over the last few years, often with the program in place for the plan year immediately following the passage of the legislation that authorized it.)

Montana House passes bill to prohibit abortion coverage for exchange plans

Last week, we told you about a bill in Montana’s House that would prohibit on-exchange health plans in Montana from covering abortion services. On Friday, the bill passed in the House by a wide margin, and mostly along party lines. (Four Democrats voted yes, while one Republican voted no.) It’s now with the Montana Senate’s Judiciary Committee for further review. Montana is currently among the minority of states where abortion coverage can be provided under on-exchange plans and at least some plans do offer this coverage.

South Dakota Senate passes legislation to allow non-insurance Farm Bureau health plans

South Dakota’s Senate passed S.B.87 last week, which would allow a nonprofit agricultural organization, domiciled in the state for at least 25 years, to offer non-insurance health benefits to its members. The legislation, which was proposed by South Dakota Farm Bureau, would specifically exempt such health plans from insurance laws or oversight. Tennessee, Kansas, Iowa, and Indiana already allow Farm Bureau health plans to be sold with similar rules. (The plans are not considered health insurance and are thus not subject to insurance laws or regulations.)

The bill is now with the South Dakota House of Representatives, where the Agriculture and Natural Resources Committee approved it 11-1 this week, sending it to a vote on the House floor. The American Cancer Society has expressed strong opposition to the bill, noting that the proposed non-insurance health plans “have the potential of segmenting the insurance market, driving up premiums and making it harder for South Dakotans who live with serious or chronic disease to find health insurance.”

State lawmakers introduce Medicaid buy-in legislation

The concept of Medicaid buy-in as a way of establishing a public option has been debated for several years. Nevada lawmakers passed a Medicaid buy-in bill in 2017, but it was vetoed by the governor. Similar legislation was considered in New Mexico in 2019, but did not pass. (United States of Care has an extensive list of the actions that various states considered in 2019 related to Medicaid buy-in programs.)

This year, lawmakers in several states have introduced various forms of Medicaid buy-in legislation:

  • Georgia: S.B. 83/H.B. 214 would create a Medicaid buy-in program that would be available to anyone not otherwise eligible for Medicaid, Medicare, or PeachCare for Kids (Georgia’s CHIP).
  • Iowa: S.F. 220 would create a buy-in program for the Hawk-i program (Iowa’s CHIP). It would allow families to purchase coverage for their kids (and young adults up to age 26) through the program if their household income is too high to meet the normal eligibility guidelines. (Currently, 302 percent of the federal poverty level.) The plan would be available through Iowa’s marketplace and could be used with premium tax credits and cost-sharing reductions for eligible enrollees.
  • Oklahoma: H.B. 1808 would create a Medicaid buy-in program in the state. The bill would alter the existing Oklahoma statute that directs the state to create a Medicaid buy-in program for people with disabilities if funds become available. The funding aspect is key; Oklahoma has not yet created a Medicaid buy-in program for people with disabilities. But another bill was introduced in Oklahoma last week, calling for the removal of the “if funds become available” language in the existing statute.
  • South Carolina: H. 3573 would create a Medicaid buy-in program that would be available to people who are not eligible for premiums tax credits under the ACA, Medicaid, Medicare, or affordable employer-sponsored coverage.
  • Tennessee: S.B. 418/H.B. 602 would create a Medicaid buy-in program that would be available to people who are not eligible for premium tax credits, affordable employer-sponsored coverage, Medicaid, or Medicare. (The wording of the Tennessee legislation is very similar to the South Carolina legislation).

Biden administration puts Trump-era association health plan rule appeal on hold

In 2018, the Trump administration relaxed the rules for association health plans (AHPS), allowing self-insured people to join AHPs, as well as small groups that share only a common geographical location. The rules would also have allowed for the creation of these associations for the sole purpose of offering health insurance, without any other business purpose. These rules were soon challenged in court, and vacated by a judge in 2019. The Trump administration appealed the decision, and oral arguments in the appeal were heard by the D.C. Circuit Court in November 2019.

But a ruling had not yet been handed down by the time the Biden administration took office, and the new administration soon asked the court to stay the appeal. The court granted that request this week, so the appeal is on hold while the new leadership at the Department of Labor reviews the case, with status reports due every two months.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post The Scoop: health insurance news – February 10, 2021 appeared first on healthinsurance.org.

The Scoop: health insurance news – January 27, 2021

In this edition

Open enrollment ends Sunday in California, New York, New Jersey, and Washington, DC

Open enrollment for 2021 individual/family health plans ended weeks ago in most of the country, but it’s still ongoing in California, New Jersey, New York, and the District of Columbia. In all four areas, however, open enrollment ends this Sunday, January 31. After that, people in those areas will need a qualifying event in order to enroll, although New York’s COVID-related special enrollment period (details below) will still allow people who don’t have health insurance at all to enroll in coverage for another two months.

Maryland, Massachusetts, New York announce COVID-related SEPs for uninsured residents

Although open enrollment has already ended in Maryland and Massachusetts, and will end in New York on Sunday, all three states have announced COVID-related special enrollment periods for uninsured residents, with the following deadlines:

  • Maryland: March 15, 2021
  • Massachusetts: March 23, 2021 (This also applies to people who have COBRA and would prefer to switch to an individual/family plan instead of exhausting their COBRA coverage.)
  • New York: March 31, 2021

It’s widely anticipated that the Biden administration will open a COVID-related special enrollment period via HealthCare.gov, with an executive order that’s expected to be signed tomorrow. Other state-run exchanges might then follow suit. In a recent letter to President Biden, several of them indicated they would like to coordinate with the federal government on this so as to create a unified national approach to reaching the remaining uninsured population. As Dave Anderson notes, an enrollment period at this time of the year might be easier for uninsured people to manage than the regular annual open enrollment period in the fall.

Legislation introduced in Arizona and Texas would remove ban on abortion coverage for qualified health plans; similar bill passed in Virginia

State legislators introduced SB1346 in Arizona’s Senate this week, calling for the removal of the state’s existing ban on abortion coverage for qualified health plans. Similar bills were introduced in Texas (SB448 and HB1362), and the Texas bills would also ensure that the state Medicaid program covers abortion services.

Last week, the Virginia Senate passed a similar bill by a vote of 20-17. Its companion bill, HB1896, passed in the House of Delegates this week, and the measure has now been sent to Gov. Ralph Northam for his consideration.

Hawaii does not prohibit qualified health plans from including abortion coverage, but new legislation introduced in Hawaii’s Senate would codify a requirement that individual and group insurers cover a variety of preventive and reproductive health benefits. The list of services that would have to be covered under the legislation includes many that are already required under the ACA (just in case the ACA is overturned by the Supreme Court), but also includes abortion services.

Connecticut lawmakers introduce single-payer bill amid push for public option, reinstatement of health insurance tax

Democratic lawmakers in Connecticut’s House of Representatives have introduced legislation that would create a single-payer health coverage system in the state. It would include coverage for medical and prescription services as well as things like dental, vision, and long-term care, would be funded via taxes as opposed to premiums (plus pass-through funding from a 1332 waiver), and would have no cost-sharing (deductibles, copays, coinsurance).

That bill is a long shot; similar efforts in Vermont and Colorado failed over the last several years. But Connecticut is a state to watch this year in terms of health care reform legislation. Lawmakers have been pushing for a public option and are considering reinstating the health insurance tax that used to be assessed by the federal government, with the proceeds used to make health coverage more affordable. New Jersey used that approach and has used the revenue to create state-funded premium subsidies that are making coverage more affordable as of 2021.

Legislation introduced in Hawaii would continue progress toward single-payer system

More than a decade ago, Hawaii created the Hawaii Health Authority (HHA), tasked with developing a universal health coverage system for everyone on the Hawaiian Islands. But the HHA stalled when the Affordable Care Act came on the scene. With the COVID pandemic highlighting the cracks in the state’s current health coverage system (which is robust but highly linked to employment), advocates began pushing to revitalize the HHA and its mission.

Last week, Hawaii Representative Scott Saiki (D, District 26, and House Speaker) introduced legislation (HB192 and HB164) that would authorize and fund the HHA “to continue planning for the adoption of a universal, publicly-administered, healthcare-for-all insurance model with a single payout agency.”

Virginia lawmakers introduce legislation to create reinsurance program

Legislation was introduced last week in Virginia’s House of Delegates that calls for the state to create a reinsurance program and seek federal pass-through funding via a 1332 waiver. Fourteen states already have reinsurance programs – which tend to have fairly broad bipartisan support – and they are highly effective in terms of bringing down full-price premiums, making it easier for people who don’t get premium tax credits to afford individual health insurance. But lawmakers in some states have pushed back against reinsurance programs over the last few years, due to disagreements over how the state’s portion of the funding should be raised.

Legislation introduced in New York would require marketplace plans to cover acupuncture

Acupuncture is not currently a state-mandated benefit in New York, nor is it covered under the state’s benchmark plan, upon which individual and small group plans must be based (some health plans in New York’s marketplace do voluntarily provide acupuncture benefits). A bill was introduced last week in New York’s Assembly that would require health insurance plans sold in the New York marketplace/exchange to cover acupuncture. If enacted, it would apply to any health plans issued or renewed on or after 90 days from the date of enactment.

New Mexico lawmakers again consider Health Care Affordability Fund

Last year, New Mexico’s House passed legislation that would have created a state fee to replace the federal health insurance tax. The proceeds would have been directed to a new Health Care Affordability Fund, which would have been used to provide additional health insurance subsidies to New Mexico residents. The 2020 legislation did not advance in the Senate, so the measure died in last year’s legislative session.

But Gov. Michelle Lujan Grisham announced earlier this month that the Health Care Affordability Fund would be a legislative priority in 2021, and the legislation to get the ball rolling on this was introduced in New Mexico’s House of Representatives last week.

Florida, Mississippi, South Dakota voters may see Medicaid expansion ballot initiatives in 2022

Over the last few years, voters in six states have approved Medicaid expansion ballot measures. As a result, Medicaid expansion has already taken effect in Maine, Idaho, Utah, and Nebraska, and will take effect this summer in Missouri and Oklahoma.

Of the dozen states that have still refused to expand Medicaid, only Florida, Mississippi, and South Dakota have constitutions that will allow Medicaid expansion via a ballot initiative. And advocates in all three states are working to get Medicaid expansion measures on the 2022 ballots.

Signatures were previously gathered for a ballot measure in Florida, but that effort was derailed in 2019. Advocates are hoping to revive the same ballot measure and continue collecting signatures this year. South Dakota’s ballot initiative and constitutional amendment were approved for circulation last fall, and signatures must be turned in by early November 2021. Advocates in Mississippi do not yet have their ballot initiative language finalized, but are hoping to begin gathering signatures this spring. Two bills have also been introduced in Mississippi to expand Medicaid legislatively, but they’re a long shot given the general opposition in the GOP-led legislature.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post The Scoop: health insurance news – January 27, 2021 appeared first on healthinsurance.org.

Will my health insurance cover the costs of coronavirus testing, vaccines, and treatment?

Key takeaways

Q: Will my health insurance cover the costs of coronavirus testing and treatment?

A: The COVID-19 pandemic has drastically impacted the world over the last year. A common question that people have is “How will my health insurance cover the coronavirus?”


The short answer? It depends. With the exception of Original Medicare, health insurance differs greatly in the U.S., depending on where you live and how you obtain your coverage. Including the District of Columbia, there are 51 different sets of state insurance rules, separate rules that apply to self-insured group plans (which are not regulated by the states), and 51 different Medicaid/CHIP programs.

Nearly half of all Americans – including a large majority of non-elderly Americans – get their health coverage from an employer. Those plans are regulated by a combination of state and federal rules, depending on the size of the group and whether it’s self-insured or fully-insured.

And about 6 percent of Americans buy their own health insurance in the individual market, where both state and federal rules apply.

Is testing for COVID-19 covered by health plans?

Under the terms of the Families First Coronavirus Response Act (H.R.6201), Medicare, Medicaid, and private health insurance plans – including grandfathered plans – are required to fully cover the cost of COVID-19 testing, without any cost-sharing or prior-authorization requirements, for the duration of the emergency period (which has most recently been extended through mid-April 2021). That includes the cost of the lab services as well as the provider fee at a doctor’s office, urgent care clinic, or emergency room where the test is administered.

Since it’s a federal law, the requirements apply to both self-insured and fully-insured health plans, whereas the testing coverage requirements that numerous states have imposed (see examples here and here) are only applicable to fully insured plans.

What kinds of health plans might not cover testing?

Health plans that aren’t considered minimum essential coverage are not required to cover COVID-19 testing under the federal rules. This includes short-term health plans, fixed indemnity plans, and healthcare sharing ministry plans. It also includes the Farm Bureau plans in Tennessee, Iowa, Indiana, and Kansas – which are not considered health insurance and are specifically exempt from insurance regulations. But some of these plans are voluntarily covering COVID-19 testing and telehealth, so the specifics depend on the plan.

States have the power to regulate short-term health plans, and Washington, for example, extended its testing coverage requirements to include short-term health plans. (Washington already has very strict rules for short-term health plans). But in most states, most plans that aren’t minimum essential coverage are not required to cover COVID-19 testing.

How will my health plan cover a COVID-19 vaccine?

The CARES Act (H.R.748, enacted in March 2020) requires all non-grandfathered health plans, including private insurance, Medicare, and Medicaid, to cover COVID-19 vaccines without any cost-sharing for the member (the same caveats described above apply, however, as plans that aren’t regulated by the ACA are not included in the vaccine coverage requirement unless a state steps up and imposes its own requirement).

The full coverage of COVID-19 vaccines includes both the vaccine itself and any charges from the provider or facility for the administration of the vaccine. The COVID-19 vaccine has been added to the list of recommended vaccines, and the CARES Act required private health plans to begin fully covering it within 15 business days — much faster than the normal timeframe (which can be nearly two years, depending on the circumstances) between when a preventive care recommendation is made and when insurers have to cover it with no cost-sharing.

How can the uninsured get COVID-19 testing and vaccines?

H.R.6201 allows states to use their Medicaid programs to cover COVID-19 testing for uninsured residents, and provides federal funding to reimburse providers for COVID-19 testing for uninsured patients. The CARES Act also provides funding to reimburse providers for the cost of administering COVID-19 vaccines to uninsured individuals.

It’s worth noting that people who don’t have minimum essential coverage are considered uninsured, so depending on availability, they would be eligible for covered testing and vaccines under these programs. In the weeks since the first COVID-19 vaccines were granted emergency use authorizations by the FDA, numerous state insurance departments have issued statements clarifying that residents will not have to pay for the vaccine, regardless of their insurance status.

How much of COVID-19 treatment costs will health plans cover?

Although the federal and state governments have stepped in decisively to ensure that most people won’t incur out-of-pocket costs for COVID-19 testing and vaccines, the cost of treatment is a different matter altogether.

Although the majority of patients are able to recover without hospitalization, Harvard’s Global Health Institute estimates that about 20 percent of COVID-19 patients need to be hospitalized, and about 20 percent of hospitalized patients will need intensive care, including ventilators.

Inpatient care, including intensive care, is an essential health benefit for all ACA-compliant individual and small group health plans (but states define exactly what’s covered for each essential health benefit, so the specifics do vary from one state to another). And although large group plans are not required to cover essential health benefits, they are required to provide “substantial” coverage for inpatient care. If they don’t, the employer can be subject to a penalty under the ACA’s employer mandate, but about 5 percent of large employers still opt to offer scanty plans that don’t comply with this regulation and would offer little in the way of coverage for COVID-19 treatment.

But even when it’s covered by insurance, inpatient care is expensive. And so is outpatient care, depending on the scope of the care that’s needed. This is where patients’ cost-sharing comes into play. Under the ACA, all non-grandfathered, non-grandmothered health plans must have in-network out-of-pocket maximums that don’t exceed $8,550 for a single individual in 2021 (this limit doesn’t apply to plans that aren’t regulated by the ACA, such as short-term health plans).

So for most patients who need COVID treatment in 2021, out-of-pocket costs won’t exceed $8,550. But that’s still a huge amount of money, and most people don’t have it sitting around. The majority of health plans have out-of-pocket limits well below that amount, but most people are still going to be on the hook for a four-figure bill if they end up needing to be hospitalized for COVID-19. Although employer-sponsored plans tend to be more generous than the plans people buy in the individual market, the average employer-sponsored plan still had an out-of-pocket maximum of $4,039 for a single employee in 2020.

With that said, however, many insurers around the country have opted to waive, at least temporarily, members’ out-of-pocket costs related to COVID-19 treatment. It’s important to understand, however, that if an insurer is acting as an administrator for a self-insured employer-sponsored plan, the employer would have to agree to waive the cost-sharing, as it’s the employer’s money (as opposed to the insurance company’s money) that pays the claims.

Some states work to ensure COVID-19 treatment is affordable

Some states (New Mexico and Massachusetts are examples) stepped up early in the pandemic and issued guidance requiring state-regulated insurers to cover treatment (as well as testing) with no cost-sharing, and others (Minnesota is an example) have strongly encouraged insurers to do so (note that the regulation in Massachusetts only applies to doctor’s offices, urgent care centers, and emergency rooms, but not to inpatient care). In addition, several states are requiring telehealth treatment with no cost-sharing. But for the most part, people who need extensive treatment for COVID-19 are going to have to meet their health plan’s deductible and likely the out-of-pocket maximum, unless the insurer has agreed to waive these costs.

Many states are encouraging or requiring state-regulated insurers to treat COVID-19 testing and treatment as in-network, regardless of whether the medical providers are in the plan’s network. And federal rules require this for the vaccine as well, with the cost fully covered regardless of whether the member gets the vaccine from an in-network or out-of-network provider. For vaccine administration, providers are generally not allowed to seek any payment from the patient, including via balance billing. But for COVID-19 testing and treatment provided by out-of-network medical providers, patients could still be subject to balance billing in some circumstances as the out-of-network provider doesn’t have to accept the insurance company’s payment as payment-in-full if it’s less than the billed amount.

And although H.R.6201 prohibits insurance plans from requiring prior authorization for testing, insurers are still allowed to impose their normal prior authorization rules for other services, including COVID-19 treatment, unless a state otherwise prohibits it on state-regulated plans.

How do I make sure I have coverage to protect myself from COVID-19?

So what can you do to protect yourself as much as possible in terms of your health insurance coverage during this pandemic? Here are a few pointers:

  • If you’re uninsured (which includes having a health plan that’s not minimum essential coverage), check to see if enrollment in 2021 health plans is still ongoing in your state, or if you’re eligible for a special enrollment period. If so, enrolling in an ACA-compliant plan is certainly in your best interest. And if your income is low (even temporarily, due to a layoff), check to see if you might be eligible for Medicaid.
  • If you have health insurance, make sure you understand what your plan covers and what your cost-sharing responsibilities are for various outpatient and inpatient care (check to see if your insurer is offering to waive costs associated with COVID-19 treatment).
  • Check to see how your health plan handles prior authorizations.
  • Pay attention to the details of your health plan’s provider network. Your best chance of avoiding balance billing is to make sure you see in-network providers, and you don’t want to be having to sort that out while you or a family member is very unwell.
  • Check with your plan to see how telehealth is covered, and be sure you understand how to use the telehealth services. For non-severe cases, telehealth is recommended as a way to prevent further spread of the disease, and many health plans have temporarily reduced or eliminating cost-sharing for telehealth services in an effort to encourage its use.
  • If you had an HSA-qualified health plan last year and didn’t contribute the maximum allowable amount to your HSA, consider doing so now if you have the money available. You can make contributions for 2020 up until April 15. And if you currently have an HSA-qualified plan, you can contribute pre-tax money to the account for this year as well, at any point during the year. Whatever money you contribute to your HSA will be available to withdraw tax-free if you end up needing it to pay out-of-pocket costs for medical care.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post Will my health insurance cover the costs of coronavirus testing, vaccines, and treatment? appeared first on healthinsurance.org.

The Scoop: health insurance news – January 13, 2021

In this edition

Open enrollment for 2021 health plans will end in five states on Friday

Open enrollment for individual/family health plans ended a month ago in most of the country, but it’s still underway in ten states and Washington, DC. In five of those states, there are only a few days left. Open enrollment ends this Friday, January 15, in five states:

Residents in those states can currently enroll in a plan with a February 1 start date. But after Friday, enrollment in those states will only be possible for people who experience a qualifying event (and most qualifying events require that the person already had minimum essential coverage within the prior 60 days).

Exchange enrollment has already surpassed last year’s total

As of January 12, confirmed enrollment in individual market plans via the exchanges stood at 11.5 million, according to Charles Gaba of ACA Signups. And open enrollment is still ongoing in ten states and Washington, DC (plus a special enrollment period for uninsured Maryland residents). What’s more, four states – Idaho, New York, Rhode Island, and Vermont – haven’t yet reported any of their enrollment data for 2021 plans.

Last year, when all was said and done, enrollment reached 11.4 million, so it’s already surpassed the 2020 total – the first time since 2016 that year-over-year enrollment has grown during the open enrollment period. Once open enrollment closes in all states and final data are reported, Gaba projects that this year’s enrollment will exceed 12 million.

HHS extends COVID public health emergency through mid-April

Last week, HHS Secretary Alex Azar announced that the COVID-19 public health emergency was being extended for another 90 days, through April 21, 2021. The ongoing public health emergency – which was first declared in January 2020 and extended several times since then – plays a key role in various rules related to health insurance coverage.

For the duration of the emergency period, for example, most health insurance plans must cover the cost of COVID testing and vaccines without cost-sharing. States will continue to receive additional federal matching funds for Medicaid through June 2021, and cannot disenroll people from their Medicaid programs during the COVID emergency period, unless the person moves out of state or requests a coverage termination. The public health emergency also expands access to telehealth and reduces reporting burdens for hospitals.

Tennessee’s Medicaid block grant waiver approved

In November 2019, Tennessee submitted a waiver proposal to CMS, seeking approval to transition to a block grant funding approach for the state’s Medicaid program. Last week the Trump administration announced that the state’s proposal had been approved for 10 years, with the extended timeframe intended to “reduce administrative burden and allow the state sufficient time to evaluate its innovative approach.” Instead of the open-ended matching system that the federal government uses with the rest of the states, Tennessee will have an annual spending cap, which can grow if enrollment grows, but which will not adjust to keep up with increasing healthcare spending.

In its approval letter, the Trump administration repeatedly touts the flexibility that the block grant waiver will provide for Tennessee. But block grants for Medicaid funding have been widely panned by public health experts, and are strongly opposed by leading patient advocacy groups due to the potential for reduced benefits, increased costs for enrollees, reductions in payments to providers, and state budget shortfalls.

Although the incoming Biden administration can make changes to 1115 waivers via a review process, Margo Sanger-Katz reported last week that CMS has sent letters to all 45 states that have active waivers, asking them to sign contracts that would make it harder for a new administration to terminate waivers “on a political whim.”

CMS auditing hospitals for compliance with new price transparency requirements

The hospital price transparency rule that CMS finalized in late 2019 took effect on January 1. It requires hospitals to “provide clear, accessible pricing information online” for 300 “shoppable” services, in both machine-readable and consumer-friendly formats. And the pricing information has to include payer-specific negotiated rates, which is much more useful than hospital “chargemaster” rates that don’t really reflect the amounts that payers and consumers actually pay.

There is widespread anecdotal evidence that compliance is spotty thus far (and the maximum annual penalty for non-compliance would only amount to about $100,000, which is equal to about four hospital admissions), but CMS is currently conducting an audit of some hospitals to determine whether they’re in compliance with the new rule. Hospital compliance is expected to ramp up in the coming weeks, but a lot remains to be seen in terms of how much impact the transparency rules will actually have on consumer decision-making.

Legislation in Minnesota would expand MinnesotaCare, create a public option

HF11, sponsored by Rep. Jennifer Shultz (DFL, District 7A), was introduced in Minnesota last week, calling for various changes to the MinnesotaCare program that would allow more people to enroll. MinnesotaCare is a Basic Health Program, which provides coverage to people who aren’t eligible for Medicaid and who have household incomes of up to 200 percent of the poverty level.

HF11 would extend MinnesotaCare eligibility to undocumented immigrants, and would also eliminate the “family glitch” for MinnesotaCare eligibility. HF11 would also create a public option, via MinnesotaCare buy-in, for people with income above 200 percent of the poverty level, with a sliding fee scale for premiums. The legislation would also allow small employers to buy into the MinnesotaCare program as a means of providing coverage for their employees.

Rep. Shultz published an op-ed in the Minnesota Reformer last week, outlining her goals for health care reform and the incremental steps that Minnesota could take to make coverage and care more accessible and affordable in the state.

Utah Insurance Department proposes new minimum standards for short-term health plans

The Utah Insurance Department has proposed new minimum standards for short-term health insurance coverage, including a benefit cap of at least $1 million, copayments/coinsurance that can’t exceed 50 percent of covered charges, and various inpatient and outpatient services that would have to be covered. But the three benefit categories that are most commonly excluded on short-term plans – outpatient prescription drugs, mental health care, and maternity care – are not among the mandated benefits that the Department has proposed. The Department is accepting public comments on the proposal until March 3.

BCBS Association suspends contributions to members of Congress who voted to reject electoral college results

Last Friday, the Blue Cross Blue Shield Association announced that it was suspending political contributions “to lawmakers who voted to undermine our democracy,” referring to the members who challenged the electoral college results from the November presidential election. Numerous other companies have followed suit, including Disney and Wal-Mart, but the Blue Cross Blue Shield Association was the first major healthcare group to take this step. Others have since announced similar decisions, including PhRMA, and to a lesser degree, Cigna. The Blue Cross Blue Shield Association represents the 36 independent Blue Cross Blue Shield insurers that operate across the country, insuring more than 107 million Americans.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post The Scoop: health insurance news – January 13, 2021 appeared first on healthinsurance.org.

The Scoop: health insurance news – January 6, 2021

In this edition

Democrats win both Georgia Senate races, paving way for federal health policy reforms

The biggest health policy news this week is the victory of both Rev. Raphael Warnock and Jon Ossoff in Georgia’s runoff Senate races. Their wins bring the Senate to a 50-50 split, with Vice President-elect Kamala Harris casting tie-breaking votes as necessary. There is a wide range of administrative health policy actions that the Biden administration will be able to implement without involving Congress, but the shift in power in the Senate opens the door for a variety of changes that require legislation but that can be accomplished with just 51 votes in the Senate – including making the California v. Texas lawsuit moot before the Supreme Court issues its ruling later this year.

Maryland opens new COVID-related special enrollment period

Maryland was one of just two state-run exchanges that opted to not extend open enrollment for 2021 coverage. But Maryland announced this week a new COVID-related special enrollment period for uninsured residents, which will continue through March 15. Maryland previously offered one of the nation’s longest COVID-related special enrollment periods, which began last March and continued through December 15, 2020. The new special enrollment period offers the same generous effective date rules that the state was using in 2020, allowing uninsured residents to sign up for coverage with an effective date that’s either retroactive or no more than two weeks after the date they enroll. Uninsured Maryland residents who enroll by January 15 will have coverage backdated to January 1.

Open enrollment ends in five states on January 15

Open enrollment for individual/family health plans is still ongoing in ten states and DC. But it ends next Friday, January 15, in five of those states:

Residents in those states can still enroll in a plan with a February 1 effective date. But after January 15, a qualifying event will be necessary in order to enroll.

Legislation introduced in New York to create a health insurance guaranty fund

Legislation has been introduced in New York that would create a health insurance guaranty fund that would step in to cover unpaid claims if a health insurance company becomes insolvent. Most states already have health insurance guaranty funds, but New York’s existing guaranty fund covers life insurance companies but not health insurance companies.

New York’s legislature considered similar legislation in 2016 after New York’s health insurance CO-OP failed (and again in each of the subsequent legislative sessions). But it was opposed by both Gov. Cuomo and the state’s health insurers, who objected to the assessment that would have been charged to fund the program. The current bill has 35 sponsors in New York’s Assembly, all of whom are Democrats.

North Dakota legislation calls for longer but more robust short-term health insurance plans

Legislation (SB2073) has been introduced in North Dakota, at the request of Insurance Commissioner Jon Godfread, that would allow for short-term health insurance plans with longer durations but also stronger consumer protections. Under North Dakota’s current rules, short-term health insurance plans can have terms of no more than 185 days. One renewal is permitted, but the total duration of these plans cannot exceed one year, including the renewal period.

The newly introduced legislation calls for the state to allow association short-term limited duration health plans to follow current federal rules, which means they could have total durations of up to 36 months. But while federal rules allow short-term plans to be renewable (for up to 36 months in total), North Dakota’s SB2073 would require association short-term plans to be renewable at the option of the insured.

SB2073 would also require association short-term health plans to cover all of the ACA’s essential health benefits, with the exception of pediatric dental and vision services. This would be a significant change, as short-term health plans are not currently required to cover essential health benefits, and most tend to lack coverage in at least a few of the essential health benefit categories.

Haven closing three years after beginning joint venture to improve healthcare quality and affordability

Three years ago, Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. announced a new partnership to “address healthcare for their U.S. employees, with the aim of improving employee satisfaction and reducing costs.” Their new joint venture, named Haven, was an independent entity, “free from profit-making incentives and constraints,” which set out to shake up the conventional health insurance model and provide “simplified, high-quality and transparent healthcare at a reasonable cost.”

But as David Anderson noted at the time, this was never going to be an easy road. And Haven announced this week that it will no longer exist as an independent entity as of the end of February. Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. plan to “continue to collaborate informally” as they work on health care solutions for their own employees, but they’re winding down their joint venture.

Appeals court panel allows Trump administration to deny visas to immigrants without health insurance, but Biden expected to reverse this rule

More than a year ago, the Trump administration issued a proclamation that requires immigrants to have health insurance – or proof that they would have coverage within 30 days of entering the country – in order to obtain a visa. The rule was blocked by a judge before it could take effect, but a three-judge panel for the U.S. Court of Appeals for the Ninth Circuit overturned that injunction last week in a 2-1 ruling.  The court’s ruling does not take effect immediately, however, and the Biden administration is expected to overturn the rule soon after taking office, making it unlikely that the health insurance requirements for immigrants will be implemented.

California prohibits insurers from denying gender-affirming medical care based on age

Last week, the California Department of Insurance notified health insurers in the state that they cannot deny coverage solely based on age when an insured is undergoing a gender-affirming female-to-male transition and seeking male chest reconstruction surgery. The Department was made aware of several insurers that had denied these claims solely due to the patient being under the age of 18, and took action to address the issue. The state’s letter to insurers clarifies that mastectomy and male chest reconstruction can be carried out while the person is still a minor, and that any claims decisions should be made on a case-by-case basis and cannot discriminate based on age.

New prior authorization consumer protections in Minnesota

A new law took effect on January 1 in Minnesota, expanding consumer protections with regards to prior authorization in health insurance. When a consumer switches from one health plan to another, the state now requires the person’s new insurer to honor, for at least the first 60 days, any prior authorizations that had been granted by the prior insurer. The new law also prohibits insurers from revoking already-approved prior authorizations unless the authorization was based on fraud or misinformation or was in conflict with state or federal law. And insurers are required to publicize a wide range of data pertaining to prior authorizations, making it easier for consumers to see how frequently these requests are approved or denied, and the reasons that prior authorization requests are rejected.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

The post The Scoop: health insurance news – January 6, 2021 appeared first on healthinsurance.org.

 

Maddox Insurance Agency

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Licensed in Tennessee, Mississippi & Arkansas

Contact

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