50 populations whose lives are better thanks to the ACA

The Affordable Care Act (ACA) has faced numerous legal challenges, but has been upheld three times by the Supreme Court. Over the years, the headlines surrounding the possibility of the ACA (aka Obamacare) being overturned have often focused on people with pre-existing conditions who buy their own health insurance. (This is certainly a valid concern, as those individuals would undoubtedly be worse off without the ACA.)

But the impact of the ACA goes well beyond securing access to healthcare for people with pre-existing conditions. Who are these Americans, whose lives are better off, thanks to the ACA? See if you can find yourself – or your loved ones – in this list:

  1. More than 14 million Americans (91% of all Marketplace/exchange enrollees) who are receiving premium subsidies in the exchanges that make their coverage affordable. The average full-price premium is $605/month in 2023, but the average subsidy amount ($527/month) covers the majority of the average premium.
  2. More than 7.5 million people who are receiving cost-sharing reductions that make medical care more affordable and accessible.
  3. People who are (or want to be) self-employed and wouldn’t have been able to qualify for and/or afford a privately purchased health insurance plan without the ACA’s guaranteed-issue provisions and premium subsidies.
  4. People with pre-existing conditions who gain access to an employer-sponsored plan after being uninsured for 63+ days. HIPAA guaranteed that they could enroll in the employer-sponsored plan, but there were waiting periods for pre-existing conditions. The ACA eliminated those waiting periods.
  5. People who lose access to an employer’s plan and no longer have to rely on COBRA (or mini-COBRA/state continuation) for health coverage.
  6. People who gain access to an employer’s plan and have a waiting period of no more than 90 days before their coverage takes effect. Pre-ACA, employers could determine their own waiting periods, which were sometimes longer than three months.
  7. Full-time (30+ hours/week) workers at large businesses who are offered real health insurance instead of “mini-med” plans, thanks to the employer mandate. (Employers can choose not to comply, but they face a penalty in that case.)
  8. People with serious conditions often exhausted their coverage under pre-ACA plan because of annual or lifetime benefits caps.

    People with serious conditions often exhausted their coverage under pre-ACA plan because of annual or lifetime benefits caps.

    People with serious medical conditions who would otherwise have exhausted their coverage in the private market, including employer-sponsored plans. Pre-ACA, annual and lifetime benefit caps were the norm. And it could be shockingly easy to hit those maximums if you had a premature baby or a serious medical condition.

  9. Coal miners with black lung disease, and their survivors. The ACA made benefits under the Black Lung Benefits Act of 1972 available to more people.
  10. Medicare beneficiaries who use Part D prescription coverage and who would have ended up in the donut hole.  before. (The ACA closed the donut hole as of 2020.)
  11. Medicare beneficiaries who receive free preventive care.
  12. American taxpayers and Medicare beneficiaries who benefit from ACA cost controls that have extended the solvency of the Medicare Hospital Insurance trust fund and improved Medicare’s long-term financial outlook.
  13. Seniors who are able to remain in their homes as they age, thanks to the ACA’s expansion of Medicaid funding for in-home long-term care services and supports.
  14. Nursing home residents – and people with loved ones living in nursing homes – who benefit from federal funding for background checks on employees who interact with patients.
  15. The 12 million low-income Americans who are elderly and/or disabled, covered simultaneously by both Medicare and Medicaid, and who benefit from the improvements the ACA made for the dual-eligible population.
  16. College students who are no longer offered skimpy health plans.
  17. Women (and their partners) who have access to contraception at no cost – including birth control methods such as IUDs, implants, and tubal ligations that are highly effective but would have prohibitively high up-front costs if they weren’t covered by insurance.
  18. Pregnant women who have access to free routine prenatal care.
  19. Expectant parents – male and female – who can enroll in a health plan in the individual market. (Pre-ACA, expectant parents’ applications were rejected in nearly every state.)
  20. People who buy their own health insurance and would like to have a child. Pre-ACA, individual health insurance rarely covered maternity care.
  21. Breastfeeding mothers who have access to breast pumps and breastfeeding counseling as part of their insurance benefits. The ACA also guarantees that breastfeeding mothers who work for large employers have access to adequate breaks and a private, non-bathroom area for pumping milk.
  22. Anyone who is better off in a world where people in need of mental health care can access it – because their health insurance covers it and they aren’t rejected altogether when they apply for a new health plan.
  23. People with substance abuse disorders who can obtain treatment that would be unaffordable without health insurance coverage.
  24. The 21 million people who have gained access to Medicaid thanks to the ACA’s expansion of coverage to low-income adults.
  25. Low-income families and individuals who no longer have to meet asset tests in order to qualify for Medicaid or CHIP, with eligibility now based on the ACA’s modified adjusted gross income instead (some populations, including the elderly and disabled, are still subject to asset tests for Medicaid eligibility).
  26. People in some rural areas of the country where hospitals have been able to remain open thanks to Medicaid expansion.
  27. Young adults who are able to remain on their parents’ health insurance as they work to start their careers.
  28. Young adults who were in foster care until age 18, and who are allowed to continue their Medicaid coverage until age 26, regardless of income.
  29. Early retirees who can enroll in self-purchased health insurance for the pre-Medicare years, without worrying about pre-existing conditions.
  30. ACA's marketplace plans must cover a list of vaccinations for children from birth to age 18.

    ACA’s marketplace plans must cover a list of vaccinations for children from birth to age 18.

    Children who have access to free vaccines and well-child care.

  31. Adults who have access to a wide range of preventive health services at no cost.
  32. Families whose health plan covers their kids’ dental care.
  33. People in New York and Minnesota who earn a little too much for Medicaid but are eligible for coverage under Basic Health Programs (Oregon plans to debut a Basic Health Program in mid-2024).
  34. People who find themselves needing to appeal their health plan’s decision on a prior authorization request or claim.
  35. Medicare Advantage enrollees whose health plan is required to spend at least 85% of revenue on members’ medical claims and quality improvements.
  36. Individuals and employers whose insurers are required to spend at least 80% or 85% of premiums on members’ medical claims and quality improvements.
  37. People age 65 and older, including recent immigrants, who are able to enroll in ACA-compliant health plans if they’re not eligible for premium-free Medicare (pre-ACA, individual market insurers generally would not enroll people over age 64).
  38. Women, who no longer pay more for health insurance than men.
  39. Older people (including those age 65+ who aren’t eligible for premium-free Medicare), whose premiums are no more than three times as much as the premiums for a 21-year-old.
  40. People who buy their own health insurance and no longer have to worry that the policy could get rescinded because they forgot to mention something on the application. (This was usually due to an omission in the medical history section, and those questions are no longer asked – thanks, also, to the ACA.)
  41. Everyone who benefits from the more robust premium review processes that states have as a result of the ACA.
  42. Everyone who benefits from the ACA’s risk adjustment program, which levels the playing field and helps to prevent plan designs that would be unappealing to individuals and groups with high-cost medical conditions.
  43. People with individual and small-group coverage that includes all of the essential health benefits.
  44. People who pay full price for individual health insurance in Alaska, Colorado, Delaware, Georgia, Idaho, Maine, Maryland, Minnesota, Montana, New Hampshire, New Jersey, North Dakota, Oregon, Pennsylvania, Rhode Island, Virginia, and Wisconsin, who are paying lower premiums thanks to reinsurance programs that were implemented under Section 1332 of the ACA.
  45. Native Americans and Alaska Natives, who can enroll year-round in plans sold through the exchanges, and who are eligible for plans with zero cost-sharing if their income doesn’t exceed 300% of the poverty level. (That’s $90,000 for a family of four enrolling in 2024 coverage.)
  46. Native Americans and Alaska Natives who receive care via Indian Health Services – as the ACA permanently reauthorized the Indian Health Care Improvement Act.
  47. People who are protected from discrimination in healthcare based on race, national origin, sex, age, or disability, thanks to Section 1557 of the ACA. (The details of how these protections work are determined by HHS, so there have been some changes over time. HHS initially issued rulemaking in 2016, but it was rolled back in 2020. However, HHS proposed new rules in 2022 that would largely revert to the stronger anti-discrimination protections that were implemented in 2016.)
  48. People who are able to make more informed food choices thanks to nutritional and calorie information on restaurant menus. This stems from Section 4205 of the ACA, and was implemented in 2018.
  49. People who shop for coverage in the health insurance exchange and find the new star rating system for health plans to be helpful during the plan selection process.
  50. People who could benefit from new biosimilar drugs becoming available. Section 7002 of the ACA created the pathway under which biosimilar drugs are approved by the FDA.

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.

South Dakota Medicaid expansion is underway

South Dakota is the 39th state to expand Medicaid eligibility to cover low-income adults, with coverage that could take effect as early as July 1. Applications were accepted starting June 1, and enrollment continues year-round.

What are the new Medicaid eligibility guidelines after expansion?

South Dakota’s Medicaid expansion makes coverage available to many low-income adults who weren’t previously eligible and now meet eligibility criteria. This includes adults who:

  • Are under age 65.
  • Have a household income up to 138% of the poverty level. (For a single person, that’s $20,120 in 2023; for a household of four, it’s $41,400.)
  • Are not eligible for or enrolled in Medicare.
  • Are lawfully present in South Dakota and have or have applied for a Social Security number.
  • Have been lawfully present in the U.S. for at least five years. (Low-income lawfully present immigrants who have been in the U.S. for any amount of time are eligible for premium subsidies in the Marketplace instead.)

Previously, non-disabled adults under age 65 were only eligible for South Dakota Medicaid if they had minor children and a household income that didn’t exceed 46% of the poverty level. (For a household of two, that was just over $9,000 in total annual income.)

Who became newly eligible for Medicaid in South Dakota as a result of expansion?

As a result of Medicaid expansion, an estimated 52,000 low-income adults in South Dakota are newly eligible for Medicaid as of July 2023.

This includes parents/caretakers with income above 46% and not more than 138% of the poverty level, as well as childless adults with income up to 138% of the poverty level.

Can I apply for expanded Medicaid if I recently lost Medicaid in South Dakota?

Yes, some people who have recently lost Medicaid in South Dakota will find that they’re once again eligible for coverage under the new guidelines.

During the COVID pandemic, states could not disenroll anyone from Medicaid unless they moved out of state, passed away, or requested a disenrollment. But that rule ended April 1, 2023 and South Dakota was among the first states to begin disenrolling people. South Dakota Medicaid enrollment dropped by more than 21,000 people by May, after just two months of disenrollments (enrollment in March was nearly 153,000, and by May it had dropped to under 132,000).

If you’ve recently been disenrolled from South Dakota Medicaid, you may have already received a notification from the state about your potential eligibility for Medicaid expansion and a reminder to submit an application.

Will Medicaid expansion affect South Dakotans who currently have Marketplace plans?

Some people who currently have subsidized private coverage through the South Dakota Marketplace will be newly eligible for expanded Medicaid as of July 1.

In addition to the non-disabled adults without minor children described above, this includes adult parents and caretakers with household income between 100% and 138% of the poverty level. For a single person, that’s between $14,580 and $20,120 in annual income this year. The amount increases if there are more people in the household.

These individuals were eligible for Marketplace subsidies to purchase private plans prior to July 1, 2023. And they will not automatically be transitioned to Medicaid in July. They’ll have the option to keep their Marketplace coverage (and subsidy) through the end of the year.

Or they can choose to apply for Medicaid and then drop their Marketplace plan if and when they’re approved for Medicaid. It’s important to wait until the Medicaid application is approved before dropping a Marketplace plan to prevent a gap in coverage. There would not be an opportunity to re-enroll in the Marketplace plan prior to January 1 unless the person has another qualifying life event.

For people in this income range who have Marketplace coverage and choose to keep it for now, Medicaid eligibility will be redetermined during open enrollment this fall. At that point, if a person is eligible for Medicaid (i.e. income up to 138% of the poverty level), they will be notified that they are no longer eligible for a subsidy in the Marketplace after the end of 2023, and are instead eligible for Medicaid.

People whose projected 2024 income is above 138% of the poverty level will continue to be eligible for subsidies in the Marketplace, as long as they can provide any requested income verification documentation. (There is no set upper income limit for subsidy eligibility. Subsidies are available as long as the benchmark plan would cost more than 8.5% of your household income.)

Which states might implement Medicaid expansion next?

South Dakota was the 39th state to expand Medicaid, leaving 11 others that have not yet done so. North Carolina appears likely to be the next state to expand Medicaid, with coverage expected to become available in late 2023 or early 2024.

Most of the states that have expanded Medicaid in the last few years have done so as a result of voter-approved ballot measures. But those are not an option in most of the 11 remaining states, and are unlikely to be a successful strategy in the states where they are possible.

North Carolina was the first state in several years to approve Medicaid expansion legislatively, and some of the remaining states might follow suit in the coming years. Other states – including Wyoming and Kansas – have seen multiple failed attempts in the past five years to advance expansion legislation

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 since 2013. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Six strategies for avoiding the Affordable Care Act’s coverage gap

In eleven of the twelve states that have so far refused to enact the Affordable Care Act’s expansion of Medicaid eligibility (which the Supreme Court made optional for states in 2012), there’s good news and bad news for people who are seeking health insurance for 2022 and don’t earn a lot of income.

The good news is that COVID-19 relief legislation signed by President Biden in March of this year, the American Rescue Plan Act, vastly improved subsidies in the ACA private plan marketplace. Comprehensive coverage – a Silver plan with strong cost-sharing reductions –  is now free to many low-income Americans, and heavily subsidized for people who earn a bit more.

The bad news is that in states that have refused to enact the Medicaid expansion, the government still offers no help to people who report household incomes below the poverty line.

ACA’s coverage gap

The ACA’s creators intended for people in this income category to get Medicaid, but governors and legislators in the twelve “nonexpansion” states said no – even though the federal government foots 90% of the cost. More than 2 million low-income adults in these states are in the ACA’s coverage gap – eligible neither for Medicaid nor for help paying for coverage in the ACA private plan marketplace.

The remaining non-expansion states (excluding Wisconsin, which has no coverage gap,* and Missouri, where expansion is imminent) are as follows:

The minimum income to qualify for subsidized marketplace coverage in “nonexpansion” states is 100% of the federal poverty level (FPL). For enrollment in 2022, the cutoffs are as follows. (They are slightly lower for those still seeking coverage for the remainder of 2021.)

Persons in
family/household		 100% FPL
(minimum to qualify for coverage)
1 $12,880
2 $17,420
3  $21,960
4  $26,500

A Silver plan with strong cost-sharing reduction is free to enrollees with incomes between 100% FPL and 150% FPL. (In 2022, that’s $19,230 for an individual, $39,750 for a family of four.) At 150-200% FPL, Silver coverage costs no more than 2% of income.

At incomes above 200% FPL, the percentage of income required for a benchmark Silver plan rises with income to a maximum of 8.5% of income.  But again, in non-expansion states, subsidies are not available to people in households with incomes below 100% FPL.

Stumbling blind into the coverage gap

The application for coverage on HealthCare.gov – the federal marketplace for health coverage used by all of the non-expansion states (and 24 other states) – does not highlight the minimum income required for coverage. As a result, many low-income applicants who might expect to get federal aid find themselves confronted with a choice of plans quoted at full, unsubsidized cost – an average of $452 per month per adult for benchmark Silver coverage, unaffordable for almost all low-income enrollees.

Very few low-income enrollees know about the minimum income requirement, or know that their state legislatures and governors have denied them the Medicaid coverage that the ACA’s creators intended for them.

Many who work uncertain hours, or are self-employed, or do seasonal work, may not recognize how many variables go into their estimate of annual household income, which determines the size of subsidy – or whether a subsidy is available at all.

For applicants with incomes near the federal poverty line, knowing the stakes – that good coverage is free just above the 100% FPL threshold, and unaffordable just below that threshold – can make the difference between coverage and no coverage. For anyone not on a fixed salary, a good-faith estimate of next year’s income allows for some wiggle room. Many applicants may miss including allowable income sources, or fail to take fluctuations in their income into account, or otherwise miss the opportunity to claim a qualifying income.

A budget resolution introduced last week by Sen. Bernie Sanders proposes to create a new federal program that would offer insurance to people in this “coverage gap.” But with Democrats holding narrow majorities in both houses of Congress, their ability to create such a program is at best uncertain. Even if they do, it likely won’t go into effect in 2022.

Open enrollment for 2022 in non-expansion states begins on November 1 and HHS has proposed an end date of January 15. For those still seeking coverage in 2021, an emergency special enrollment period open to all who lack coverage ends soon – on August 15. After that date, you need a qualifying “life change” to get coverage for the remainder of 2021.

Six tactics for avoiding the coverage gap

Here is a checklist of strategies that may help you achieve eligibility for subsidized ACA coverage.

1. Know the eligibility cutoff.  As noted above, to qualify for subsidized coverage, an applicant must estimate an annual income for the coming year that’s above 100% of the Federal Poverty Level ($12,880 for an individual, $17,420 for a couple, etc. in 2022. See the list above.) This point can’t be emphasized enough, according to Shelli Quenga, Director of Programs at the Palmetto Project, a nonprofit health insurance brokerage in South Carolina.  “You need to know what amount you’re shooting for,” Quenga says. “You need to know where that line is. HealthCare.gov does not tell you.”

2. Use gross income, not net.  Many applicants don’t recognize these terms, which denote income before and after taxes. Gross income, which the application requires, is basically the largest number on the pay stub or tax form.

3. Consider earning more income if necessary.  When clients’ estimates fall short, Quenga will ask them what they can do to hit the target. “I’ll say, ‘Can you think of something you can do that’s going to earn you another $150 a month? Bake cakes? Clean houses? Mow grass? Do some babysitting? Provide some care to a nearby elderly person?’” Extra income of this sort can be entered on the application as self-employment, with wage income entered elsewhere.

4. Recognize uncertainty. The marketplace application for coverage provides a box to check “if you think your income will be difficult to predict.” That’s the case for many people – especially at low wages. If it’s hard to forecast how many hours you’ll work per week, how much you’ll make per hour (tips or overtime may make this variable), or how much work you’ll get if you’re self-employed, keep the eligibility threshold in mind as you estimate these factors.

5. Count everyone’s income. Household income includes income earned by everyone included in your tax return, including those who are not seeking coverage. Jennifer Chumbley Hogue, CEO of KG Health Insurance in Murphy Texas, cites the case of a woman in her early 60s whose husband is on Medicare and Social Security. “If your spouse is getting Social Security income, don’t forget to include it,” she says. That also holds for pensions, retirement accounts, and alimony (if awarded before 2019).

6. Consider how to count. The application allows you to estimate income on an hourly, weekly, twice-monthly, monthly or annual basis – and, if your income changes during the year, it invites you to estimate a different income for next year than for the current year. This flexibility allows you to take account of factors described below.

You can view the application on the HealthCare.gov site here. The income questions are on page 3. Note that the form recognizes the uncertainty involved in forecasting future income.

income changes on marketplace application

Considerations for individuals earning an hourly wage

If your income estimate is based on an hourly wage, consider the following questions:

  • Is the amount you and other workers in your household earned in the current month (or on the pay stubs you’re looking at) representative of what you are likely to earn throughout the year?
  • If you or a household member are a seasonal worker, have you fully accounted for that person’s likely full-year income?
  • Do you work more hours or earn more tips during the holiday season (or at other times of the year?) Have you fully accounted for that? Does anyone in the household take on a second job or temp job during the holiday season (or other season)? Have you included that income?
  • Do you sometimes get paid overtime?  Do the pay stubs you’re using to estimate income reflect that?
  • Do you have reason to anticipate a raise in the coming year? (For example, Florida will raise the state minimum wage to $10 per hour in September 2021, and to $11 per hour in September 2022).  If so, estimate your income on the basis of future pay rates.

Many who report income on an hourly wage basis work uneven and uncertain schedules. If a single person is unsure how many hours per week they’re likely to work, “I often tell them to put down 30 hours,” says Hogue – an amount that generally will qualify a solo applicant for coverage at an hourly wage of $8.50 or higher.

Strategies for the self-employed

Many of the low-income clients served by the Palmetto Project are self-employed, Quenga says. “Charleston is a huge destination wedding site. We have a lot of wedding planners, DJs, photographers, videographers.” Estimating next-year income is especially difficult if you’re self-employed, Quenga notes.

And for the self-employed, “Your projected income is your best guess of what you hope to earn.”  She notes that the self-employed are generally oriented toward minimizing their income for tax purposes. For the health insurance application, they have to reverse that mindset.

Considerations when estimating your income for 2022

When you apply for coverage for 2022 (or the remainder of 2021), you may have your 2020 tax return to refer to, as well as well  as pay stubs for at least 10 months’ income in 2021.  If the totals for 2020 or 2021 are below the eligibility cutoff, that’s not necessarily going to be true in the year following. When estimating income in this case, consider these questions:

Were your hours cut because of the pandemic? Regardless, can you realistically expect to work more hours in 2022 (or the remainder of 2021)? These questions apply to everyone in your household – that is, all who file taxes together and earn any income. If so, you can estimate a higher income for the coming year in good faith.

Should you check off allowable tax deductions?  The health insurance application asks about tax deductions that, if taken, reduce your gross income. The application points out that reporting these deductions “could make the cost of health coverage a little lower.” That’s true – if your income is above 150% FPL (Coverage is free up to that threshold.)

But if your income hovers near 100% FPL, these deductions could put your income below that threshold and disqualify you from subsidized coverage.  The deductions listed on the application are those taken for interest paid on student loans,  tuition and fees, retirement plan contributions, and alimony paid. If your income is near the cutoff, “do not check off a deduction that will put you under 100% FPL,” says Hogue.

If you were unemployed in any part of 2021 The American Rescue Plan provides free marketplace coverage in 2021 for any applicant who received any unemployment insurance income at any point in the year. After the emergency special enrollment period (SEP) ends on August 15, you will need to apply for a personal SEP to access this benefit – and do so within 60 days of having lost employer-sponsored coverage or experienced another qualifying life event. This particular benefit is not available in 2022.

What if your income estimate turns out to be higher than what you actually earn?

Low-income applicants may worry that they will owe large sums of money if their income estimate proves inaccurate. While those who underestimate their income do have to pay back a portion of their subsidy at tax time, that is not the case for those who overestimate income (in fact, if over-estimators pay any premium at all, they will get a partial refund).

If income for the year in question ultimately proves to fall below the 100% FPL threshold, there is no clawback of subsidies granted, unless the applicant’s income estimate is made with “intentional or reckless disregard for the facts.”

Your income estimate has to be good faith. You can’t make stuff up. But within the range of the realistically probable, you have leeway. “Suppose you mow grass for a living, and there was a drought,” Quenga posits. “You can’t control that. There is no penalty if you don’t end up hitting your target.”

Who’s checking your income anyway?

The ACA exchanges do check applicants’ income estimates against data sources such as employer records. In 2019, the Trump administration implemented a rule requiring the ACA exchanges to demand income documentation from applicants who claimed an income above 100% FPL if “trusted data sources” indicated an income below the threshold. If the enrollee failed to provide the documentation, the federal subsidy would be cut off, and the enrollee would likely lose coverage due to the unaffordability of the unsubsidized premiums.

But that rule was challenged in court, and in March 2021 a federal court ordered the Department of Health and Human Services (HHS) to rescind it. HHS responded promptly, rescinding the documentation requirement this past May. HHS did warn that its computer systems could not be retooled instantly, so that for some time, a request for income documentation would be sent in this situation. But HHS added that it would send a follow-up communication to the enrollee, saying that documentation was not required.

The ACA’s creators did not intend to shut poor Americans out of its benefits. But governors and state legislatures that refuse to enact the ACA Medicaid expansion do willfully perpetuate the coverage gap. Low-income people in non-expansion states should use every tool available to produce a good faith income estimate that will give them access to quality government-subsidized health insurance.

* * *

* States that enact the ACA Medicaid expansion offer Medicaid to all legally present adults with household incomes up to 138% FPL. Wisconsin, uniquely, offers Medicaid to adults with incomes up to 100% FPL – which is also the bottom threshold for subsidy eligibility in the private plan marketplace. No one, therefore, is excluded from aid on the basis of income.

Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Digital Media Award. He holds a Ph.D. in English literature from the University of Rochester.

The post Six strategies for avoiding the Affordable Care Act’s coverage gap 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 – December 16, 2020

In this edition

Open enrollment continues in 11 states and DC

In most of the country, open enrollment for 2021 individual/family health plans ended yesterday. (HealthCare.gov gave people until 1:59 a.m., Pacific time, and due to high call volume, they gathered contact information for some callers and will be reaching out to those people over the next few days to help them complete their enrollments.) The Trump administration rejected numerous calls to extend open enrollment in light of the ongoing global pandemic. Although the Biden administration might reopen the enrollment window next month, enrollment is currently closed for people in most states who hadn’t at least begun the enrollment process or left their contact information with the marketplace by the end of open enrollment (unless they have a qualifying event).

But in twelve states and DC, open enrollment is still ongoing. This includes Connecticut, where the extension was announced on December 16, and Idaho, where an extension was announced on December 18; the rest of those states had announced their extensions several weeks ago.

In some of these states, people who are currently enrolling (after December 15) will have coverage effective in February or March, instead of January. But several are offering extended enrollment deadlines for a January effective date. Pennsylvania, California, Colorado and Idaho all announced such extensions this week. Here are the applicable enrollment deadlines:

California’s state-run exchange, Covered California, has permanently extended open enrollment through the end of January. But CoveredCalifornia is working to try to give more Americans access to an extended open enrollment window for 2021 coverage, asking CMS this week to extend open enrollment via HealthCare.gov until the end of December or even through January. Oregon and Wisconsin have recently made similar requests, but CMS has given no indication that they plan to offer an extended enrollment window.

As of December 5, when there were still at least 10 days remaining in open enrollment nationwide, 3.8 million people had enrolled in plans through HealthCare.gov in 36 states. And by December 9, nearly 1.2 million people had enrolled in plans through several of the state-run exchanges, although not all of them have published enrollment data yet. There is always a significant spike in enrollment activity in the final few days of open enrollment, and auto-renewals will be processed by HealthCare.gov now that open enrollment has ended.

COVID-19 vaccine added to covered preventive care benefits for non-grandfathered health plans

On Friday evening, the FDA granted an emergency use approval for the Pfizer-BioNTech COVID-19 vaccine. Within hours, the CDC’s Advisory Committee on Immunization Practices (ACIP) held an emergency meeting and voted to add the COVID-19 vaccine to the list of vaccines that are recommended for routine preventive care. CDC Director Robert Redfield soon signed off on the recommendation, clearing the way for the vaccine to be covered by nearly all health insurance plans in the United States.

Under the CARES Act, enacted last spring, non-grandfathered health insurance plans have to add coverage for COVID-19 vaccines (with zero-cost-sharing) within 15 business days of the ACIP recommendation. This is much faster than the normal timeline for adding new preventive care services to health insurance plans, and it will help to ensure that when the vaccine becomes available for various populations, their health insurance will cover the cost.

South Carolina lawmakers pre-file Medicaid expansion legislation

There are a dozen states that still have not accepted federal funding to expand Medicaid. One of them is South Carolina, where several Medicaid expansion bills have been pre-filed for the upcoming legislative session. House Bill 3226 and Senate Bill 210 call for the state to expand Medicaid as of January 1, 2022, under the terms of the Affordable Care Act. Senate Bill 83 and House Bill 3269 call for the state to hold an advisory referendum during the 2022 general election, which would ask South Carolina residents to weigh in on whether the state should expand Medicaid as of 2024.

But advisory referendums are not binding. And unlike other states where Medicaid expansion has been implemented via ballot measures in recent elections, South Carolina does not have a mechanism that would allow voters to approve Medicaid expansion via a ballot initiative. (Of the remaining states that have not expanded Medicaid, only Mississippi and Florida have a ballot initiative process.)

Both chambers of South Carolina’s legislature have strong Republican majorities, and have spent the last decade rejecting Medicaid expansion. But as the number of non-expansion states dwindles to a small minority of the country, there’s increasing pressure on lawmakers to address the coverage gap, protect rural hospitals, and ensure access to medical care – especially in light of the ongoing global pandemic.

Legislation introduced in New Jersey to create an ‘easy enrollment’ system

Legislation to create an “easy enrollment” system was introduced last week in New Jersey’s Senate. The legislation is modeled on a similar program that Maryland debuted this year, and that Colorado will start to use in early 2022.

The idea is to use state tax returns to identify uninsured individuals and then determine, based on the tax returns, whether those individuals would qualify for Medicaid or financial assistance through the New Jersey exchange. If enacted, New Jersey’s bill calls for the state to implement the program starting with either the 2021 tax year (ie, the returns that people file in early 2022) or, if that’s not feasible, the 2022 tax year.

Surprise balance billing legislation gains bipartisan, bicameral support, but future still uncertain

Last Friday, leading Democrats and Republicans in committees in both the House and Senate reached an agreement on a legislative proposal, dubbed the “No Surprises Act,” that would end surprise balance billing in most situations. Loren Adler, Associate Director of the USC-Brookings Schaeffer Initiative for Health Policy, explains the details in this Twitter thread. ThinkAdvisor’s Allison Bell has a good summary of the proposal and its legislative prospects, as does Dylan Scott at Vox and Christopher Holt at American Action Forum.

There is widespread political and public support for taking consumers out of the middle of surprise balance billing situations, and this is an issue that regulators and lawmakers have grappled with for years. But there continues to be disagreement between health insurers and medical providers in terms of how the details should be handled. The No Surprises Act relies on arbitration to settle price disputes between providers and insurers, and America’s Health Insurance Plans has expressed concerns about that approach. The American Hospital Association has also expressed concerns about various aspects of the payment negotiation process.

Supreme Court issues a unanimous ruling that allows states to regulate pharmacy benefit managers

Last week, the Supreme Court ruled unanimously that Arkansas did not overstep its regulatory authority when it passed a law in 2015 that requires pharmacy benefit managers (PBMs) to pay independent pharmacies at least the wholesale cost of drugs, and that allows pharmacies to refuse to sell drugs at a loss. A consortium of PBMs had sued the state, claiming that they are regulated under ERISA instead, and that the state did not have regulatory authority. (Self-insured health plans are regulated by ERISA, and states do not have regulatory authority over them).

The Supreme Court’s ruling paves the way for other states to regulate PBMs in an effort to protect consumers’ access to independent pharmacies. (The court’s ruling was 8-0; the case was argued before Justice Coney Barrett was confirmed to the bench.)

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 – December 16, 2020 appeared first on healthinsurance.org.

 

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