Tag Archive: federal exchange marketplace

States that opted not to set up exchanges have opportunity to go their own way in 2017

Nearly three dozen states opted not to operate their own health benefit exchanges serving the individual and small group markets starting in 2014. In these states, the federal government became the default exchange operator under a provision of the Patient Protection and Affordable Care Act that’s invoked if states decline to establish an exchange. Typically red states hostile to the health reform law, these states also aren’t keen on other provisions of the law such as the individual and employer mandates. An Affordable Care Act provision that takes effect next year allows them to apply to the federal government to dispense with these mandates and the individual and small business exchanges as well as other major ACA health insurance market reform elements.

Section 1332 of the law affords states broad latitude to create their own health insurance programs serving individuals and small employers for coverage beginning in 2017. Section 1332 waivers even provide states federal funding for them, paying states what they would otherwise receive in the form of advance tax credit premium assistance payments to state residents to subsidize premiums for coverage purchased through exchanges.

The freedom and the federal funding come with some important provisos. According to federal guidance issued in December 2015, states must provide coverage for a comparable number of their residents and on terms that are as comprehensive and affordable as would be the case without the waiver. Funding for the states also cannot increase the federal deficit. The waivers would be for renewable five year periods.

While health plan issuers would still be barred from medical underwriting, states could even do away with foundational insurance market reforms such as those defining small and large employer group markets and those that affect rating such as a single statewide risk pool, rating territories and limited annual enrollment periods.

For those states that defaulted to the federal government to operate their exchanges, the guidance makes clear that if they want a Section 1332 waiver to set up their own state programs, they will be making a clean break with any federal government involvement other than monitoring to ensure they comply with the major waiver provisos. They would not be permitted, for example, to continue using the federal eligibility and enrollment portal, healthcare.gov, or to receive some modified form of advance premium tax credits in support of their programs. Nor could they mix Section 1332 funding with any federal Medicaid funding received under a state Section 1115 Medicaid waiver, according to the guidance.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Maryland mulls high risk pool fallback for individuals with exchange enrollment problems

Maryland Health Exchange Emergency Bill to be Submitted Next Week « CBS DC.

The proposed legislation would enable individuals seeking coverage through the Maryland’s health benefit exchange but whose enrollments encountered processing glitches to obtain coverage through the state’s high risk pool. According to the story, the coverage would be retroactive to January 1, 2014, when state high risk pools were to end operations under new Patient Protection and Affordable Care Act market rules barring medical underwriting for individual health plans effective that date or later.

Several other states operating their own health benefit exchanges that experienced severe problems with the launch of their web portals face a similar predicament as Maryland including Hawaii, Oregon, Minnesota, Vermont and Massachusetts.

The account also quotes Maryland Gov. Martin O’Malley as stating Maryland is considering the possibility of switching from a state-based to federal exchange either completely or in part, as well as partnering with other states.

Section 1311(f) of the Affordable Care Act authorizes the operation of “Regional or Other Interstate Exchanges” operating in more than one state, subject to the approval of the involved states and the federal Department of Health and Human Services.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

New transitional policy to mitigate IT delay affecting Medicaid, CHIP enrollment in federal exchange marketplace

The Obama administration this week announced a new transitional policy for the three dozen states where the federal government is operating state health benefit exchange markets to mitigate an IT glitch affecting enrollees eligible for state assistance programs. The U.S. Department of Health and Human Services issued guidance (.pdf) on the transitional policy November 29. It allows these states to submit abbreviated enrollee data files in order to allow eligibles to enroll for 2014 coverage.

This new, transitional opportunity for states to enroll individuals assessed or determined eligible by the FFM, using the information provided through the AT flat files, will ensure that enrollment can be completed in a timely way without regard to temporary file transfer system issues at either the federal or state level. It will also help states pace their workloads with respect to enrollment of residents who have applied through the FFM.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Medicaid enrollment glitch in federally operated state exchanges impairs “no wrong door” policy, initial enrollment for QHP issuers offering Medicaid plans

Today’s New York Times follows on a previous report by The Washington Post on a glitch involving the eligibility and enrollment process in state exchange marketplaces operated by the federal government. According to The Times, the federal website HealthCare.gov that serves as the online enrollment portal in those states is currently unable to electronically transfer applications to state Medicaid offices for individual plan applicants whose incomes qualify them for Medicaid under the guidelines established by their states.

That’s a serious issue for a couple of reasons. The exchanges are intended to operate as a single, integrated marketplace for both subsidized commercial insurance plans (referred to as Qualified Health Plans or QHPs) and Medicaid. The idea is affording people a single source for coverage regardless of household income makes it easier to enroll, thereby reducing the number of medically uninsured individuals. However The Times story notes under the current circumstance, those determined eligible for Medicaid will have to make a separate application though their state Medicaid offices, adding another step that could discourage enrollment.

Second, the glitch is problematic for QHPs that offer both commercial health plans as well as Medicaid managed care plans since it could deter initial enrollment of Medicaid eligibles in these plans. According to an issue brief (.pdf) by the Association for Community Affiliated Plans (ACAP), QHP issuers in 33 states and the District of Columbia have both commercial and Medicaid managed care plans, with 39 percent operating Medicaid plans in the same state. Having both commercial and Medicaid plans in the same state exchange marketplace could help reduce administrative costs and coverage gaps when enrollees’ incomes fluctuate across income guidelines for commercial and Medicaid plans, the ACAP brief notes.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Troubled launch of federal online exchange marketplace shows importance of IT project risk management

One of the essential elements of prudent project management is to have a plan to manage risks that can derail a project from getting done. Project managers everywhere are likely asking what kind of plan, if any, did the U.S. Department of Health and Human Services have in place to mitigate the risk of the online federal health insurance exchange marketplace that serves nearly three dozen states suffering a serious, systemic failure at launch. If the online marketplace simply bogged down due to heavy traffic during the first week after it opened for 2014 enrollment October 1, that would be a minor risk that could be mitigated by leasing more server capacity or simply by the passage of time as the initial rush died down.

According to today’s New York Times, however, the situation appears more serious than that. The Times quoted people working to get the online system functioning as saying it might not be ready by the December 15 deadline for individuals to enroll for coverage effective January 1, 2014. That would be a catastrophic start to the marketplace since the federal Affordable Care Act and conforming state laws contemplate the new individual health insurance market rules and exchange marketplace effective as of New Year’s Day.

Aware of the time pressure, the Obama administration is crashing the project, pouring in a team of IT experts to work 7/24 to get the online marketplace up and running properly. Many seasoned project managers would likely suspect that wasn’t in the risk management planning but is instead a last ditch response to a crisis.

One option that could have been in the risk management component of the project would have been a team developing a parallel system. If the site didn’t come up, IT staff could then switch over to the parallel site. Yes, it would cost more to have multiple development teams working in tandem. But given the novelty, complexity and high stakes of a functional online exchange marketplace project serving more than half the states, the higher costs would be justifiable.

If the crash fix doesn’t yield rapid relief as The Times story suggests, it’s possible administration officials have a contingency plan to effectively privatize the online federal exchange marketplace by outsourcing it to a commercial entity with experience running an online health insurance marketplace. If it did so, a possible candidate would be EHealth. The company, which operates the online insurance brokerage ehealthinsurance.com, was awarded a $19.3 million contract in July to help develop the federal online marketplace.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

%d bloggers like this: