Dec, 08, 2023

State-Based Marketplaces Continuing to Innovate for Open Enrollment 2024

Laura Buddenbaum, State Health and Value Strategies

The 11th annual open enrollment period (OEP) is underway, providing consumers with an opportunity to enroll in health coverage for plan year 2024 through the Affordable Care Act (ACA) Marketplaces. The Centers for Medicare & Medicaid Services (CMS) announced that enrollment is outpacing expectations with nearly 7.3 million people who have selected a plan since November 1. While 2023 reached overall record-breaking levels of enrollment, this year Marketplaces have the added responsibility of ensuring transitions for those no longer eligible for Medicaid during the unwinding of the continuous coverage requirement. To support consumers during this open enrollment, CMS has implemented policy improvements to HealthCare.gov–such as new application questions, modified plan comparison tools, updated automatic enrollment policies–and Marketplace consumers continue to see enhanced financial assistance under the Inflation Reduction Act. Likewise, states that operate their own State-Based Marketplaces (SBMs) are innovating to make health coverage more affordable and easier for consumers to enroll. Many SBMs have established or improved existing state subsidy programs to reduce out-of-pocket costs, expanded coverage for undocumented populations, or implemented policies to improve the enrollment process. This expert perspective highlights new and innovative initiatives being implemented by SBMs during the plan year 2024 OEP.

California

Beginning this OEP, over 650,000 individuals are eligible for additional reduced costs through Covered California for the first time due to the state’s new state-based subsidy program. California’s fiscal year (FY) 2024 budget included the appropriation of $82.5 million of the state’s Health Care Affordability Reserve Fund to reduce out-of-pocket costs for consumers.[1] The program builds on cost-sharing reductions (CSRs) under the ACA for consumers up to 250% of the federal poverty level (FPL), increasing the actuarial value of silver plans and eliminating deductibles entirely. The state subsidy program also reduces out-of-pocket maximums for consumers and copays for generic drugs and services such as primary care, emergency care and specialist visits. To maximize the number of eligible individuals receiving these savings, the Marketplace is automatically transferring about 35,000 individuals who were enrolled in other metal plans in 2023 into silver plans for 2024 coverage. 

Colorado

New this year is the increased availability of financial assistance for low-income undocumented Coloradans to purchase health coverage. In 2023 Colorado implemented a CMS-approved section 1332 state innovation waiver establishing the “Colorado Option” and unlocking significant federal pass-through savings. The Colorado Option is a public health insurance option with a standardized benefit design that is intended to be cheaper for consumers than other qualified health plans due to premium reduction targets. While the ACA prohibits individuals who are undocumented to enroll in Marketplace coverage (even without financial assistance), this population is eligible to enroll in coverage outside of the Marketplace.[2] Colorado’s OmniSalud program allows individuals without documentation–and individuals who are recipients of the Deferred Action for Childhood Arrivals (DACA) program–to purchase Colorado Option plans through a separate “off-Marketplace” portal with savings provided by the state for individuals up to 150% FPL.

The Colorado Division of Insurance announced that for 2024, the state increased the availability of financial assistance in the OmniSalud program to 11,000 individuals, a 10% increase from the 10,000 individuals who enrolled in 2023. At the start of this year’s OEP, after less than a day and a half, Connect for Health Colorado announced that the maximum number of 11,000 individuals enrolled in OmniSalud with financial assistance for 2024 coverage.[3] Historically, non-citizen communities may be fearful of applying for and accepting government benefits, and often forgo enrollment in health insurance for fear that doing so will jeopardize their immigration status. The speed at which OmniSalud reached capacity shows both the demand for affordable coverage and the strength of the community network and trust that Colorado has built.

Also this year, Marketplace coverage in Colorado is more affordable for consumers due to the expansion of the existing state subsidy program which provides CSRs to low income individuals and families. In previous years, consumers between 150% and 200% FPL who enrolled in silver plans were eligible for this financial assistance provided by the state. The Colorado Health Insurance Affordability Enterprise has now expanded these CSRs up to 250% FPL and has further lowered out-of-pocket costs for many who qualify for the program. According to the state, individuals who were enrolled in silver plans for 2023 coverage may see a reduction in their deductibles by up to 98% with maximum out-of-pocket costs reduced by up to 77%.

Colorado is also highlighting new policies that the state has implemented to prepare for this OEP to make it easier for consumers to enroll through the Marketplace. Connect for Health Colorado has moved all call center operations in-house, with a dedicated team that has been trained to assist consumers. The state has also made improvements to the Marketplace’s technology and application system to prepare for increased website traffic during OEP.

Maryland

Thanks to the expansion of the Maryland Health Benefit Exchange’s young adult subsidy program this OEP, more Marylanders with Marketplace coverage will save on their premiums in 2024. Individuals between the ages of 18 through 37 (an increase from age 34) receive financial assistance on a sliding scale, with the youngest and lowest income adults paying the least for their premiums. These savings can be applied to plans at any level through Maryland Health Connection. In 2023, monthly premiums dropped by around $40 for more than 33,000 young adults, and now with expanded age requirements more Marylanders will experience these savings. While Maryland’s program is designed to attract a population that is hard to reach, this population is also typically healthier–which could improve the risk pool and reduce federal spending on premium tax credits overall.

Maryland Health Connection has also updated how value plans are presented to consumers who are shopping through the Marketplace, making health costs clearer and more consistent across insurance companies. Value Plans are the state’s standardized health plans, with set cost-sharing amounts, coverage for certain services pre-deductible, and lower out-of-pocket costs for prescription drugs. When shopping on the Marketplace, standardized plans make it easier for consumers to compare health plan choices and find a plan that fits their needs.

Massachusetts

Massachusetts is piloting a new expansion of the state-based subsidy program ConnectorCare, which provides financial assistance on a sliding scale to enrollees based on income. The two-year pilot, approved by the state’s FY 2024 budget, increases the income limit for the program from 300% to 500% FPL. In addition to the 156,000 residents currently in the program, 50,000 people have become eligible for these savings. ConnectorCare plans have $0 or low monthly premiums, $0 deductibles, and low out-of-pocket costs. For the first time, every commercial health insurance carrier offering plans through the Massachusetts Health Connector is participating in the program.

Minnesota

Minnesota’s official health insurance Marketplace, MNsure, has made new partnerships this year to improve the availability of certified brokers to assist consumers with understanding health plan options and enroll in coverage. Minnesota has added five new enrollment centers, for a total of 23 MNsure-certified broker locations throughout the state. The centers provide walk-in assistance and virtual sessions at no cost to consumers. Brokers and other enrollment assisters, such as Navigators, play an important role in assisting individuals throughout the enrollment process, including consumer education about health coverage programs, eligibility for financial assistance, and the plan selection process.

Virginia

On November 1, the state officially launched Virginia’s Insurance Marketplace, the State-Based Marketplace for consumers to enroll in health coverage for plan year 2024. This makes Virginia the 19th state to transition from the Federally Facilitated Marketplace (FFM), HealthCare.gov.[4] The State Corporation Commission highlighted how over 340,000 Virginians who previously had coverage through the FFM have been successfully transferred and enrolled in the state Marketplace, and in just the first week of open enrollment, over 10,000 new applications were submitted. With the transition to the Virginia Insurance Marketplace, consumers may access enrollment assistance through the Marketplace’s new help center. The transition to  State-Based Marketplace will allow Virginia greater flexibility to meet the needs of the state’s population, leverage existing infrastructure to coordinate across state agencies, including Medicaid to ensure seamless transitions in coverage; and the ability to provide more targeted outreach to the uninsured.

Washington

For the first time beginning with this OEP, Washington residents regardless of immigration status are eligible to purchase qualified health plans with financial assistance provided by the state. Washington is the first state to utilize a section 1332 state innovation waiver to allow individuals who are undocumented to purchase coverage through the Marketplace. While this population remains ineligible for federal subsidies, individuals up to 250% FPL qualify for Cascade Care Savings, the state’s premium assistance program for the state’s public option program, Cascade Care. According to the state, more than 105,000 Washington residents, nearly a quarter of the state’s uninsured population, were previously ineligible for healthcare coverage due to the federal restrictions for undocumented populations. Families with mixed immigration statuses (such as families in which the parents are undocumented and children are U.S. citizens) are now able to enroll in a single family plan through the Marketplace, reducing the complexities of having to enroll children and parents into different plans with different networks, deductibles, and other benefits.

 

[1] For coverage year 2025, funding will increase to $165 million, per the budget agreement.

[2] While Colorado has established the OmniSalud program for residents who are undocumented, other states are pursuing legislative or administrative actions to extend affordable healthcare coverage to all residents, regardless of immigration status, using state-only funds (“state-funded affordable coverage programs”).

[3] The state is still encouraging people to apply for the OmniSalud program but financial assistance is no longer available and individuals will have to enroll in coverage at full cost.

[4] 18 states and the District of Columbia operate a State-Based Marketplace.